New Zealand has a two-tier health system with elective surgery provided by both publicly funded state hospitals and by private hospitals. Issues of equity should be considered across such systems-where the better off can access surgery in private hospitals regardless of relative clinical need. This study evaluated equity of provision of surgery after the introduction of a prioritization system to manage access. Data for people receiving publicly funded elective joint replacement, prostatectomy or cataract surgery between 2000 and 2005 were obtained, as well as most recent data for people receiving privately funded surgery (2001 and 2002). Denominators were derived from the 2001 census for the population of District Health Board regions. NZDep2001, a small-area deprivation index, was used to identify people in poorest deciles. Despite the introduction of a prioritization system aimed at increased equity and fairness, the provision of elective surgery remains inequitable geographically. High private provision was not associated with better access to publicly funded surgery. Moreover, the argument that private provision for the well off reduces the burden on the public system allowing better access for the poor was not supported. Consequences of two-tier health systems, as in New Zealand, need more investigation and public discussion.