Global Audiology/Oceania/New Zealand

Estimated population: 4,802,973. Of these, an estimated (2017) 734,200 themselves as indigenous Maori or consider themselves to be culturally affiliated with Maori. (Population | Stats Nz, n.d.) Net migration (Oct 2017): 70,694.

New Zealand lies about 1,600 km from both Australia and Polynesia. It has three main islands: the North and South Islands, with Stewart Island, lying due south of the South Island. New Zealand is the visible part of a large, submerged super-continent. Today, the remains of this supercontinent form an archipelago with over 700 smaller islands, many of them uninhabited. New Zealand sits on the boundary of the Indo-Australian and Pacific tectonic plates, and frequently experiences earthquakes. (Taonga, n.d.)

New Zealand is a predominantly urban country, with 86.5 percent of the population living in an urban area. About 73.0 percent of the population lives in the 17 main urban areas (population of 30,000 or more), and 53.8 percent live in the four largest cities: Auckland, Christchurch, Wellington, and Hamilton. Auckland is the largest city with a population of around 1.5 million. A little under a quarter of the population lives in the South Island (“Geography of New Zealand,” 2021).

The capital city is Wellington (population: 496,000 or around 10.6% of the population) (Living in Wellington, n.d.), which is where parliament and most government offices are.

Population Make-up
New Zealand was originally populated by Maori peoples who arrived, it is thought, in the 13th century. Currently, (2013 census) 74% of the population identifies as European, 14.9% identifies as Maori, 11.8% as Asian, 7.4% as Pacific peoples, and 1.2% as Middle Eastern, Latin-American, or African (for 2018 census) (Home | Stats Nz, n.d.).

Official languages are English, Maori (since 1987), and NZ Sign Language (NZSL, since 2006). English is the main spoken language, with 96.1% of respondents in the 2013 census indicating that they spoke English. In the same census, 3.7% of respondents reported conversational fluency in Maori, and 20,235 people reported the ability to use NZSL. Many migrants are multilingual.

There is no state religion, but the principal religion is Christianity. Originally, Maori people were animistic, but many were converted to Christianity when missionaries arrived in the 19th century. Other religions, especially Hinduism, Islam, and Buddhism, have been growing in recent decades. Just over 40% of respondents (2013 census) have no religion.

The adult literacy rate is 99%, with over half of the population aged 15-29 holding some sort of tertiary qualification.

Governance
New Zealand is a parliamentary democracy established in 1856.

For local governance purposes, New Zealand is divided into 16 regional councils. There are 20 District Health Boards (DHBs) in New Zealand (2018), which provide funding to Primary Health Organizations (PHOs).

Salaries in New Zealand
The average salary (for all occupations) before tax in New Zealand is $51,500 (Household Income and Housing-Cost Statistics: Year Ended June 2018 | Stats NZ, n.d.).

The average salary for a clinical audiologist in New Zealand (2018) is around NZ$80,000. The range is from NZ$60 to NZ$106k depending on role and experience. Some privately owned clinics offer additional bonuses, profit-sharing, commissions based on hearing aid sales, and other performance indicators. Private clinics tend to pay more than District Health Boards (Audiologist Salary in New Zealand | Payscale, n.d.).

It is very difficult to find figures regarding hearing loss incidence and prevalence in New Zealand that have been derived from New Zealand-based research. In December 2016, Deloitte published a report commissioned by the NZ National Foundation for the Deaf on the social and economic cost of hearing loss in New Zealand (The National Foundation for the Deaf, 2016).

This report estimates that over 880,000 people in New Zealand (18.9%) may have suffered from some form of hearing loss at the time of the report, with the total cost of hearing loss reaching an estimated NZ$4.9 billion. The cost to the economy was estimated at $957.3 million. These figures are extrapolated to the New Zealand situation from information collected in other countries (such as Scandinavia) and are not based on New Zealand data. However, this report is widely referred to by hearing industry groups and deaf support groups, as well as government bodies.

More recently, the NZ Hearing Industry Association, an industry lobbying group representing manufacturers and audiology corporations such as Amplifon and the retail arm of Sonova, have issued a report giving information underpinning sales-relevant information for hearing aids in New Zealand (New Zealand Hearing Industry Association, 2018)

While it is well known that only a small proportion of people with hearing loss seek and obtain hearing aids, even in countries like the UK where they are free, the following figures for partially subsidized and fully funded aids (not the fitting fee) have been provided by the NZ Ministry of Health:

History
Audiology is a relatively new discipline in New Zealand.

