5. Provision of services
esponsibilities for legislation, implementation and supervision of public health services are split between the Confederation and the cantons. Consequently, public health activities are not well coordinated and provided services vary greatly across cantons. Expenditure on public health is relatively low (2.1% of THE in 2012). The new EpG/LEp, which will come into force in 2016, aims to better define responsibilities of the Confederation and the cantons, and to better coordinate activities of the different levels. A proposed Federal Prevention Law was rejected by Parliament in 2012.
Ambulatory care is provided mostly by self-employed physicians working in independent single practices offering both primary care and specialized care. In general, patients have a very large degree of freedom concerning choice of physician and hospital. Easy access to all levels of care, including inpatient care, without need for a referral has been a key characteristic of the Swiss health care system. However, over the past decade, an increasingly large proportion of physicians have joined physician networks or HMOs, which contract with insurers for the provision of care for their insured. In 2012, about 20.8% of all insured were estimated to be insured by either an HMO plan or a physician network plan (excluding simple list models), where patients benefit from more actively managed care.
Acute care hospitals provide inpatient care and play an increasingly important role in the provision of ambulatory and day care services. Public and private hospitals that are included on cantonal hospital lists can provide services reimbursable by MHI. Traditionally, choice of hospital was somewhat restricted by cantonal borders. However, since the implementation of a hospital financing reform in 2012, patients can choose any hospital located outside their canton of residence as long as the hospital is included on the hospital list of the canton of treatment. Nevertheless, reimbursement follows the rules of the canton of residence, which means that it is limited to the level of costs that would have had to be paid if the patient had been treated in his canton of residence.
Cantons are responsible for the organization of long-term care, rehabilitation care, palliative care and psychiatric care but may delegate responsibility to municipalities. Institutional (residential) long-term care is provided by medical nursing homes or nursing departments of old-age or disability homes, while home care nursing services are provided by so-called Spitex services. In addition, informal carers play an important role, carrying a considerable part of the total care burden. Better integration of care across different institutions and providers has been under discussion for some years, especially for mental health care activities but progress in this direction remains limited.
Expenditure on pharmaceuticals in Switzerland in 2012 were US$ PPP 562 per capita, which was below the amounts spent in Germany or France. Considerable efforts have been made in recent years to reduce the relatively high retail prices in Switzerland and to increase the use of generics. The market share of generics as a proportion of all reimbursed pharmaceuticals in terms of volume rose from 6.1% in the year 2000 to 23.9% in 2013 but remains far below the share of generics in other countries, such as Germany (78.2% in 2012) or Austria (48.5% in 2012). A particularity is that pharmaceuticals are not only distributed by pharmacies but – in some cantons – also by so-called self-dispensing doctors, who sell about 24% of all pharmaceuticals sold in Switzerland (in terms of value) in their in-practice pharmacies.
5.1 Public health
Public health in Switzerland continues to be characterized by a fragmentation of responsibility for legislation, implementation and supervision of activities. The main national institution responsible for public health is the FOPH. However, according to the constitutional division of powers, the federal level is responsible only for framework legislation in the areas of hygiene and health protection, including food safety, infectious disease and malignancy prevention, drug control and radiation protection. There is no legal basis for the federal level to become active in other areas, such as psychiatric, metabolic, cardiovascular or respiratory diseases. Environmental health falls under the remit of the Federal Office of the Environment and the Federal Office for Spatial Development (Perritaz, 2010).
Expenditure on public health in Switzerland is relatively low (2.1% of THE in 2012 according to OECD Health (2014) and 1.3% of THE according to national statistics; see section 3.2) and the proportion of THE spent on public health has declined over recent years. The main activities of the FOPH are concentrated on programmes to combat HIV/AIDS, to reduce alcohol, tobacco and drug consumption, and to promote healthy nutrition and physical activity (OECD/WHO, 2011) (see Table5.1).
