The ownership elephant is becoming a mammoth: a policy focus on ownership is needed to transform Aotearoa New Zealand's health system.

Explicit government policy about ownership of health services is an important yet missing element in Aotearoa New Zealand's health system. Policy has not systematically addressed ownership as a health system policy tool since the late 1930s. It is timely to revisit ownership amid health system reform and increasing reliance on private provision (for-profit companies), notably for primary and community care, and also as an integral part of digitalisation. Simultaneously, policy should recognise the importance and potential of both the third sector (NGOs, Pasifika, community-owned services), Māori ownership and direct government provision of services to address health equity. Iwi-led developments over recent decades, along with the establishment of the Te Aka Whai Ora (Māori Health Authority), and Iwi Māori Partnership Boards provide opportunities for emerging Indigenous models of health service ownership, more consistent with Te Tiriti o Waitangi and mātauranga Māori. Four ownership types relevant to health service provision and equity are briefly explored: private for-profit, NGOs and community, government and Māori. These ownership domains operate differently in practice and over time, influencing service design, utilisation and health outcomes. Overall, the New Zealand state should take a deliberate strategic view of ownership as a policy instrument, in particular because of its relevance to health equity.