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Health minister systems thinking is needed, and a back- ...... ground in the health professions is an advantage. But when I think about the dozen or The ideal health minister so health ministers (federal and state) with whom I have worked and some- J Dwyer times struggled, it seems to me that the keys for success are a combination of ...... commitment to policy goals that stand above the dusty arena of politics, and the Has an ability to reinvent themselves strength to maintain control of the policy agenda. n November 2001, Dr Michael retain control over health policy against Dr Neal Blewett (health minister from Wooldridge, Australia’s health minister the depredations of the central agencies, 1983 to 1990 and one of the few not to Iof nearly six years, retired from politics the departments of prime minister, fade from the front bench immediately) at the age of 45. In retiring early, Dr treasury and finance, which are the may well be judged the most significant Wooldridge fulfilled his own longstanding natural enemies of this largest of the achiever in the portfolio over the past 30 prediction that the health portfolio would “spending portfolios”. The second key years. Dr Blewett will be remembered for be his political graveyard, and in this he test is the ability to do more than his success in reinstating universal ac- shared the fate of most Australian health this—to move beyond health financing cess to health care through Medicare, ministers over the past 30 years. It seems and into more substantive areas. and for his leadership of Australia’s prompt and successful strategies in that, in Australia, there is little chance of The task of the health ministers is also response to the HIV/AIDS epidemic. life in politics after health and the ideal complicated by a jurisdictional problem. Both of these initiatives have survived health minister needs the capacity for a Australia has a population of less than 20 second or third career as well as the abil- and now enjoy popular support (al- million people, and nine ministers of ity to live with political risk. though Medicare remains under con- health—one federal and eight for the Yet the health portfolio is a senior stant challenge from conservative gov- States and Territories. Responsibilities cabinet position, and health policy is a ernments that profess commitment matter over which government can be for all aspects of the health portfolio— while they chip away at the policy foun- won and lost. Our tax based system of policy, public health, and health care— dations). But at the time, they were universal access to medical, hospital and are divided and overlapping across the politically courageous, socially progres- subsidised pharmaceutical services, sup- two levels of government. We have no sive, and required the ability to extract plemented through private insurance shortage of ministerial attention, and a new money for health care. Ideal charac- teristics for a health minister. and private health services, ensures that large infrastructure of coordinating copyright. health is an electoral issue, and never mechanisms has grown up to enable J Epidemiol Community Health 2002;56:888 long out of the media and public debate. national action on key policy areas—like ...... But not, apparently, a training post for research, food and drug policy, aborigi- future party leaders or prime ministers. nal health and public health. Author’s affiliations J Dwyer, Health Services Management, La Health remains a deeply contested In this setting, the ideal health minis- Trobe University, Victoria 3086, Australia and ground, and a test of strength for the ter needs a talent for coalition building Board Chair, Australian Resource Centre for minister. One of the key tests— towards a coherent policy agenda. Just Hospital Innovations regardless of the political colour of the understanding the dynamics and contra- Correspondence to: Professor J Dwyer; government—is the minister’s ability to dictions can take years for a novice, so [email protected] http://jech.bmj.com/ Health minister employment, social welfare, education, ...... housing, labour, etc, do will inevitably have much greater influence on popula- tion health than what the minister of The ideal minister of (public) health health does. The traditional public health approach to this problem has been to N Pearce attempt to “turn the health services into

...... public health services” and to attempt to on September 25, 2021 by guest. Protected persuade the health services to become Should be in a minister of public health, not a minister of interested in these broader issues. This is health not surprising; given that most public health workers have initially trained in clinical medicine, and have continued to am going to answer this question nursing) have been less successful. The work within the health services, albeit in indirectly, for two reasons. Firstly, second, and more important, reason is a different role after their conversion to Ibecause I don’t think it is possible to that I don’t think the question can be the public health approach that focuses make a prescription for the ideal minis- answered without first discussing what on prevention in populations rather than ter of health as so much depends on per- the role of the health services would ide- treatment of individuals. sonal skills and the current circum- ally be. However, I think it is time to recon- stances (apart from the need for her/him The fundamental problem for sider this approach. It has rarely if ever to be electable!). Some of the best New ministers of health, as well as public worked, for the obvious reason that Zealand ministers of health have had no health researchers and policy makers, is when public health attempts to influence obvious qualifications for the job, that the health services at most have a the health services it is a very small tail whereas other ministers with more minor influence on the health of a popu- trying to wag a very large dog, which relevant backgrounds (in medicine or lation. What the ministers of finance, wants to run in another direction.

