21.02.2019 “We are already holding the instrument in our hands”
In an age when healthcare costs are rising and the number of people with chronic diseases is growing, Switzerland is trying to reverse the trend by adopting a Health in All Policies (HiAP) approach. Ilona Kickbusch is one of the world’s foremost experts in the field. As part of this interview, she tells us what Switzerland could do better.
Could you start by telling us what the term Health in All Policies means to you?
Health in All Policies isn’t always about the big political strategies. The Ottawa Charter for Health Promotion says that health starts in people’s everyday lives. It’s not just the big things that are important, but also the small improvements we can make to everyday life – say banning sales of cola in schools or introducing an extra PE lesson each week. If everyone in Switzerland were to take half an hour’s walk every day, the overall effect would be colossal. In other words, we’re talking about a small change in a large population.
And what would the result be at national level?
HiAP is primarily people-driven because we all have a right to health. Money plays a secondary role. HiAP not only saves money, it also does society as a whole a favour because one of the consequences of effective HiAP is reduced social assistance costs. Ultimately, a healthy population saves the state – and by extension all of us – a lot of expense.
How healthy is Switzerland?
The country has one of the healthiest populations in the world. Nevertheless, the costs caused by chronic diseases are constantly rising. This is obviously linked to demographics too, because Switzerland has one of the highest life expectancies in the world. Nowadays most people are staying healthy for longer, and they simply start to develop chronic diseases later. We cannot assume that everyone will have no need of healthcare services until they get very old. I’ve been fortunate so far, but no one knows what the future will bring.
What happens when people do need healthcare services?
We need to rethink our approach to elderly people. There is a lot of talk about integrating migrants, yet while that’s going on we are building a parallel society of the elderly. There are old people’s homes, senior citizens’ meetings, pensioners’ dances and lots more. My mother always used to say, “I’m not going, it’s all old people there”, even though she was elderly herself, and that statement sums up the situation perfectly. We need to organise our society in such a way that the growing number of senior citizens can take an active part in life. That also means new forms of accommodation for the elderly. The more old people are embedded in society, the less they will spend their time sitting in doctors’ waiting rooms.
What is the situation as regards HiAP in Switzerland?
There’s a lot of discussion about it, but as yet no political impetus for it at national level. Multisectoral health policy therefore has an extremely important role to play at regional and local level. In my view, investigating exactly what impact HiAP is having at cantonal level would be a worthwhile research activity. The people in charge do not always realise that they are also helping to improve people’s health when they build a bypass, for example. This is in contrast to the local residents, who generally become aware of the fact very quickly because they benefit almost immediately. Let’s take another example. Climate goals are environmental goals and therefore relevant to health.
In what areas has HiAP been most successful so far?
Excellent cooperation has evolved in certain areas. One good example is the nationwide Strategy on Antibiotic Resistance, where experts in human and veterinary medicine are working with environmental and agricultural specialists. The same goes for Switzerland’s health-related foreign policy. Switzerland was the first country to come up with this type of policy.
Where is there still a particularly large amount to do?
We are only slowly beginning to get a better understanding of mental illness and its consequences for the people affected, their environment and society. For example, how people organise their work when they also have family commitments, what the effects of always being available are and the general pressure to achieve that is part of our fast-moving society. WHO Director-General Tedros Adhanom Ghebreyesus and pop star Lady Gaga, who suffers from depression herself, recently published a joint statement urging people to help break down the stigma that goes with such conditions. This kind of thing is obviously great because the stigmatisation of certain diseases is a major problem. I can still remember the days when even cancer was stigmatised and a taboo subject.
What other problems are there?
Work pressure is a major issue. The question here is how to organise the way people work so that fewer of them experience depression or burnout, or have a heart attack. We need to think about how we can structure society so that the pressure is spread more evenly throughout people’s lives, something that should make it more bearable. But pressure is not just something we are exposed to at work or school. It happens on social media too and affects children and young people in particular. Obviously, there was bullying when I was young, but it tended to stay in the school playground. Nowadays, with social media, it can assume completely different dimensions. We are seeing a shift in the policy fields addressed by HiAP. Where we once used to focus primarily on work, income or living space, we now have to think about how we can monitor the Internet more effectively, for example, because online harassment, intimidation or extortion are major problems that can cause depression and anxiety in victims.
So, from what you say, the Internet and social media are also an area for HiAP?
Definitely. That being said, there are obviously many beneficial sides to modern technology. For example, my son lives in Berlin, while I live in Bern and travel a lot. There’s nothing nicer than sending each other photos by WhatsApp so that we can share a bit of our lives with someone else.
How firmly established is HiAP at international level?
There’s a very strong international awareness of the need for multisectoral working. In fact, no country can afford not to adopt HiAP. The poorer a country is, the more indispensable HiAP becomes. In poorer countries, efforts focus on providing good schools and basic healthcare. After that, economic growth is important to create jobs. The state should therefore view healthcare systems as an employer in their own right. Above all, healthcare systems need nursing staff – who are mainly women. We know that these women generally spend the money they earn more responsibly than men. Women tend to buy food, clothing and medicines, or pay their children’s school fees – all things that are beneficial to family health.
How important is international collaboration?
Very important. It’s impossible to view HiAP in isolation. We can learn from each other, and that’s a huge opportunity. We need joined-up thinking because it’s a globalised world. Switzerland has a major responsibility here by virtue of its highly international nature.
Where does HiAP fall down at a day-to-day level?
When people start going it alone. It’s difficult to get people to work together.
Prof. Ilona Kickbusch is a political scientist who grew up in Munich and Chennai, India, where her father worked as a diplomat. From 1981 to 1988 she worked for the World Health Organization (WHO), where she was responsible, among other things, for the Ottawa Charter for Health Promotion. From 1998 to 2004 she was a professor at Yale University. That same year she set up her own consulting practice, since when she has acted as an independent consultant to organisations, governments and the WHO. She has been a visiting professor at the Universities of Tokyo, St. Gallen and Vienna, is a member of several scientific advisory boards and has been director of the Global Health Centre at the Graduate Institute of International and Development Studies in Geneva since 2008.