Post-World War II, office electronic technicians moved into audiology, working with basic analogue body aids.

The first qualified New Zealand audiologists were trained in the UK in the 1960s to work in educational or pediatric areas. In the 1970’s/80’s a few graduates completed PhD qualifications in the USA.

Dr Bill Keith led the National Audiology Centre in Auckland, where graduates would be trained onsite but not receive a formal qualification.

In 1977, the NZ Ministry of Health paid an average of four graduates per year to attend the University of Melbourne in Australia to complete a post-graduate degree in audiology. In return, the audiologists were bound to stay in public health employment for 3 years.

A 1984 report from the then Department of Health found there to be 34.4 full-time equivalent audiologists in total in New Zealand -giving a ratio of 92,300 people per audiologist. Unofficial data estimated there were 41 otolaryngologists in 1984, representing a ratio of 77,000 people per specialist. A 2015 estimate was of 52, 443 people per otolaryngologist (Exeter et al., 2015)

Number of Audiologists and Audiometrists
First incorporated in 1976, the NZ Audiological Society (NZAS) became the professional society for audiologists, and it has included audiometrists since 2012. The society is self-regulating, and membership is voluntary.

The November 2018 list of the New Zealand Audiological Society records that there are 377 full audiologist members of the Society and 26 full audiometrist members. These are members who have sat OSCE-style examinations run by the NZAS and are deemed to have passed. Audiologists and audiometrists have different scopes of practice. Only audiologists are required to have a two-year masters-level qualification in audiology. Some audiometrists have bachelor’s degrees in audiology or other qualifications from other countries. Other categories of the NZAS (as of November 2018) are: 67 inactive full-time audiologist members; 59 provisional audiologists (yet to sit professional exams); 16 provisional audiometrists, and a handful of “honorary” members. Including student members, there are now over 600 members of the NZAS.

Masters in Audiology (audiologists)
There are two universities in New Zealand that offer a master’s level degree in audiology. In 1990, Auckland University (North Island) began a two-year master’s program in audiology (M.Aud) followed in 2005 by Canterbury University in Christchurch (South Island). Both now average around 15 new students per year.

Audiometrists
For many years, audiometrists (known in other countries as hearing aid dispensers, audiology assistants, or hearing aid technicians), ran their own society (ANZAI), which still exists.

In 2010/11, the NZAS Executive Council, with encouragement from the Ministry of Health, ANZAI, and the corporate lobbying group the NZ Hearing Industry Association, decided to work towards the inclusion of this group within the NZAS. This allowed some audiometrists to access the government subsidy for hearing aids on their patients’ behalf and made audiometrists subject to NZAS supervision, rules, and complaints process. Up until then, many audiometrists in New Zealand were trained in clinic and on the job, but the NZAS had no jurisdiction over them. Many audiometrists in New Zealand now have degrees or training in audiology from overseas. Audiologists trained overseas who do not have a two-year master’s degree in audiology may apply to become an audiometrist member of the NZAS.

Educational Institutions
A two-year master’s degree in audiology (M.Aud) is offered at two universities: Auckland in the North Island, and Canterbury (Christchurch) in the South Island.

The courses include clinical and research (thesis) components, as well as engineering, auditory neuroscience, anatomy, ear pathology, and pediatric and adult audiology. Practical components of the course are run at volunteer clinics in both the private and public sectors that have agreed to take students to observe clinical practice. In the summer, at the end of year one of the course (December to February), students take up placements with volunteer clinics that offer places for a total of 8–9 weeks. This summer's practicum may be spread across two clinics, with a mixture of public and private experiences for students when possible. During this time, the student will also do a hearing aid project based on a patient they have observed with consent from (Audiology, the University of Auckland, n.d.; (UC Speech and Hearing Clinic | Communication Disorders | College of Science | University of Canterbury, n.d.).

Audiology Practice: Public and Private
Generally, audiological treatment at a public facility (audiology department at a hospital) requires a referral by a general practitioner (family practice doctor). Not all hospitals have audiology departments, and some hospitals struggle to recruit audiologists due to the pay differential between public and private clinics.

Audiological treatment at a private clinic does not require a referral, and potential patients may self-refer to any of the numerous private clinics around the country. Despite the tax base being relatively small, the New Zealand government, via the Ministry of Health, grants subsidies and funding based on various criteria for hearing aids and some cochlear implants (but not for vestibular or other audiology treatments such as tinnitus management and counseling).