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People working in the health services transform the health services towards If this approach were adopted, then like to do what they were trained for, and public health as much as this is possible. the minister of health and the minister generally do very well—that is, treating However, the ministry of public health of public health would both clearly play illness in individuals, and they usually would tackle the real public health issues an important part in government, but have neither the time, the ability, or the at the population level. It would solely would require different skills. The first resources, to deal with larger issues of have a monitoring and advocacy role, not would need the skills required to run the health services (including public health prevention in populations. Their admin- only with regards to routine monitoring services at the individual level). The sec- istrators also usually have more urgent of death rates, the population burden of ond would require the skills needed to priorities. As a result of this well disease, etc, but also with regards to meaning but naive attempt to transform play a monitoring and advocacy part to monitoring and influencing the work of the health services, public health has ensure that the likely population health the other government departments and gone backwards internationally over the effects were taken into account in the ministries (including the ministry of past two decades. It has continually lost work of all other government depart- out to the “conventional” health services health). One way (but not the only way) ments and ministries, including the in battles for resources, and it has had to do this is through Health Impact ministry of health. little influence on the important public Assessments of the possible health ef- J Epidemiol Community Health health problems at the population level. fects of different policy options proposed 2002;56:888–889 by the other government ministries and Perhaps it is time to seriously consider ...... departments. Health Impact Assessment another approach—that is, establishing Author’s affiliations a ministry of public health. Public health is not straightforward, but such quanti- N Pearce, Centre for Public Health Research, services for individuals (for example, tative estimates, however debatable and Massey University Wellington Campus, Private immunisation) would continue to be tentative, can play a key part in ensuring Box 756 Wellington, New Zealand delivered through the ministry of health, that health concerns are taken into Correspondence to: Professor N Pearce; and we would continue to attempt to account in economic and social policy. [email protected]

Health minister year gestations and hence attitudes and

...... options available to youngsters are worth copyright. thinking about. Many have common causes and we need to know about their My ideal minister of health relative potencies. So public money needs to be spent on finding out. This is K McPherson not to get stern or impose restrictions ...... but to invest in making healthy options more attractive—indeed sexier. Will have the guts to maximise health All this needs a new and credible scientific infrastructure to ensure that a competent workforce is well consoli- he perfect minister of health would communities. Nobody wants to be ill but dated in daily life. Odd that we have law-

have to understand about health— few have real opportunities for doing http://jech.bmj.com/ yers, doctors, engineers, teachers, and not so much the desperate manifes- much about impending disease 40 years T whatever else and not even a word, never tations of ill health. Such a person would on. But this is a social and political mind a coherent function, for public have to understand that a large pro- choice for government to facilitate under healthists. Public health really is quite as portion of chronic illness—at least until a national initiative. Immunisation and important as the rest, surely? age 75 or thereabouts is essentially vaccination are well accepted and clearly So we need a minister for public avoidable. Then health policy might require support, both intellectual and health in the highest echelons of govern- change so that in the longer run the actual, to enable them to work. ment power whose remit is maximising population served would be healthier Why then are highly cardiotoxic diets on September 25, 2021 by guest. Protected health and hence minimising health and the expenditure of medical services (in the longer run) widely marketed and services, to deal much more effectively proportionately less. That should be their the safer and (in many people’s view) with unavoidable illness and the needs objective. better options more expensive, less avail- of the elderly population. At the moment But all that requires courage and a able, and culturally alien. And they taste we are mostly getting the worst of both commitment to experiment sensibly and worse too. Why do governments with a worlds—too much avoidable illness and efficiently. Policy would incorporate, as minister for health allow schools to sell massively inadequate health services. It matter of course, rigorous evaluation their sports fields, procrastinate about is time to break out of that vicious cycle components and would get to serious tobacco advertising, take no lead on in all of our interests. grips with changing circumstances and dietary change, and so on. Mainly opportunities to enable real choice for because they don’t understand that J Epidemiol Community Health 2002;56:889 people that matter. The minister would health is, in the main, not determined by involve the public in a serious public health services. And also because they ...... health endeavour that eschewed all relish the power of controlling an impor- Author’s affiliations coercion, all patronising, and all nanny- tant and vital public institution. Klim McPherson, Department of Social ing. The objective would become a Get a strong minister who under- Medicine, University of Bristol, UK national enthusiasm—that would be stands the basics of the biology of Correspondence to: Professor K McPherson; different and special among different health—most chronic diseases have 50 [email protected]

