Healthcare system & Market
Switzerland is a small Alpine country, with a population of about 8.1 million people and four official languages (German, French, Italian and Romansh). Switzerland has a highly decentralized administrative and political structure, organized around three levels of government: the federal level (the “Confederation”), 26 cantons and 2352 municipalities. The country has a unique political system, arguably the closest in the world to a direct democracy with almost all issues of importance being decided upon through public referendum. Switzerland is a wealthy country; its GDP per head is among the highest in Europe, and indeed the world.
Like many western European countries, Switzerland faces an ageing population, with the ratio of older people to people of working age having risen to 26.1 per 100 (although this is still below the EU average of 28.1). Both life expectancy and healthy life expectancy are among the highest in Europe and well above the averages for the EU.
Organisation and governance
The Swiss health system is highly complex, combining aspects of managed competition and “corporatism” (the integration of interest groups in the policy process) in a decentralized regulatory framework shaped by the influences of direct democracy.
This explains the sharing (and some would say fragmentation) of decision-making powers between:
- the three different levels of government (the federal level, the cantons, and for social services the municipalities);
- recognised civil society organizations (“corporatist bodies”), such as associations of health insurers and health care providers; and
- the Swiss people, who can veto or demand reform through public referenda.
The federal setup of the country gives all power to the cantons except in
areas where the constitution has explicitly assigned competences to the federal level. Historically, the federal level had very little legislative power in the area of health. This led to the emergence of different patterns of financing and health care provision across the country. Today, as the result of a slow but steady process of greater centralization over recent decades, the federal level plays an important role in regulating most areas of the health system, including:
- the financing of the system (mandatory health insurance (MHI) and other social insurances);
- the quality and safety of pharmaceuticals and medical devices;
- public health (control of infectious diseases, food safety, some areas of health promotion); and
- research and training (tertiary education, training of non-physician health professionals).
Switzerland ensures access to health care through a system of MHI, which has been compulsory for all residents since 1996 (although some cantons had compulsory insurance as early as 1914). Citizens who want to purchase MHI cannot be turned down by insurers, and cantons provide subsidies for people on low incomes (although the nature and level of these vary widely by canton). The standard benefits package is regulated by federal legislation and includes most general practitioner (GP) and specialist services, as well as inpatient care and services provided by other health professionals if prescribed by a physician.
Cantons are responsible for securing health care provision for their populations, although they may also include hospitals from other cantons on their lists of providers, and they finance about half of inpatient care. Cantons are also in charge of issuing and implementing a large proportion of health-related legislation, and they carry out prevention and health promotion activities. In order to coordinate their activities, in particular for highly specialized medical care, the cantons work together in the Conference of the Cantonal Ministers of Public Health (GDK/CDS).
Corporatist actors, in particular associations of MHI companies and providers (associations of physicians and hospitals) play an important role in the Swiss health system. They are charged with determining tariffs for the reimbursement of services, they negotiate contracts and they oversee their members at the cantonal level.
Popular initiatives and referenda have a pervasive influence in shaping health policy-making. Certain reforms of the health care system require a positive referendum by the Swiss population, in particular when concerning the reallocation of responsibilities between the three levels of governance. In addition, popular initiatives often drive legislative activity, responding to citizens’ demands for change.
In 2013, total health expenditure (THE) in Switzerland was 11.5% of GDP, one of the highest shares in Europe.
Financial flows are fragmented and split between different government levels and different social insurance schemes. Resources are collected mostly through taxes (32.4% of THE in 2012) and MHI premiums (30.0% of THE) but a considerable part of tax resources are subsequently allocated to the different social insurance schemes, in particular as subsidies to lower- and lower middle- income households for the purchase of MHI. As a result of this reallocation, MHI companies are the largest purchasers and payers in the system, financing 35.8% of THE. The next largest components are out-of-pocket (OOP) payments, amounting to 26.0% of THE, and government spending (mostly from the cantons) covering 20.3% of THE.
WHO Switzerland healthcare review
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