• health reform
• minister of health

I am going to answer this question indirectly, for two reasons. Firstly, because I don’t think it is possible to make a prescription for the ideal minister of health as so much depends on personal skills and the current circumstances (apart from the need for her/him to be electable!). Some of the best New Zealand ministers of health have had no obvious qualifications for the job, whereas other ministers with more relevant backgrounds (in medicine or nursing) have been less successful. The second, and more important, reason is that I don’t think the question can be answered without first discussing what the role of the health services would ideally be.

The fundamental problem for ministers of health, as well as public health researchers and policy makers, is that the health services at most have a minor influence on the health of a population. What the ministers of finance, employment, social welfare, education, housing, labour, etc, do will inevitably have much greater influence on population health than what the minister of health does. The traditional public health approach to this problem has been to attempt to “turn the health services into public health services” and to attempt to persuade the health services to become interested in these broader issues. This is not surprising; given that most public health workers have initially trained in clinical medicine, and have continued to work within the health services, albeit in a different role after their conversion to the public health approach that focuses on prevention in populations rather than treatment of individuals.

However, I think it is time to reconsider this approach. It has rarely if ever worked, for the obvious reason that when public health attempts to influence the health services it is a very small tail trying to wag a very large dog, which wants to run in another direction. People working in the health services like to do what they were trained for, and generally do very well—that is, treating illness in individuals, and they usually have neither the time, the ability, or the resources, to deal with larger issues of prevention in populations. Their administrators also usually have more urgent priorities. As a result of this well meaning but naive attempt to transform the health services, public health has gone backwards internationally over the past two decades. It has continually lost out to the “conventional” health services in battles for resources, and it has had little influence on the important public health problems at the population level.

Perhaps it is time to seriously consider another approach—that is, establishing a ministry of public health. Public health services for individuals (for example, immunisation) would continue to be delivered through the ministry of health, and we would continue to attempt to transform the health services towards public health as much as this is possible. However, the ministry of public health would tackle the real public health issues at the population level. It would solely have a monitoring and advocacy role, not only with regards to routine monitoring of death rates, the population burden of disease, etc, but also with regards to monitoring and influencing the work of the other government departments and ministries (including the ministry of health). One way (but not the only way) to do this is through Health Impact Assessments of the possible health effects of different policy options proposed by the other government ministries and departments. Health Impact Assessment is not straightforward, but such quantitative estimates, however debatable and tentative, can play a key part in ensuring that health concerns are taken into account in economic and social policy.

If this approach were adopted, then the minister of health and the minister of public health would both clearly play an important part in government, but would require different skills. The first would need the skills required to run the health services (including public health services at the individual level). The second would require the skills needed to play a monitoring and advocacy part to ensure that the likely population health effects were taken into account in the work of all other government departments and ministries, including the ministry of health.