Swiss Conference of the Cantonal Ministers of Public Health

There is a great need for coordination between cantons with regard to public health, not least in times of cross-border health crises. A conference of health authorities was called into being in 1919 during the Spanish flu epidemic; in 2004 it was renamed the Conference of the Cantonal Ministers of Public Health. The aim of this Conference is to ensure an exchange of information between the cantons, the national government, and key organizations in the health care sector.

The 1919 health authorities’ conference (SDK) emerged in response to the Spanish flu outbreak in Switzerland, its goal to expand the medical system and coordinate cantonal efforts in fighting epidemics. A modern public health authority did not yet exist in many cantons; the city cantons acted as pioneers and gave the impetus for establishing the SDK. Fritz Aemmer (1867-1934), city councillor and head of the health department of the canton of Basel-Stadt and himself a physician, was a key figure. The founding meeting of the SDK in August of 1919 was attended by 16 governing councillors who were responsible for health policy in their respective cantons; by 1921, all the cantons were represented. Until 1934, plenary meetings of the councillors were held once or twice a year. The topics to be discussed were prepared by Aemmer and a managing board. Through the participation of external experts, a basis of common knowledge was developed; the smaller cantons in particular benefited from this.

This SDK saw itself as a federalist instrument representing the interests of the cantons vis-à-vis the national government. At the same time, it wanted to facilitate joint action by the cantons, and did help bring about a regular exchange of views between cantons, federal offices, and various specialized agencies on health care matters. SDK decisions were not binding but were more in the manner of recommendations; by 1978, the SDK had a permanent secretariat.

The primary goal of the SDK was to co-ordinate health policies on a cantonal level enabling the authorities to provide adequate care. For this purpose, the cantonal appointment of physicians officially responsible for public health was important. The role of such public health physicians included making sure mechanisms to monitor physicians were in place as well as to implement important sanitary measures in cantons and cities. The SDK also sought to better regulate non-academic health professions. Another focus lay in combating infectious diseases such as tuberculosis. The SDK as a result advocated creating a federal law to combat tuberculosis and actively participated in drafting the tuberculosis law that was passed in 1928.

In the interwar period, the SDK was concerned about fighting “widely prevalent” diseases, including goiter, cancer, alcoholism, and venereal diseases. Measures to reduce infant mortality were intensely discussed as well. To curb infectious diseases, cantons took hygienic measures that were usually implemented at the municipal level. These included improving the supply of potable water, residential and commercial hygiene, food inspection, and waste disposal. In addition to the SDK, private organizations which had banded together in national health leagues also worked to combat disease. In the context of social hygiene, an awareness began to emerge of how important social factors, including dietary or drinking habits, were in the development and spread of illnesses. As a result, preventative health care increased in importance.

In 1949, a law on combatting the spread of tuberculosis was rejected in a popular referendum, as it would have included mandatory health insurance for those with low incomes. In the meanwhile, it had also become easier to control tuberculosis through protective vaccination and antibiotics, so the fight against this disease became less important to the SDK during the 1950s.

During the economic boom and population growth of the post-war period, both cantons and towns massively expanded their hospitals. This led to an increasing shortage of health care personnel, prompting the SDK to become involved in trying to find solutions by suggesting appropriate training policies for staffing the health care sector. In doing so, they drew on the expertise of Lydia Leemann (1885-1979), who had called for better legal protection for those in the health care and nursing professions, as well as improvements in their working conditions. After the Second World War, cantonal public health ministers lobbied to adapt nursing and health care occupational training to be in accord with Swiss Red Cross guidelines. They also recommended limiting the workweek to 60 hours. This was implemented by the Federal Council in 1947 in the standard employment contract for this sector, but a shortage of nursing and health care staff nevertheless remained a problem.

Hospital expansion remained uncoordinated into the 1960s, with barely any joint or cross-cantonal planning, and it would only be as a result of growing criticism of rising costs in the health care sector that planning issues gained in importance by the later 1960s.

