A solution for creating competent health-care specialists: the Swiss School of Public Health+
Ursula A Ackermann-Liebrich a, Sandra Nocera a, Sonja Merten a
The Swiss health-care system (the second most expensive worldwide) is fragmented into 26 cantonal authorities for a population of 7.5 million. Cantons differ in policy, legislation and structure. Health insurance is compulsory although contributions vary greatly between cantons. A recent report by the Organisation for Economic Co-operation and Development (OECD) pointed out that weak governance has led to a system in which “efficiency can be improved”, “a broader legal framework for health promotion and disease prevention is overdue” and “equity is not guaranteed”.1 To a certain extent, this situation is due to the scarcity of specialists who know how to judge and respond to health needs and who also understand the complexities of financial flows and the effect of policy interventions in complex systems. As in most countries, health economics and public health have developed independent training programmes, mostly without any coordination or cooperation. Health services therefore are often managed by lawyers or business economists who apply free-market instruments to this regulated system. In the Swiss context, this leads to ever-increasing costs and inequalities without evaluation of potential health gains.2,3
A new solution
The Swiss government and six major universities proposed a new initiative to respond to this situation. In July 2005, the Universities of Basel, Bern, Geneva, Lausanne, Lugano and Zurich signed an agreement of cooperation for the creation of the Swiss School of Public Health+ (SSPH+; Fig. 1). The purpose of the SSPH+ is to coordinate and improve the existing postgraduate training programmes in public health and health economics and to stimulate the creation of new collaborative programmes (Table 1). The “+” in the name symbolizes the strong emphasis on collaboration between the two fields, promising to open new possibilities for training professionals competent in both public health and health economics.
The SSPH+ has stimulated close collaboration between the leaders of its different programmes through regular exchange and discussions. The following objectives have been launched so far:
Due to the European Bologna Reform, Swiss universities have introduced a two-step study system offering bachelor’s and master’s degrees. The medical faculties are adapting to this process by reorganizing their study programmes. Public health, which today can only be studied at the post-master’s level, might become a discipline at the master’s level, which will then lead directly to the doctoral level. In this context, doctoral programmes have become particularly important. In order to provide a high-quality public health education, it is crucial that public health research at an internationally compatible level is firmly consolidated in Switzerland itself, otherwise the limited training and career opportunities will lead to a brain drain of the best-qualified teachers. Internationally recognized doctoral training offered by Swiss universities through SSPH+ is indispensable. PhD training opportunities in public health complement the Master of Advanced Studies (MAS) programmes, such as Master of Public Health or Health Economics, which are not primarily research-oriented. They offer thorough scientific competencies at the highest level and are partly engaged in international collaboration. The national collaborations between universities and disciplines in the SSPH+ also allow students to obtain a broad and transdisciplinary vision of public health. In combination with thorough research experience, this is certainly a desirable asset for managers of our health services.
Nevertheless, the need for interdisciplinary training of experienced professionals from different fields, who want to change professional orientation and thus need further advanced studies, will still create a demand for MAS programmes. These programmes should be more integrative between health economics and public health because future leaders of our health services need both competences. The tendency to have managerial training without respecting the field in which it will be applied should be discouraged in health care.
Our hypothesis is that the training of health professionals with competencies in health economics and in public health will eventually make a difference to the organization of the Swiss health-care system. When postgraduate training in public health and health economics started in the 1990s, three or four cantonal physicians (who act as medical advisors to the government and are responsible for health surveillance in the canton) had a degree in either of the two specialities. This is reflected in the cantonal public health politics and planning. Until recently, only a few cantons had a binding policy addressing prevention and health promotion; they were notably those with a close collaboration with university institutes of social and preventive medicine. In the 1980s, a proposed national law on health protection and prevention was turned down by the cantons, mainly on the advice of cantonal physicians who feared intervention by national authorities.
By 2007, the number of cantonal physicians with postgraduate qualifications in public health and health economics had increased to about 30%. The same is true for professionals in cantonal health departments, where we now find employees with a degree in public health working directly with a cantonal physician in at least five cantons. Does this have an impact on population health?
The cantons that employed competent persons for health promotion certainly have developed better programmes and increased government awareness of population needs. The first canton with such a person was St Gallen, followed by Ticino and Aargau. In the French- and Italian-speaking areas, there are now organized programmes for breast cancer screening, resulting in decreasing breast cancer mortality rates when compared to the cantons without screening.4 St Gallen will be the first canton to introduce it in the German-speaking part in 2008.
Cantons with competent advisors (16 out of 26 cantons) were able to increase the national sample of the Swiss health interview survey to produce a report for their respective populations.5 It is not by chance that Vaud was the first canton to introduce Diagnosis Related Groups (DRG) for financing of hospitals.6 There is close collaboration between the leading Institute of Health Economics and the Institute for Social and Preventive Medicine (the public health institute in the medical faculty), both located at Lausanne University in Vaud. DRG is a system that allows comparisons between caseloads of different hospitals and thus provides the means to limit or even control excessive costs. This system will now be introduced in all cantons. At the national level, a new law on health promotion and prevention is now under discussion without resistance from the cantons.
Evaluating the impact of training on the changes in health services ought to be a subject for research within our doctoral programmes and could well be developed with international collaboration. ■
- OECD reviews of health systems - Switzerland. Organisation for Economic Co-operation and Development (OEDC) and WHO; 2006 (ISBN: 92-64-02582-0).
- World health report 2004: changing history. Geneva: WHO; 2004 (ISBN-13: 978-9241562652).
- Spoerri A, Zwahlen M, Egger M, Gutzwiller F, Minder C, Bopp M. Educational inequalities in life expectancies in German-speaking part of Switzerland 1990-1997. Swiss Med Wkly 2006; 136: 145-8.
- Bulliard JL, La Vecchia C, Levi F. Diverging trends in breast cancer mortality within Switzerland. Ann Oncol 2006; 17: 57-9.
- Calmonte R, Galatai-Petrecca M, Lieberherr R, Neuhaus M, Kahlmeier S. Gesundheit und Gesundheitsverhalten in der Schweiz 1992-2002 [Swiss Health Interview survey]. Bundesamt für Statistik: Neuchâtel; 2005 (ISBN: 3-303-14090-1).
- Ruffieux C, Marazzi A, Paccaud F. Exploring models for the length of stay distribution. Soz Praventivmed 1993; 38: 77-82.
- Swiss School of Public Health+, Stampfenbachstr. 63, 8006 Zurich, Switzerland.