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Health minister health related interests, including those ...... of doctors and other health profession- als, of hospitals and other public and pri- vate service providers, of the drug indus- An ideal minister of health try and regulatory agencies. Throughout this editorial, we have not C La Vecchia, S Garattini tackled the issues of ethnic background and gender, as they are neutral, and only ...... for the sake of simplicity we have used Should work across government and be a collaborator “he” instead of “she” in the text. Within the relatively small political differences seen in most western Europe countries, n developed countries, health systems The minister of health is frequently even the political orientation is probably are complex structures that may run seen as a technical job, and—at least in not vital. Left wing politicians tend to be Ieven in the absence of a minister of Italy—most health ministers over the past more open to social and hence equity health, and at least in Italy the idea of decade have been doctors. Not surpris- related issues, but health is such a basic abolishing the ministry of health and ingly, however, their impact even on requirement that most right wing politi- de-centralising its powers has long been important health related issues has been cians would not be willing to support or considered. limited. Thus, none of them was able to increase inequalities in health. A key issue is, therefore, what can an implement a modern tobacco legislation ACKNOWLEDGEMENTS ideal minister of health add, and what despite several attempts and substantial support from public opinion.23 This work was conducted with the contribu- skills are required. To successfully final- tion of the Italian Association for Cancer ise his activities, a minister of health Whatever the background of the ideal minister, he must be able to identify and Research. The authors thank Mrs M Paola should have a deep knowledge of the Bonifacino for editorial assistance. select competent collaborators from vari- way the ministry—and the government ous disciplines, including medical, social J Epidemiol Community Health 2002;56:890 at large—are working. Otherwise, the sciences, economics and ethics, and to minister may will be overwhelmed by organise multidisciplinary working ...... bureaucrats, and even the best initiatives groups. A minister should, in any case, be Authors’ affiliations will never be approved. able to identify groups of competent and C La Vecchia, S Garattini, Istituto di Ricerche Farmacologiche “Mario Negri”, Milan, Italy The minister must be able to commu- independent advisors to evaluate and nicate the value and importance of C La Vecchia, Istituto di Statistica Medica e review official acts and their implica- Biometria, Università degli Studi di Milano, health related issues, in order to provide tions. The minister should not have— Milan, Italy adequate support to them. The minister present or past—conflicts of interest, copyright. must also be able to communicate priori- Correspondence to: Dr C La Vecchia; including links with the pharmaceutical [email protected] ties in health, giving information on industry, private hospitals, or other quantitative relevance of various issues health related economic activities. The REFERENCES on the health of the population. For minister must also have adequate time 1 La Vecchia C, Anelli M, Zuccato E, et al. instance, a minister of health should and competence to follow the organis- Perceived risk of cancer in population samples have adequate skills and prestige to from 5 European countries. Int J Cancer ation and efficiency of services provided 2000;86:747–8. explain in quantitative terms the health by the ministry. 2 La Vecchia C, Garattini S. Attitudes to consequences of tobacco, BSE, and elec- A minister should be able to organise legislation on restriction of smoking. Lancet tromagnetic fields,1 and give conse- budget and resource allocation—if re- 1987;i:1310. 3 La Vecchia C, Garattini S, Colombo P, et al. quently rational priorities for interven- quired. Political attitudes will also be Attitudes towards smoking regulation in Italy. tions. required to assess and balance various Lancet 2001;358:245. http://jech.bmj.com/

Health minister therefore, health status reflects the social ...... and economic organization of the country”. These legal documents incorporated The ideal minister of health the rationale used by national and inter- on September 25, 2021 by guest. Protected national public health movements to M L Barreto understand and elaborate global strategies for achieving good standards of ...... health. On these grounds, we expected that the ministry of health would have Should mainstream public health defined effective policies to improve the health of Brazilians. Unfortunately, the fter more than two decades of to a health care system oriented towards ministry of health has failed to assume its dictatorial government, Brazil health promotion, protection and constitutional responsibility. More than a Abegan a new democratic era in recovery”, (Federal Constitution of Bra- decade after the constitution of 1988, lim- 1985. The new constitution, elaborated zil, Article 196, 1988). Following this, ited advancements in health services and promulgated in 1988, stated that Article 3 of Law 8080 enacted in 1990, organisation and healthcare delivery have “health is an universal right and a State stated that “ food, housing, sanitation, been achieved so far; health standards in obligation guaranteed by social and eco- the environment, work, income, educa- Brazil are still low for large segments of nomic policies aimed at reducing the risk tion, transportation, leisure and the our population, and curative oriented pro- of diseases and other ill-related events access to essential goods and services grammes are still given priority over and by universal and egualitarian access are all important health determinants; disease prevention and health promotion.