The Swiss Hospital Association (VESKA; called H+ Swiss Hospitals since 1996) suggested the cooperation between national government and cantons in hospital planning should be improved, and this led to founding the Swiss Hospital Institute (SKI) in 1972, in which the national government, the cantons, and more specialized agencies worked together. The SDK supported VESKA in bringing the SKI to life, as the cantonal public health ministers viewed the cost explosion within the hospital sector with concern and felt better inter-cantonal coordination was indispensable. The SKI existed until the early 1990s. It formulated quality standards in the health care system and monitored the economic efficiency of the health care being provided; the SDK also worked closely with it in hospital planning. The SDK took a lead role in coordinating cutting-edge medicine inter-cantonally and drafted a corresponding agreement on highly specialized medicine that all cantons had signed by 2008.

The collaboration between SDK, VESKA and the Swiss Red Cross involved making arrangements for health care occupational training. Since the 1960s, various measures had been introduced to develop new occupational categories and improve the recruitment of health care personnel. However, they did not always have the desired effects, and personnel shortages remained a persistent problem in this sector. In the 1990s, the cantons ceded their regulatory authority over health care and nursing professions to the national government.

Rising health care costs prompted the SDK already in the 1960s to look more closely at approaches being used in social and preventive medicine. On SDK recommendation, the cantons, for example, introduced fluoridated table salt as a tooth decay prophylaxis. Institutionalized relations between the SDK and the World Health Organization further raised awareness of issues surrounding the promotion of health. On the initiative of the Federal Council, efforts were made in the early 1980s to pass a Prevention Act, but the cantons successfully resisted what they perceived as an effort to centralize health promotion. Instead, working with the health insurance funds, they created the Swiss Foundation for Health Promotion, which took up its work in 1989.

In the 1990s, the SDK supported the complete revision of the Health Insurance Act, one which would ultimately become law at the outset of 1996. It fundamentally altered the responsibilities of national and cantonal governments, and the communication between them – and thus also the role of the SDK – became more important. By the end of the 1990s, the two jointly launched the National Health Policy Project, which served as an instrument in coordinating health care, and by 2003, it was working under the name "National Health Policy Dialogue". Measures to rein in costs have remained a central concern for all parties, with the SDK becoming increasingly focused on holding to the international standards defined by the World Health Organization.

In 2004, the SDK changed its name to the Swiss Conference of the Cantonal Ministers of Public Health (GDK); it has continued to play a pivotal role as liaison between national and cantonal governments. For example, the cantons agreed on jointly formulated hospital planning recommendations within the framework of the GDK 2018. The GDK has supported digitalization in the health care sector as well, overseeing the introduction of electronic patient records in hospitals and promoting cantonal commitment to this transformation. The GDK also played an important role in the 2020/21 Covid 19 crisis, issuing recommendations to the cantons on how to combat the pandemic and advocating a coordinated approach to the implementation of measures against Covid 19.

Literatur / Bibliographie / Bibliografia / References: GDK (18.09.2020), Coronavirus: Neue Empfehlungen für besonders betroffene Kantone, o. O. Online: https://www.gdk-cds.ch/de/die-gdk/medienmitteilungen/detail/coronavirus-neue-empfehlungen-fuer-besonders-betroffene-kantone, Stand: 26.03.2021; GDK (Hg.) (2019), 100 Jahre 1919-2019, Bern. Online: https://www.gdk-cds.ch/fileadmin/docs/public/gdk/gdk/Jubila__umsbroschu__re-DE-Web.pdf, Stand: 05.02.2021; GDK (2019), Jahresbericht 2019. Online: https://www.gdk-cds.ch/fileadmin/docs/public/gdk/gdk/jahresberichte/GDK_DE_Jahresbericht-2019-Web.pdf, Stand: 26.03.2021; HLS: Fritz Aemmer, Lydia Leemann; O. A. (o.D.), GDK-CDS Porträt, o. O. Online:  https://www.gdk-cds.ch/de/die-gdk/portraet, Stand: 05.02.2021; SDK (1994), 75 Jahre SDK. Notizen zur Geschichte der Schweizerischen Sanitätsdirektorenkonferenz, Bern; SDK (1997), Jahresbericht 1997. Online: https://www.gdk-cds.ch/fileadmin/docs/public/gdk/gdk/jahresberichte/Jahresbericht_1997_df.pdf, Stand: 05.02.2021; SDK (2000), Jahresbericht 2000. Online: https://www.gdk-cds.ch/fileadmin/docs/public/gdk/gdk/jahresberichte/Jahresbericht_2000_df.pdf, Stand: 05.02.2021.