New Zealand has access to the latest hearing aid technology and support from the so-called “Big 6”: Sonova, William Demant, GN Resound, Signia, Widex, and Starkey. (Cook, 2016). Signia and Widex merged in March 2019 to become WS Audiology, but there is still separate support within NZ for these products (Sivantos and Widex Complete Merger, 2019).

Government Funding for Hearing Aids and Hearing Services: Public & Private
Funding and subsidies towards the cost of hearing aids are available in New Zealand to adult patients attending both public and private clinics.

The Ministry of Health provides free hearing aids and related services for children and young people (up to the age of 21 who are full-time students) via hospital audiology departments. Parents who wish to take their children to a private clinic for the same services will pay for the services to the private clinic, but the hearing aids will be covered.

Only Audiological Society (MNZAS) audiologists and some audiometrists who also belong to the society, can access Ministry of Health government subsidies and funding for hearing aids on behalf of their patients.

Government Funding for Hearing Aids and Hearing Services: Public & Private

Funding and subsidies towards the cost of hearing aids are available in New Zealand to adult patients attending both public and private clinics.

The Ministry of Health provides free hearing aids and related services for children and young people (up to the age of 21 who are full-time students) via hospital audiology departments. Parents who wish to take their children to a private clinic for the same services will pay for the services to the private clinic, but the hearing aids will be covered.

Only Audiological Society (MNZAS) audiologists and some audiometrists who also belong to the society, can access Ministry of Health government subsidies and funding for hearing aids on behalf of their patients.

The Accident Compensation Corporation (ACC), incorporated in 1974, is a government-funded agency that provides tax-payer funding on a “no-fault” basis, for hearing loss deemed to be due to accident, medical misadventure, or occupational noise exposure (ACC – Home, n.d.). There is a minimum requirement of 6% hearing loss, using National Acoustic Laboratory population-based age percentage-reduction calculations (National Acoustic Laboratories –, n.d.). The ACC regulations are set by legislation, and periodically updated after consultation with a broad range of stakeholders.

Applicants must live permanently in New Zealand (residency or citizenship) and have suffered all or most of the hearing damage in New Zealand.

In the past, all hearing aid provision costs were covered for eligible people. However, since 2010, there have been several changes in the legislation. Hearing aid funding now comes in three bands (ranging from approximately NZ$3,000 to NZ$5,000 (incl GST for a pair of aids), which includes a fitting fee for audiologists. Replacement batteries and two annual appointments are paid for by the ACC, as well as repairs up to a capped amount within every 2-year period. Funding is available no more than once every 6 years for eligible claimants.

Funding is accessed by patients through MNZAS audiologists, (not audiometrists, although this may change). Audiologists must carry out a full diagnostic test (as per NZAS requirements) on candidates for ACC funding in an ISO 8253-1:2010 clause 11 compliant sound-treated environment (as per ACC rules). Audiologists must also declare on an ACC form that they do not work for a hearing aid manufacturer or associated entity (although companies that are “vertically-integrated” avoid this rule).

Determination of eligibility and the further apportionment of the percentage hearing loss due to ACC’s criteria is made by Ear-Nose-and-Throat specialists, but aids are fitted by audiologists/clinics chosen by the individual ACC claimant. Funding granted can be used towards any level of technology, make, and model of hearing aids. ACC encourages patients to obtain second opinion quotes for their aids from another clinic if unhappy with their first pricing option.

The Ministry of Health subsidy scheme
This is managed by Enable on behalf of the Ministry. This currently stands at NZ$511.11 incl GST per ear, not more than once every 6 years for residents or citizens of New Zealand aged 16 or older. This subsidy is applied to the wholesale cost of the aid, not to the fitting fee, and is available to patients who go through either public or private clinics (Health and Disability Support Resources » Enable New Zealand, n.d.).

The Ministry of Health Funding scheme
This is also managed by Enable. Eligibility requirements exist, e.g. hearing loss since childhood, dual disability including hearing loss (e.g. Deaf/Blind), or other criteria. Wholesale costs of aids are paid directly to manufacturers by the government up to capped amount, but a fitting fee of varying amounts, decided by each clinic or clinic group, is paid by the patient directly to the audiologist.

Veterans’ Affairs Funding
Funding includes a capped amount for eligible New Zealand military veterans for hearing aids, and other services, such as repairs. A battery allowance is added to eligible veterans’ pensions. Apply through an MNZAS audiologist for Veterans’ Affairs Funding (Home | Veterans’ Affairs, n.d.)

Work and Income NZ (WINZ) loans for hearing aids
These are for people who may be receiving a government benefit, such as a pension or a disability allowance and are means-tested. The loaned amount is gradually paid back by being deducted at source from the benefit. Apply through an MNZAS audiologist registered to do WINZ loans.