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Considering that this pattern of health of health, which gives more relevance to these risk factors must be modified by service organisation occurs in most na- diseases than to their causes. Shifting societal actions.5 tions we must ask—is this an acceptable the emphasis to the causes of disease J Epidemiol Community Health standard, or a generalised mistake? requires the promotion of broad social 2002;56:890–891 In my opinion, at least two major and economic policies that seek to ...... issues need to be tackled. Firstly, at the improve all aspects of life. As a result, the political level, health policies are in- development of guidelines for a ministry Author’s affiliations of health in consonance with the Brazil- M L Barreto, Instituto de Saúde Coletiva, cluded as an isolated sector of the social Universidade Federal da Bahia, Rua Padre agenda, which, by its turn, is considered ian Constitution and laws depends on: Feijó, 29, Salvador-Bahia, 40, 110-170 Brazil secondary to the economic agenda. (1) reorganisation of the State adminis- tration, with health as a central and Correspondence to Dr M L Barreto; From this perspective, the health sector strategic goal of the social and economic [email protected] has its focus limited to the effects rather agendas; and (2) prioritisation of epide- than the causes of diseases. In addition, REFERENCES miological research and practice that we must consider the tendency to 1 Rockhill B. The privatization of risk. Am J Public Health 2001;91:365–8. 12 elucidates the intricate and complex individualise or privatise health risks. effects of biological, environmental, and 2 Wing S. Limits od epidemiology. Med Global This tendency is reinforced by the over- Survival 1994;1:74–86. social factors on health, and actions that 3 Rose G. Sick individuals and sick population. emphasis of individual based risk fac- target populations rather than individu- Int J Epidemiol 1985;14:32–8. tors identified by epidemiological stud- als. We epidemiologists need to share the 4 Barreto ML, Alves PC. O coletivo versus o ies, and leads to a health system that individual em epidemiologia: contradiça˜o ou view that the important part of the risk síntese. In: Costa JFFL, Souza RP, eds. targets individuals rather than factors in the contemporary world are Qualidade de Vida: Compromisso Histórico populations.34 not “natural” but generated by actions of da Epidemiologia. Belo Horizonte: COOPMED/ABRASCO, 1994:129–36. Both of these issues are related to the human beings, not as individuals but as 5 Breilh J. Epidemiologia: Economia, Medicina mainstream “biomedical” understanding members of societies. As consequence, y Política. Mexico: Fontamara, 1989.

Health minister process, through strategic planning, ...... collective health monitoring, and social control of health practice and pro- grammes. Only this way will it be possible A minister of health to build up a health system based on

equity (social, ethnical, and gender wise), copyright. J Breilh solidarity, and collective quality monitor- ing. Voices from all over the world express ...... the public demand for dismantlement of Should challenge trendy global corporatism neoliberal policies, geared towards a lucrative, mercantile, and inequitable scheme of health distribution that have egrettably it is in the so called and public health and to deconstruct the widened social, gender, and ethnical “democracies” of the North and hegemonic models for research, teach- inequity. We must rescue our institu- RSouth where globalisation has be- ing, and practice; models that conceal tional expertise and the talent of health come the scenario for market fundamen- their lack of solidarity, imagination, and professionals for building a health sys- talism and an absurd race to the bottom, dreams, behind the shield of a variety of tem that reflects democracy and good in which economical and social rights functionalist technologies. quality of life in itself and holds straight- http://jech.bmj.com/ have been demolished and countries The construction of a democratic forward human rights advocacy as fun- compete for, what will in fact, see the process of health reform does not de- damentals of prevention and health care. situation of first being the worst in pend mainly on personal leadership, nor It is time to revert that regressive human terms. The neoliberal state in on the profile of a person that is placed at “modernisation” and deconstruct the those democracies has installed a process the head of a power structure, that is rigid and Cartesian perspective that has of social and cultural counter reform that because good intentions and personal dominated the practical and theoretical deny equity in principle and in fact, con- talent cannot revert the policies and health scenarios of care, prevention, secrating a systematic violation of the strategies of that power structure. The teaching, and research, submerging us in on September 25, 2021 by guest. Protected codes that guarantee standards of life reason why, with alarming repetitive- a positivistic and techno-bureaucratic and dignity, which are the basis for ness, people with scarce talent, academic vision of science and technology; a vision health. Our societies have institutional- proficiency, and ethical links to their that is now proposing that we erase all ised a combination of subtle and cruel people reach leading posts of public human meaning from health practice mechanisms to deprive people of means offices, is not because the adequate and convert it into an expensive mer- to develop their own identity and the profiles remain unknown, in contrast, chandise, inaccessible by the vast major- best in their culture, turning, as such the recruitment process of public officers ity of the developing world and even of into oppressive and violent societies, and ministers, depends on political the developed world. with apparently democratic but essen- strategies that assess compliance of Only under collective, well informed, tially authoritarian governments. Cul- those officers to hegemonic policies and leadership and only by organisational tural institutions are deteriorating, uni- their willingness to accept the game strengthening of the people and of their versities and educational centres are rules of such power structure. technical and academic allies, will we be being converted in docile sources of It is much more important to empha- able to implement socially equitable, functionalist formulas. sise collective leadership and social high quality and universal health Under such conditions we have to organisation as means of health reform. resources; and it is only towards that mobilise all our efforts to recuperate the The main problem resides in how to con- purpose, and inscribed under that logic human and scientific nature of medicine struct a parliamentary and participative that it makes sense to inquire about

