Interview: Pascal Strupler – Director General, Federal Office of Public Health (FOPH), Switzerland

p-strupler_08Pascal Strupler of the Federal Office of Public Health discusses the intricacies of the Swiss healthcare system, highlighting the importance of the NCD in health prevention, strategies for cost reduction, and his support for open dialogue between healthcare stakeholders in order to provide the public with an accessible and efficient system.

Switzerland has an unconventional structure in terms of its healthcare system with the Federal Office of Public Health under the Federal Office of Home Affairs. Could you give our international audience an introduction to the Federal Office of Public Health and its mandate?

[The Swiss healthcare] system works well and we have learned the importance of open communication, and discussing differences

We are a small country with seven ministers that each have numerous responsibilities. My minister is among others responsible for public health, social security, culture, statistics and gender equality. In the Federal Office of Public Health we employ approximately 600 people. Our main responsibility is to ensure a well-functioning health system. We have a very federalist political system, which is reflected in the way we function in the public health field. The majority of the responsibilities of the healthcare system belong to the cantons. They are responsible for healthcare delivery, which includes the functioning of the hospitals and for executing the laws that we draft. We are responsible primarily for regulating the health insurance system, developing federal laws and strategies to cope with major health challenges as well as controlling epidemics or other crisis situations in the health sector.

This system reflects Switzerland’s history and our culture. Of course it is not always easy to manage because we have 26 cantons that need in certain fields to align under a single policy. This system works well and we have learned the importance of open communication, and discussing differences. We have a national health dialogue that includes our minister and those politically responsible for the healthcare system in each canton. As director general of the office I meet with these committees regularly. Aside from a dialogue on the political level, we also have various platforms that work to overcome any challenges that a federalist system poses; this includes a platform where different stakeholders can discuss problems such as the education of general practitioners in Switzerland. We are also responsible for foreign health policy.

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Could you tell us more about representing Switzerland’s healthcare system on the international stage?

My minister and my office represent the official Swiss position on international fora and collaborate closely with other Departments in defining a coherent policy. One of these platforms certainly is the WHO with its headquarters in Geneva, which we consider the informal capital of health because of this fact and because other organizations within this field are also located there. We benefit from this situation and we try to build relationships each year during the World Health Assembly. We are not a member of the European Union, but we are invited twice a year to the informal health ministers’ meetings and participate in some of the expert networks. This is an occasion where we gain insight into the health issues that are debated at European level. An agreement on public health that would provide Switzerland with an access to some of the EU Health institutions, such as the European Centre for Disease Control and Prevention (ECDC), has been drafted, but we are still waiting for a political solution regarding the overarching bilateral relations with the Union in order to be able to finalize and sign it. We also meet frequently with the other German speaking countries to compare and contrast health systems. Additionally, each year I participate at the meeting of the symposium of the Commonwealth Fund in Washington. This is a very proactive and innovative fund of 14 countries that supported for example Obama’s healthcare policy. They publish a survey each year and hold a dialogue in DC where the countries come together. The OECD has created two reports on the Swiss health system, the last one being in 2013; an example of one of the ways in which we increase our global exposure. We have a well-functioning system and a great majority of the Swiss population has a positive opinion of the healthcare scheme. However, it is also an expensive system in which we invest 11 per cent of our GDP.

You became director general in 2010, what have been your main priorities during this time?

The problem, and a priority of mine, has been in managing the costs of the system. This is a continuous task, although we have made strides by outlining a strategy for prevention. Shortly after I became director general, a law in parliament concerning prevention was rejected. We are now finishing our NCD-strategy. This was an important task with a view of reducing costs to the system on the long run, and was certainly one of our main priorities.

From a broader perspective, each health system has similar challenges. The first is demographics, which includes the aging population. The fact that people are aging in a system is a sign of that system’s success; although it also means that we have more chronically ill people and more morbidity. The second challenge is in terms of an efficient use of healthcare infrastructure and technology, which is on a cantonal level. The third is regarding coordination and access to healthcare for everybody and its coordination.