Public (Hospital-based Audiology)
About 20 hospitals in New Zealand have audiology departments. Audiologists working in public health tend to focus on pediatric work, for which a specialist NZAS “Pediatric Certificate” is required. Auditory brain-stem responses, and otoacoustic emissions are more likely to be tested and measured in a hospital rather than a private setting. Hospital audiology services are funded by the taxpayer and therefore, are often free to the public and hearing aids at a reduced cost.

However, due to funding constraints, there are fewer adult services able to be offered and often eligibility requirements for adults are generally linked to people on lower incomes. Hearing aids obtained through the hospital may still require some co-payment from the patient.

Hearing aids purchased through a hospital will generally cost a person less than through a private practice for similar technology levels. This is because the staff salaries and departmental general costs are met by the New Zealand taxpayers However, follow-up appointments are likely to be fewer at a hospital due to staffing constraints.

Eligibility Criteria for Hearing Tests at Hospitals (taxpayer funded)
Hearing tests are available for:


 * children and young people up to the age of 21 (provided they are full-time students)
 * adult Community Services Card (CSC) holders (means-tested for those on low-income to assist with health benefits).
 * adults referred by a hospital specialist

People outside of these criteria will need to be assessed at a private clinic (Audiology, n.d.)

Hearing Assessments for Children at Hospitals (taxpayer funded)
Hearing assessments may include:


 * auditory brainstem response including AABR
 * visual reinforcement audiometry
 * play audiometry
 * distortion product otoacoustic emissions
 * acoustic immittance testing
 * conventional audiometry
 * auditory processing disorder assessments

Children
There is no significant wait list for children’s hearing aids because hearing is essential to early speech, language, and social development.

Adults
To be eligible for free or reduced-price hearing aids via the public service, adults must hold a current Community Services Card and either:


 * qualify under the Ministry of Health (MOH) Hearing Aid Funding Scheme, or
 * have a moderate to severe bilateral hearing loss (defined as an average hearing loss of ≥ 56 dB across the 3 worst thresholds from 0.5, 1, 2 and 4 kHz in the better ear).

There may be a waiting list for adults, and this can exceed two years at some hospitals unless there are significant safety concerns.

Referrals are accepted from:


 * general practitioners (doctors)
 * ear, nose and throat specialists
 * pediatricians
 * Plunket (newborn babies) nurses
 * speech and language therapists
 * newborn hearing screeners
 * vision and hearing screeners

Audiologists may ask patients who meet the above requirements to request that their doctor refer them to hospital audiology departments. Audiologists are not currently on the published list of people who can refer directly to hospitals.

Cochlear Implants in New Zealand
Implants are available via both public (the majority) and privately funded routes. There is limited public funding, and adult (but not child) waiting lists are currently at around 2-3 or even 4 years.

The NZ Ministry of Health funds cochlear implant services for people who meet the following criteria:


 * Severe to profound hearing loss in both ears.
 * Hearing is not helped by standard (acoustic) hearing aids.
 * Assessed as likely to benefit from a cochlear implant.
 * Eligible for publicly funded health and disability services.
 * Live permanently in New Zealand.
 * Do not qualify for cochlear implant funding through ACC.

The funded (public) service includes:


 * the assessment
 * the device (an implanted electrode and a sound processor which is worn externally)
 * the surgery
 * audiology mapping
 * maintenance and support
 * associated ongoing support services
 * rehabilitation for adults or habilitation for children
 * speech processor replacement.

For children, the funded service also covers the cost of any repairs or spare parts for their speech processors. Adults (aged 19 years or older) don’t have these costs covered.

Only one implant is funded per adult. The Ministry does not fund follow-up services for adults (aged 19 or older) who received their implant outside of New Zealand or who paid for their implant privately.

Due to the long waiting lists, adults may choose to apply for one-off government grants to pay for a single cochlear implant; however, implants paid for using these grants are treated in the same way as a privately-paid implant; repairs and upgrades are not covered by the government. This has apparently made some potential implantees hesitate to take up the offer (Cochlear Implants, n.d.).

Children May Have Two Implants Funded
Children under 19 years of age with severe to profound hearing loss in both ears and are newly assessed as needing a cochlear implant can receive Ministry funding for one ear or both ears, whichever is clinically recommended by their specialist. Follow up services are funded for both ears.

Universal Newborn Hearing Screening (UNHS)
First rolled out in 2010, following regional pilot schemes, this free nationwide screening program aims to have every child screened by the age of three months (New Zealand Deafness Notification Database | National Screening Unit, n.d.).