www.jech.com 892 EDITORIALS J Epidemiol Community Health: first published as 10.1136/jech.56.12.890 on 1 December 2002. Downloaded from individual leader profiles; not only of end up being more “holier than the ...... health ministers, but of all health officers Pope”, and end up using an alternative Author’s affiliations and leaders. Our experience is saturated progressive lexicon, supposedly counter- J Breilh, Health Research and Advisory Centre by negative examples of notorious hegemonic, to disguise their truly neolib- and Development Research Centre, Quito, personalities—even some of democratic eral misdoings. Ecuador and well educated backgrounds—that J Epidemiol Community Health Correspondence to: Dr J Breilh; once inserted in that power structure 2002;56:891–892 [email protected]

Health minister was even a thought as to whether a ...... health ministry is needed at all at the central level. Only the fact that many of the disease control programmes are cen- The ideal minister of health trally funded and the state governments are not inclined to pick up the bills, has S K Kapoor ensured its continuation. Undoubtedly there is a need to bring health into the ...... centre of focus. We therefore need people Background and outlook matters, not necessarily medical who have a high public profile and are media savvy. However, it is also true that qualifications such a high profile politician is unlikely to be happy with the health ministry and deals exist only in fiction but shape our this kind of work, our experience is that might consider it as a “let down”. Unlike thinking. Over the years, only a few this empathy does not get translated into in the past, we now have young urban, Ihealth ministers in India have man- any concrete action at policy or imple- sophisticated professionals entering aged to leave a lasting impression. In my mentation level. Having a real grass root politics. This augurs well for politics in personal opinion, the two best were Raj- experience, preferably with a rural back- general but whether this will usher pro- kumari Amrit Kaur and Karan Singh. ground, has its advantages. This gives fessionalism in the health ministry is to Both had a royal lineage and were you a sense of equity and a real close look be seen. steeped in Indian values and part of the at the problems that you are trying to In conclusion, there is no doubt that freedom struggle. While Rajkumari pro- solve. However, you should be careful we need to clean the Augean stables of vided the initial impetus and dynamism that, while you get a ringside view of the the health ministry. There is nothing like copyright. to the ministry immediately after inde- things, we need a bird’s eye view for a woman, preferably a dominating one (a pendence, Dr Singh came at a time when policy matters so that we get the right la Brundtland perhaps!) to wield a health was declining in importance in perspective. broomstick for cleaning the corridors of the government. Both of them were In India, the health ministry currently the health ministry. We need to jolt the philosophical (Dr Singh has a doctorate) gets a very low priority. On many bureaucrats and technocrats of the and had a very broad vision and looked occasions there is not a full fledged cabi- health ministry into action. at health in its entirety. India also had net minister but only a minister of state. J Epidemiol Community Health 2002;56:892 doctors as the health minister, though Partly the reason for this is that health is they did not do as well. Our experience in a concurrent list, which means that ...... has been that doctors as health ministers state governments have an equal part to Author’s affiliations tend to have a narrow interpretation of play. Many states are larger than most S K Kapoor, Comprehensive Rural Health health and look more into curative countries in the world in terms of popu- Services Project, All India Insititute of Medical http://jech.bmj.com/ aspects than public health aspects. While lation. In states, the priority for health is Sciences, New Delhi 110029, India in general, it is believed and is probably even less important. In this era of Correspondence to: Dr S K Kapoor; true that, women have more empathy for decentralisation and restructuring, there [email protected]

