• health reform
• minister of health

In his effort to escape from the individualising and particularising approach of German historicism,¹ Max Weber developed a key conceptual tool, the notion of the ideal type. An ideal type is an analytical construct that serves the investigator as a measuring rod to ascertain similarities as well as deviations in concrete cases. What are the similarities and deviations from “ideal type of health minister” among ministers of health around the globe? And what would be an ideal minister of health in the 21st century? Perhaps the minister should be validated against the following objectives: stewardship, loyalty, authority, efficiency.

The question is to whom the “ideal” minister of health should direct his stewardship? “Stewardship is about vision, intelligence, and influence” is probably the most strategic sentence of the WHO World Health Report 2000.² If the minister of health would like to act as a “good steward” responsive to the citizens and their needs she should concentrate on three substantial health issues: overuse, underuse, and misuse of health services. In many countries, both developed and developing interventions that are of little value are commonly overused; care that is effective is commonly underused; and care that is of unproved value is frequently misused.³ More diagnosis creates the potential for labelling and detection of pseudodisease—disease that would never become apparent to patients during their lifetime without testing. Survival rates after acute conditions like acute myocardial infarction (heart attacks), stroke, and gastrointestinal bleeding were not correlated with more intensive healthcare spending.^4,5 Overuse of antibiotics increases the chance that bacteria can breed new strains able to survive the drug onslaught, rendering it ineffective. Paradoxically 30% of the world lacks access to essential antibiotics like penicillin or chloramphenicol, but at the same time, in the United States and Canada, 50% of outpatient prescriptions for antibiotics are unnecessary.⁶ Underuse refers to the failure to apply, when indicated, treatments that have been shown to be effective in medical care. In developing countries underuse because of poor access to services is overwhelmingly the most severe problem, followed by misuse. The South African HIV story is good example of divided loyalty. The minister has to decide where to direct his loyalty and accountability: international regulations, financial interest of the national treasury, pharmaceutical industry, or health needs of the citizens. Approximately 200 HIV positive babies are born each day in South Africa, and use of nevirapine can reduce mother to child transmissions by half. Some doctors illegally prescribe nevirapine to pregnant women. Finally, the Treatment Access Campaign (TAC) won a lawsuit against the South African minister of health, Manto Tshabalala-Msimang, and nine provincial health ministers, forcing the government to provide nevirapine through the public health sector for the prevention of mother to child transmission of HIV.⁷

Facing both political and professional challenges the minister of health should not try to act as a standard charismatic 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 on the appeal of the medical profession that claim allegiance because of their extraordinary virtuosity resulting in internists, surgeons, radiologists, psychiatrist, and microbiologists’ minds at the post of health ministers without strong public health action. “My successor will be a pathologist” pointed out by the Croatian minister of health, Andro Vlahušić. Authority of the health minister should not arise from such “professional” background but rather from public health advocacy and responsiveness to the citizens health needs. She should apply theory of modern public administration assuming that the authority to order certain matters by decree does not entitle the ministers to regulate the matter by commands having the reputation of the most bureaucratic and least effectively managed institutions in the public sector.⁸ Effective and efficient health policy should be guided by priorities, objectives, processes, and outcomes. This stands in extreme contrast with the regulation of all relations through individual privileges and bestowals of favour*, absolutely dominant in a political and professional health patrimonialism.⁹