Vision Hearing Screening for pre-schoolers is part of the B4 School, free, country-wide school check for health and well-being. Vision and Hearing Technicians give preschool and school hearing screening tests to four-year old, before they start school at age 5. If a child fails the test, they are referred on to hospital audiology (Vision and Hearing Screening | RPH, n.d.).

NZ deafness notification database
This has been running since 1982, first via the National Audiology Centre/Auckland DHB, and now as a separate entity. The details of children who are found to have permanent hearing loss (greater than a slight loss, and not a conductive loss), with the written consent of parents, are entered online into this database by the audiologists who diagnose the hearing loss. Since the rollout of Universal Newborn Hearing Screening, consent forms are signed at the time of the screening for later deafness notification should it be necessary (New Zealand Deafness Notification Database | National Screening Unit, n.d.).

Ear hygiene mobile free services for children aged 0-18
In many areas, there is a free ear mobile service run by the local DHB which may visit more remote areas with a registered nurse who is trained as an ear nurse specialist. Services are ear checks for discharging ears, education, and wax and foreign object removal (Porirua Children’s Ear van | Rph, n.d.)

Private Audiology Clinics
There are several different types of private audiology clinics throughout the country. Of these, the majority offer diagnostic and screening hearing testing and hearing aid fittings and related rehabilitation services. A few also specialize in tinnitus management or auditory processing disorders. There are very few clinics specializing in vestibular disorders, and this area is also served by vestibular physiotherapists. All clinics with MNZAS audiologists may access government funding for eligible patients who need hearing aids, on the understanding that work carried out by a non-MNZAS clinician is supervised or checked by an NZAS member. Anyone may self-refer to a private clinic, although referrals also come from GPs and specialists.

Children may also access hearing aids through private clinics if their parents choose this route. The privately accessed hearing aids will be fully funded by the Ministry of Health through their Enable funding body, but there will usually be a fitting fee which varies from private clinic to private clinic.

Private clinics fall into 5 main categories:


 * Independently-owned-and-operated clinics.
 * Manufacturer-owned clinics (usually owned through “vertical integration”)
 * Large overseas-owned corporate clinics.
 * University clinics
 * Franchise-type clinics where clinicians own a capped-percentage share of their clinic with the rest held by a single entity or person.

Many private clinics also have so-called “satellite clinics” which may only operate a few days per month and are in less-populated areas.

Anyone can attend a private audiology clinic – no referral is required from an ear-nose-and-throat specialist, general practitioner, or other medical specialist.

Most private clinics in New Zealand offer a “bundled” pricing model for hearing aids, fittings, and follow-up appointments. That is, while costs for services such as hearing tests are individually priced, costs for hearing aids are bundled with the cost of fitting and adjusting the aids over a trial period as well as counselling. Trial periods can range from 2-8 weeks. Aids can be returned for a refund during this trial period. Some clinics will then charge for the failed fitting, and some will not.

A small number of clinicians work in conjunction with ear-nose-and-throat specialists and may have shared ownership or shareholdings.

Other independent clinics may operate in a franchise-like arrangement, where one owner of a company has shares ranging from 25% to 75% in several other clinics, each operated by a semi-autonomous clinician, who also draws a salary.

Some independent clinic owners belong to Independent Audiologists NZ (IANZ). This is affiliated with Independent Audiologists Australia and has links with ADA. IANZ supports and promotes independent clinics owned by audiologists and supports the registration of audiology as applies to other healthcare and allied workers but is not yet required for audiologists operating in New Zealand. IANZ members must be practicing audiologists and must own at least 51% of their practice (or, if in shared practice, a combined controlling share). They agree not to pay commission to their staff based on their hearing aid sales and so the audiologists are not incentivized to up or oversell products to patients. IANZ members also agree not to enter percentage sales contracts with manufacturers, so that they remain free to fit whichever aids are the most appropriate for any given patient. They have no financial links to manufacturers or overseas-owned companies. They pay tax in New Zealand.

Manufacturer-owned clinics of overseas parent companies tend to fit their own-brand hearing aids more than other brands. Currently in New Zealand, there are clinics owned by Sonova (Triton clinics: brand Phonak and Unitron), Sivantos (brand Signia, formerly Siemens), William Demant (Formerly “Hearing Life” clinics, now rebranded as “Audika”: brands, Oticon, Bernafon, and Sonic), and Widex (Bloom clinics: brand Widex). (Sivantos and Widex parent companies have merged). All of these brands are also available at independent clinics and public clinics, in addition to brand Starkey which currently does not have its own-brand clinics in New Zealand. Some manufacturer-owned clinics may not pay much, or any, tax in New Zealand, as they can make use of international tax vehicles such as transfer pricing. Some appear to post no or little profit in New Zealand. Amplifon NZ owns non-manufacturer clinic “Bay Audiology”, with global agreements with Phonak, GN Resound, and other manufacturers.