Health minister Japan is now in transition to funda- on September 25, 2021 by guest. Protected ...... mental reform of its administration sys- tem. It is moving a large, rigid govern- ment bureaucracy to a system that The ideal minister of health favours deregulation, transparency, and smaller government. In this context, the T Takano work of Japan’s ministry of health is ...... expected to change from a vertical approach to a comprehensive one that Should be an outsider can act promptly and incorporate inter- sectoral collaboration. However, this change has not been progressing quickly he ideal minister of health needs to devote themself to serving the public. enough. be a vigorous political or social This person needs to be a visionary, a Japan’s rigid bureaucratic system led Tleader, above all. The minister needs strategic thinker, a master of organisa- health development through the entire to be someone who knows political reali- tional skill, and a skillful communicator country in the past through vaccination ties and can push their health policies to the general public and with ministry programmes, school health programmes, forward. The minister should selflessly of health bureaucrats. a public health insurance system, and so

www.jech.com EDITORIALS 893 J Epidemiol Community Health: first published as 10.1136/jech.56.12.890 on 1 December 2002. Downloaded from on. The compulsory and collective meas- position from outside the ministry of minister needs to be a very good listener ures were effective. The system was also health. This means that the minister and pay attention to outside academics, able to accumulate the experiences of could come from, for instance, the upper and the public. The minister needs to professionals and create specialists who levels of an university, a large, transna- have the power to install the bureau were experts in narrow fields. However, tional NGO, a large corporation, or a chiefs of the ministry of health. In short, because of changes in society the old way large organisation. A degree in medicine the ideal minister has to have a rare doesn’t work anymore. In the past 10 is not always needed. The minister does mixture of idealism and realism. years, there have been several important not need to be well known before In addition to the above, there is one public health scandals: HIV infected assuming the position, either. essential prerequisite for the ideal minis- blood products were allowed to be used, Japan’s citizens would now like to ter. S/he needs to be a long time reader of a severe lack of collaboration between participate in health issues more subjec- this journal! the ministry of health and the ministry tively. They want prompt and open J Epidemiol Community Health of agriculture helped increased contami- measures against new health problems. 2002;56:892–893 nation of BSE prions, and sufferers of They want leadership that has inter- ...... Hansen’s disease had to wait far too long ministerial collaboration. These positive to be rehabilitated into society. The list of potentialities have not yet been em- Author’s affiliations T Takano, Health Promotion/International scandals continues. Ministry structure braced by the ministry. An outstanding Health, Division of Public Health, Graduate has basically continued unchanged even minister would be needed to make two School of Tokyo Medical and Dental University, though superficial restructuring was large changes at the same time: change Yushima 1-5-45 Bunkyo-ku, Tokyo 113-8519, carried out. the ministry’s conventional structure Japan The ideal minister should be skilled at and invite citizens into health adminis- Correspondence to: Professor T Takano; politics, but should come into the tration in their communities. The ideal [email protected]