Gesundheit 2020 was introduced in 2013 with the goal of preparing the health system for the costs ahead, while keeping it affordable. What have been the initial results?

We have more transparency, more people understand the complicated health system now and it has brought accountability to political entities. With this strategy we have set goals and we will be measured on these goals. This creates additional pressures, but I believe it is a system that must be under constant pressure due to diverging interests. Gesundheit 2020 has improved dialogue and visibility, and created a measurement system.

It was announced earlier this year that Switzerland will resume the benchmarking of drug costs with other countries by 2017. What is your view on the significance of this move?

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A number of years ago we had a system for reducing the costs of drugs, the goal being to check the prices of all drugs within three years and to reduce them if possible. We have reduced costs by CHF 600 (USD 623) million through comparing drug prices with a basket of nine countries and comparing the additional therapeutic value of the drug. This value is the incremental value the drug adds compared to what is currently on the market. Pharmaceutical companies have challenged us in court and we have therefore to adapt our legislation. This is the first challenge, litigating with pharmaceutical companies; the second challenge concerns new combined cancer therapies which may lead to unsustainable prices. Additionally, our generics cost twice as much as others in Europe. We have two strategies to bring the costs of generics down. The current price reduction strategy is that drugs that reach the end of their patent receive a price reduction that is calculated based on the volume of their past sales. This reduction will increase in the future. The second strategy is still being considered, which is to have the government fix a price for insurers to pay, and the rest to be paid out of pocket.

Switzerland is unique in that it is the first country to adopt a foreign health policy through the pioneering agreement on health foreign policy objectives. This was then built on by the 2012 Swiss foreign health policy. How has this pioneering work helped to enhance Switzerland’s role as a leader in the international arena?

The question itself shows the success of the policy. As you have mentioned, we are a leader. We are a small country and our stakeholders do not always agree, so it helps to bring internationally adopted ideas into the political discussion. But we also like to share our experience. For example, we have a policy on illegal drugs composed of four pillars: therapy, prevention, harm reduction, and repression. Many countries have copied this system, and we have international delegations come here to be informed about the system. On the other hand, we compare with the best in order to improve our system as well.

Do you think there are any areas that Switzerland could further work on to strengthen its presence internationally?

I try to be active on the international floor to do so, and the office also has an excellent ambassador who represents us internationally. She presents new ideas and has built a strong network. We also collaborate with developing countries to improve their healthcare systems and work together with the foreign ministry and its Development and Cooperation Agency to provide advice. Every strong country has a strong health system and we see this as a crucial element for developing countries.

Looking forward over the next five to ten years, what are the most important objectives that you would like to achieve for the Office of Public Health?

I would like to reiterate the importance of increasing the efficiency of the system and thus to reduce the cost, which is crucial

I would like to reiterate the importance of increasing the efficiency of the system and thus to reduce the cost, which is crucial. Even though people are very satisfied with the current system, each year costs rise which leads to the mandatory insurance premium rising. Even though the system is good, the pressure is growing on the lower income bracket. Another important focus is the NCD strategy. Currently, when compared to other European countries, we have a lower percentage of GDP invested in prevention. Of course, quality is very important in terms of delivering healthcare and we want to promote programs such as safer surgeries, drug safety, and transmit information about the patient needs. We will also run into a lack of health personnel in a decade. We have therefore entered into an intense dialogue with the cantons to increase the number of medical practitioners and nursing personnel since the field of education is a cantonal competence. The efforts are visible but not yet sufficient. The last point that I would like to underscore is the electronic patient record which will hopefully, among others, strengthen the efficiency of healthcare.

Is there any final message that you would like to leave our international audience with?

We have a strong pharmaceutical industry and a well-functioning system. It is expensive, and we are working towards cost reduction, but we will do our best to avoid rationing. We want all people to have access to healthcare and we hope to have a fruitful collaboration with the pharmaceutical industry towards this goal.

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