Some manufacturer and corporate-owned clinics have ties to “The Hearing Industry Association”, a lobbying group.

University clinics operate as for-profit businesses, but also are used for teaching and research purposes. Both university clinics are also involved in research. The University of Auckland audiology department is known for tinnitus research, with their clinic specializing in tinnitus assessment and treatment (Hearing and Tinnitus Clinic – The University of Auckland, n.d.). https://www.auckland.ac.nz/en/on-campus/facilities-and-services/university-of-auckland-clinics/hearing-and-tinnitus-clinic.html

“Specsavers Optical group ltd”, a British multinational optical retail chain operates mainly in the UK, Ireland, Nordic countries, and Australasia (including New Zealand). As well as selling glasses, many Specsavers also sell hearing aids. The first Specsavers selling hearing aids opened in Auckland in 2019 with plans afoot for more in the future. Their model is a “joint or shared venture partnership” where Specsavers also has shares in the franchise (“Specsavers,” 2021).

Costco has recently (2019) announced it is opening in New Zealand and will also likely sell hearing aids (Costco Is Coming to New Zealand, Changing the Way We Shop, 2019).

There have been some attempts to sell hearing aids over the internet. Thus far, there seems to be only limited success to this approach in New Zealand, but this may change in the future.

There have also been some attempts at practicing “Tele-audiology”, but this is not yet widespread. This may increase with greater use of cell-phone technology by patients due to hearing aids being linked to phones and developments in hearing aid software.

Audiological Services
Audiologists in New Zealand are trained to carry out diagnostic hearing testing on both children and adults. This includes pure-tone testing for both air-conduction and bone-conduction, as well as some form of speech perception/discrimination testing, and immittance audiometry. Some may offer otoacoustic emissions testing in an adult setting, as well as APD testing. All have been trained to do ABRs, otoacoustic emissions, APD testing, and will have knowledge of vestibular testing. However, not all go on to use these last 4 skills on a regular basis, unless they choose to specialize.

Pediatric audiologists will be able to routinely perform ABRs, otoacoustic emission tests, and APD testing as well as fitting hearing aids to the pediatric and adult population.

Hearing aid selection, fitting (including Real Ear Measurements), and adjusting with counselling for adults are routinely offered by audiologists to the adult population especially in private clinics. Repairs of hearing aids and assessment of repairs are also offered in most clinics.

Less common are tinnitus, hyperacusis and misophonia specialists, and only a few private clinics offer auditory processing disorder testing and advice.

Vestibular audiologists have often been trained overseas. There are perhaps as few as 3-4 clinics offering vestibular testing in the whole country.

Cochlear implant counselling and mapping services are offered by specialist audiologists, but referral for a cochlear implant can be made by any audiologist, so long as the patient meets the current criteria.

The Ministry of Health contracts with two providers:


 * 1) The Northern Cochlear Implant Program (NCIP) covers Northland, Auckland, Waikato, Bay of Plenty, Rotorua, and Taupo.


 * 1) The Southern Cochlear Implant Program (SCIP) covers the rest of New Zealand.

NZ$8 million per year is spent on cochlear implants and supporting services (Cochlear Implants, n.d.) This may be increased to NZ$16 million in 2021.

Services Offered by Medical Professionals
Otolaryngologists, Otologists & Otoneurologists offer private consultations and surgery, as well as public hospital work including surgery. Many do both public and private work. Most work part-time. Some otolaryngologists do contract work writing reports for the ACC (Accident Compensation Corporation) and determining if and how much of a particular hearing loss is due to one of the ACC-covered conditions. Some ear nose and throat specialists provide consulting services at audiology clinics with specializations such as vestibular disorders.

Ear nurse specialists provide cerumen-removal services using microsuction. Some audiology clinics and some medical centers employ their own ear nurses to remove cerumen.