Health minister they provide downstream cure and care, ...... also participate in upstream prevention and protection. You support efforts to cull good practices (never letting the Wanted: one ideal Canadian federal tyranny of the “best” get in the way of the simply “good”) in health education, copyright. health minister (who walks on water) community development, and the health system’s “watchdog” role as R Labonte, A Williams, L Biggs advocate for social and physical environments—in the home, the com- ...... munity, the workplace—that enhance health and form a foundation of our social capital. You are a weaver of “joined up” governance, our publics’ health. Your sophisticated ou are excited by the challenge of Cana- knowing that the publics’ health requires knowledge of population health re- da’s interesting constitutional division of collaborative policy making from many Ypowers, in which the federal govern- search allows you to acknowledge that more ministries than your own; involves ment is expected to contribute to health income inequality remains a contested many other government levels; and http://jech.bmj.com/ systems largely under the control of pro- health determinant. It also allows you to needs input from a messy range of vincial governments, most of which will point out convincingly that public in- stakeholder groups in civil society, where constitutionally disagree with anything vestments allowing universal access to business interests and public interests you propose except the promise of more education, shelter, good nutrition, and are not always the same. You know how money. environmentally safe and playfully to put problems, rather than your own You are resistant to media attacks that con- stimulating homes, neighbourhoods ministry, in the centre of intersectoral tinually point to the declining federal contri- and communities are good for our collaboration, and understand that con- bution to health systems, and are able to health, our economy, and our planetary verting others to your discourse is on September 25, 2021 by guest. Protected convince your finance and international survival. neither necessary for, nor even useful in, trade colleagues in the cabinet of the You both think and act globally, knowing effective collaboration. wisdom of progressive taxation to in- that a resistant disease in Africa can hop You are an experienced activist in the crease public funding for effective health to Canada in less than a day, and that politics of the excluded, and not simply the services. Your conviction in evidence escalating disease coupled with widen- politics of the party. You have spent time based policy making (rather than policy ing inequalities and weakened public with our Inuit, First Nations, and abo- based evidence making) allows you to services are the greatest drivers to riginal communities. You recognise the confront head on the economic interests regional conflict, hence global insecurity. diversity of women’s health needs. You behind the push for widespread privati- You are a tireless advocate in public and have a deep empathy for minority ethnic sation of health (and education, and in camera for trade agreements that pro- groups, regional variations, and linguis- social services, and anything else “ineffi- mote health and protect the environ- tic differences. You have heard the Mari- ciently public”), with convincing refer- ment, and for Official Development time lament of fishless oceans. You are ences attached. Assistance levels that do not make a fluent in both official languages. You You are inspirational in your communica- mockery of the 0.7% of GNP commit- respect the populous weight of our tion to the nation’s diverse publics that not ment. industrial centre, understand its urgent only is progressive taxation a fair way to You fully grasp the tenets of health promo- drive towards the knowledge economy, finance public goods; it is also good for tion, whereby health systems, even as and recognise the need to ensure the

www.jech.com 894 EDITORIALS J Epidemiol Community Health: first published as 10.1136/jech.56.12.890 on 1 December 2002. Downloaded from dignity of those caught in the transi- Finally, your years in community work ...... tion’s wake. You respect rural life, its are complemented by your years in Authors’ affiliations deeply valued traditions and commit- tertiary learning, providing you with a R Labonte , Saskatchewan Population Health and Evaluation Research Unit and Community ment to community. You share the fears healthy respect for the spectrum of Health and Epidemiology, University of of drought, climate change, and corpo- health research required for better Saskatchewan, Canada ratisation with our Prairie farmers. You political and public decision making, A Williams, Research Faculty, Saskatchewan Population Health and Evaluation Research Unit wrest over the dilemmas of resource and to help build our nation’s human and Geography, University of Saskatchewan based economies devastating our capital. L Biggs, Women’s and Gender Studies, environment (its health, our health), or (Ability to leap tall buildings in a University of Saskatchewan reeling from past devastations of single bound desirable but not Correspondence: Professor R Labonte, SPHERU, depletion and exhaustion, and ponder required.) Health Sciences Building, University of Saskatchewan, 107 Wiggins Road, Saskatoon, the challenges of the new global econo- J Epidemiol Community Health SK, Canada S7N 5E5; mies. 2002;56:893–894 [email protected]