Scope of Practice and Licensing
Audiology is not a registered health profession in New Zealand. This means that there is no legal protection for the title “audiologist”, and anyone can call themselves one, regardless of their qualifications. However, to become an audiologist (and more recently, an audiometrist) who can access Ministry of Health hearing aid subsidies and funding on behalf of patients, you must be a full (active) member of the NZ Audiological Society, a voluntary and self-regulation association. The NZAS runs an annual conference for their members, as well as investigating complaints against members, and upholding a Code of Ethics

Education and Qualifications
In order to become an audiologist in New Zealand who can access government funding (for hearing aids) on behalf of patients needing audiological services, you must have been an under-graduate (preferably with a science-related degree) and complete a two-year Masters in Audiology (M.Aud). This is followed by clinical work and the achievement of a Certificate of Clinical Competence, granted by the NZ Audiological Society.


 * Successful completion of a two-year Masters in Audiology is followed by an application to become a provisional member of the New Zealand Audiological Society. As a provisional member, a minimum of 11 months of supervised clinical work in public or private practice must be completed with exams at the end of this period. Exams are in OSCE format and are held several times a year. They are organized and run by the New Zealand Audiological Society, and once passed, a certificate of clinical competence (CCC) is granted.


 * If you have an overseas equivalent master’s degree or above (recognized by the NZAS and the NZ Qualifications Authority), and English is not your first language, then an average score of 7.5 or higher is required in the English Language Testing System (IELTS) exam prior to becoming a provisional member.


 * For overseas applicants wishing to join the NZAS as an audiologist member, the equivalent of the 2-year NZ Master of Audiology degree is required, including at least 200 hours of supervised experience. Some countries’ CCC requirements are recognized as being equivalent, and people who hold these qualifications may be fast-tracked into membership of the NZAS.


 * A minimum of 60 continuing education points (CEPs) must be obtained within a 3-year cycle in order to maintain active membership of the NZAS. Non-members of the NZAS may not access government subsidies or funding on behalf of patients (How Do I Become an Audiologist?, n.d.).

Scope of Practice
Scopes have been developed with input from audiologists over many years, and with reference to Australian, Canadian, British and American standards.

Education and Qualifications
Audiometrists in New Zealand who wish to apply for NZAS membership must successfully complete a recognized qualification in audiometry, where core competencies have been acquired and assessed during a qualification process as agreed between ANZAI (the society for audiometrists: (Anzai | Association of New Zealand Audiology Incorporated, n.d.). NZAS, the University of Canterbury and the University of Auckland). An audiometrist must have at least two years’ work experience after completing a recognized qualification in Audiometry.

Scope of Practice
Audiometrists’ scope covers hearing assessments and hearing aid fitting and adjustments in non-complex adult cases. They may manage selected hearing aids fittings and adjustments as directed by an audiologist. Audiometrists may treat adults, but not children.

Hearing Therapists
The Hearing Therapists group (Life Unlimited) is a charitable trust funded by the Ministry of Health. Hearing therapists can provide advice and screening hearing tests and visit people in their homes to assist them with, for example, special telephones and doorbells, as well as help when someone needs practice to use or insert a hearing aid. Hearing therapists can work closely with audiologists (HTANZ, n.d.; Life Unlimited – Health & Disability Services | Advice | Support, n.d.).

Advisors on Deaf Children
These are funded by the Ministry of Education and work alongside children identified as being deaf or hearing impaired and their families from birth until leaving school. They work with other services including the two deaf education centers and help with communication resources (Ministry of Education, n.d.)

Deaf-Blind Coordinators
Government funded, they work with people who have both hearing impairment, and are registered as blind with the Blind Foundation. They help coordinate relevant services, and will even drive people to appointments, such as with their audiologist (Blind Low Vision NZ – Support for Kiwis Who Are Blind or Have Low Vision, n.d.).

The National Foundation for the Deaf
Consumer and advocacy group

Deaf Aoteraroa
Consumer and advocacy group and member of World Federation of the Deaf

The Hearing Association
A nationwide consumer and an advocacy group (with local branches run by volunteers)

Examples of funding bodies that may give grants for hearing aids

 * The Vincentian Foundation (for people aged over 65). Hearing aid grants generally range from NZ$500 to NZ$750. Apply through or with an audiologist (Vincentian Foundation, n.d.).
 * The NZ Audiological Society. Hearing aid grants of NZ$500-NZ$1,000 are for those 65 and older and for those aged 65 and under and are means-tested. Apply through an MNZAS audiologist.

The majority of research within New Zealand into audiology and audiology-related topics is undertaken at the Universities of Auckland and Canterbury. Auckland University is also the home of the Hearing and Tinnitus clinic, a center for research into tinnitus and hyperacusis (Hearing and Tinnitus Clinic – the University of Auckland, n.d.).