Health minister authority typical for the other sectors of ...... state policy. Neither should the minister turn to belief in the sanctity of tradition, of “the eternal yesterday”, which rests The ideal minister of health on the appeal of the medical profession that claim allegiance because of their S Oreskovic extraordinary virtuosity resulting in ...... internists, surgeons, radiologists, psy- chiatrist, and microbiologists’ minds at Should be performed and managed on stewardship, loyalty, the post of health ministers without authority, and efficiency strong public health action. “My succes- sor will be a pathologist” pointed out by the Croatian minister of health, Andro n his effort to escape from the gastrointestinal bleeding were not corre- Vlahusˇic´. Authority of the health minis- individualising and particularising lated with more intensive healthcare ter should not arise from such “profes- 1 spending.45 Overuse of antibiotics in- Iapproach of German historicism, sional” background but rather from copyright. creases the chance that bacteria can breed Max Weber developed a key conceptual public health advocacy and responsive- tool, the notion of the ideal type.Anideal new strains able to survive the drug onslaught, rendering it ineffective. Para- ness to the citizens health needs. She type is an analytical construct that serves should apply theory of modern public the investigator as a measuring rod to doxically 30% of the world lacks access to essential antibiotics like penicillin or administration assuming that the au- ascertain similarities as well as devia- thority to order certain matters by tions in concrete cases. What are the chloramphenicol, but at the same time, in decree does not entitle the ministers to similarities and deviations from “ideal the United States and Canada, 50% of regulate the matter by commands hav- type of health minister” among minis- outpatient prescriptions for antibiotics are 6 ing the reputation of the most bureau- ters of health around the globe? And unnecessary. Underuse refers to the fail- ure to apply, when indicated, treatments cratic and least effectively managed what would be an ideal minister of that have been shown to be effective in institutions in the public sector.8 Effective health in the 21st century? Perhaps the medical care. In developing countries and efficient health policy should be minister should be validated against the http://jech.bmj.com/ underuse because of poor access to serv- following objectives: stewardship, loyalty, guided by priorities, objectives, proc- ices is overwhelmingly the most severe authority, efficiency. esses, and outcomes. This stands in problem, followed by misuse. The South The question is to whom the “ideal” extreme contrast with the regulation of African HIV story is good example of minister of health should direct his all relations through individual privi- divided loyalty. The minister has to decide leges and bestowals of favour*, abso- stewardship? “Stewardship is about vision, where to direct his loyalty and account- intelligence, and influence” is probably lutely dominant in a political and ability: international regulations, finan- 9 the most strategic sentence of the WHO professional health patrimonialism. 2 cial interest of the national treasury, phar- World Health Report 2000. If the minister maceutical industry, or health needs of J Epidemiol Community Health on September 25, 2021 by guest. Protected of health would like to act as a “good the citizens. Approximately 200 HIV posi- 2002;56:894–895 steward” responsive to the citizens and tive babies are born each day in South their needs she should concentrate on Africa, and use of nevirapine can reduce three substantial health issues: overuse, mother to child transmissions by half...... underuse, and misuse of health services. Some doctors illegally prescribe nevirap- In many countries, both developed and ine to pregnant women. Finally, the Treat- *Australian former health minister Dr Michael developing interventions that are of little ment Access Campaign (TAC) won a law- Wooldridge last year approved a $5 million value are commonly overused; care that is grant to the Royal College of GPs for a building suit against the South African minister of to help co-locate several doctors’ groups. That effective is commonly underused; and health, Manto Tshabalala-Msimang, and same organisation now employs Dr Wooldridge care that is of unproved value is fre- nine provincial health ministers, forcing as a consultant. Prime minister John Howard is quently misused.3 More diagnosis creates the government to provide nevirapine now ordering an investigation and flagging the the potential for labelling and detection of through the public health sector for the possibility that he might pull the plug on the pseudodisease—disease that would never prevention of mother to child transmis- contract. Dr Miodrag Kovac Federal Secretary become apparent to patients during their 7 for Labour, Health and Social Welfare of FR sion of HIV. Yugoslavia committed suicide in April in Madrid lifetime without testing. Survival rates Facing both political and professional because of accusation of corruption in decision after acute conditions like acute myocar- challenges the minister of health should making about the purchase of medical dial infarction (heart attacks), stroke, and not try to act as a standard charismatic equipment.

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...... 2 World Health Organisation. The World Chicago: The University of Chicago, Health Report 2000: Health systems: Author’s affiliations 2000:169–93. improving performance. Geneva: WHO, 6 http://www.health.fgov.be/WHI3/krant/ S Oreskovic, Andrija Stampar School of Public 2001. krantarch2000/kranttekstmay/ Health, Rockefellerova 4, 10000 Zagreb, Croatia 3 Fisher ES, Welch HG. Avoiding the 000504m07prn.htm unintended consequences of growth in 7 http://www.cptech.org/ip/health/sa/ Correspondence to: Dr S Oreskovic; medical care: how might more be worse? 8 Bosert T, Hsiao W, Barrera M, et al. [email protected] JAMA 1999;281:446–53. 4 http://www.dartmouthatlas.org/about.php Transformation of ministries of health in REFERENCES 5 Skinner J, Wennberg JE. How much is the era of health reform: the case of 1 Weber M. Basic concepts in sociology by enough? Efficiency and Medicare spending Colombia. Health Policy and Planning Max Weber. (Translated and with an in the last six months of life. In: Cutler DM. 1998:13:59–77. introduction by HP Secher.) New York: The The changing hospital industry: comparing 9 http://www.abc.net.au/lateline/archives/ Citadel Press, 1962. not-for-profit and for-profit institutions. LatelineIssuesIndex_Health.ht

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