Challenges
Audiologists face many challenges in their dealings with various groups.

The Government
Governments have many demands on limited funds.

One of the challenges to audiology as a profession in New Zealand is that corporate lobbyists may have persuaded government officials that audiology is only about selling hearing aids. Audiologists have contributed to this by bundling all their services into the cost of hearing aids. The device is elevated above the service and skills of a professional audiologist (in a broad range of activities, including diagnostics), and there may be a general lack of knowledge regarding the fitting of an aid as a process over time involving neuroplastic changes, computer adjustments, education, and counseling. This device-centric view is supported by the government, which insists that the subsidy is for the wholesale cost of a hearing aid. If that wholesale cost is less than the subsidy, then the full subsidy must not be applied for, even if the full subsidy would help those in financial difficulty pay for the service of fitting the aid.

The government may place an insufficient value on what the audiologist does (vestibular audiology, hyperacusis treatment, intra-operative monitoring, etc.), instead placing a monetary value on the device; a focus that suits manufacturers of devices. It does not appear to recognize the full scope of the profession of audiology, nor the complexity of patient need and patient-centered care. Audiologists are easily viewed in some sectors as salespeople (rather than health professionals). This view is exacerbated because audiologists are not members of a registered profession. Additionally, the device focus is not likely to assist with achieving registration for the audiology profession.

The government, of course, is most interested in the affordability of hearing aids for segments of the population with limited finances, as that is a measurable parameter. Long-term outcomes, such as cognitive abilities over the long term, educational and employment success, and hearing aid fitting success, are more challenging to measure.

The New Zealand Public
The challenge for audiologists is to put our clients or patients at the center of what we do. This involves listening to them, among other things. This may also involve educating them that hearing aids are not like glasses; auditory sensory cells are damaged in a way that retinal cells in the eye are not. Fitting hearing aids involves retraining the brain over time. People want good service, but they would like it to be low-cost or free. They would also like hearing aids to be cheaper. Because prices for audiology services have traditionally been bundled into the cost of hearing aids, there is a lack of understanding that audiology services are payable.

The NZAS and the Profession of Audiology
The NZAS might, in the future, spend more time educating the New Zealand public about the benefits of good audiological practice as a way of boosting the profession. However, the challenge will be to address the focus of public funding and public perception. NZAS faces the challenge of reconciling their lack of support for professional registration with gaining recognition for important services required for effective diagnosis and treatment of hearing and balance disorders. Of concern to the NZAS is that audiologists and audiometrists might not opt to belong to both a compulsory registration board and a voluntary professional association. NZAS partnerships with industry, such as the one they hold with the Hearing Industry Association, present a challenge for clinics that seek to promote their services as their primary purpose. In the future, audiologists’ scope of practice may be extended to remain relevant and current.

Manufacturer-owned and Corporate-owned Clinics
For their part, corporate clinics must make profits for their shareholders – how to increase these and survive challenges posed by internet sales, extreme competition (“Two for the price of one” and offering free hearing tests and follow-up services) – or any competition – is a challenge for audiologists, who are the employees who generate income, in contrast to management, who are typically not audiologists but are business managers. International transfer pricing activities may allow corporate companies to have high sales volumes in New Zealand yet pay little or no tax in the country.

Independent Clinics
Independent clinics in New Zealand face several challenges. One is that their suppliers belong to groups that own the clinics that are their competitors. Another is that the high salaries and bonuses offered by large corporations to graduate audiologists have made hiring audiologists more expensive across the board. Additionally, large, overseas-owned clinics have preferred-supplier agreements with insurance companies operating in New Zealand, such as IAG and AA. If an aid is lost or damaged, the patient is contacted directly by a corporate clinic and told they must go to that corporate clinic. However, because hearing aids are classified as medical devices in New Zealand, they are covered by the Health and Disability Act and Code of Patient Rights (Code of Health and Disability Services Consumers’ Rights – Health and Disability Commissioner, n.d.). This states that patients may choose their own provider, and that an appointment may not be made for them without their informed consent. Many choose to return to their original provider if they are made aware of this.

New Zealand is a very small country. Word-of-mouth and personal relationships with health practitioners are extremely powerful factors when New Zealanders look for health providers, including audiologists, and this may be one of the reasons that smaller clinics are still thriving (PatientEngagementHIT, 2017).


 * 1) ACC – home. (n.d.). ACC.
 * 2) Anzai | Association of New Zealand Audiology Incorporated. (n.d.). ANZAI – Association of New Zealand Audiology Incorporated.
 * 3) Audiologist salary in New Zealand | payscale.