The cantons are responsible for implementation of public health strategies, and they usually run their own public health services and have public health offices run by the Chief Medical Officer of the Canton, the so-called cantonal physicians (Kantonsärzte). Consequently, the implementation of public health programmes as well as the specific public health services available at the cantonal level differs greatly across cantons (FOPH, 2007a). The cantonal physicians, pharmacists and chemists take up leading roles in public health within the cantons and they all have their own associations. The cantonal doctors (also called cantonal officers of health) take part in infectious disease control, the issuing of professional licences, regulation of emergency and rescue services and several other tasks (VKS, 2013). The Association of Cantonal Officers of Health (VKS/AMCS) aims to coordinate activities of cantonal doctors across Switzerland, e.g. in infectious disease control and reporting. Cantonal pharmacists oversee the adherence to pharmaceutical regulations, while cantonal chemists are responsible for food safety and consumer protection (KAV, 2013; VKCS, 2013).
In 2009, a new law on prevention was drafted to create a legal basis for better coordination of disease prevention and health promotion activities but it was ultimately rejected by Parliament in 2012 (see section 6.1.4). Nevertheless, coordination of prevention activities is starting to improve as a result of intensified collaboration under the umbrella of the National Dialogue on Health Policy (see section 2.3).
One important platform aimed at coordinating efforts in disease prevention and health promotion is the Swiss Association of Cantonal Chiefs for Health Promotion (VBGF/ARPS) (OECD/WHO, 2011), which is part of the GDK/CDS (see section 2.3) and includes as so-called permanent guests the FOPH, the GDK/CDS, the Swiss Foundation for Health Promotion, Public Health Switzerland (a research focused on public health network), RADIX Swiss Health Foundation (a foundation financed mainly by cantons aiming to promote health at the municipal level) and the Network Mental Health Switzerland.
5.1.1 Infectious disease control and reporting of diseases
The control of communicable diseases is currently regulated by the 1970 Federal Epidemics Law, which is still valid until the new EpG/LEp comes into force, probably in 2016 (see section 6.1.4). The federal government is mainly responsible for the national mandatory reporting and information system, as well as for supervision and coordination of activities. Cantons are responsible for the implementation of communicable disease control measures and activities are overseen by the cantonal physicians.
Article 27 of the Epidemics Law (Swiss Confederation, 1970) specifies an obligation to report certain communicable diseases. The FOPH publishes a list of relevant diseases and regularly updates this list in collaboration with cantonal doctors and medical associations (Minder, Schoenholzer & Amiet, 2000). The obligation to report applies to both doctors and laboratories, which have to report to their cantonal physicians (see Fig5.1). The cantonal physicians then forward the information to the FOPH, which publishes case numbers for each disease on a weekly basis (FOPH, 2013g).
In addition to the compulsory reporting system, a voluntary sentinel network – “Sentinella” – exists. This serves to monitor, in particular, those diseases that could be prevented by immunization, with the aim of supporting research. Around 3% of GPs and paediatricians participate voluntarily in the data collection. Programme details are revised annually by an expert commission.
5.1.2 Occupational health
The legal framework for occupational health services is the Ordinance on Prevention of Accidents and Occupational Diseases of 1983 (VUV/OPA). Surveillance of compliance with the regulation is ensured by SUVA, and cantonal and confederate inspectorates, which are financed by UV/AA contributions (FOPH, 2013k). Responsibility for implementation and financing of occupational health services lies with employers (Schwaninger, Krieger & Graf, 2010).
The RADIX Swiss Health Foundation and SUVA offer courses for occupational health specialists within companies (Ruckstuhl, 2010). The SUVA also initiated the project Progrès to counteract a rising number of diseases associated with professional roles. Elements of the project are, amongst others, stress reduction strategies and the promotion of physical activity in the workplace (SUVA, 2013). Providers of occupational health promotion services and some companies are part of the Swiss Association of Occupational Health Promotion (SVBGF, also known as BGM Netzwerk).
Promotion of occupational health is also one of the main concerns of the Swiss Foundation for Health Promotion. The foundation develops standards and certificates for occupational health, promotes guidelines and carries out research on economic implications of occupational health (Gesundheitsförderung Schweiz, 2015). There is also an agency within the SECO promoting occupational health (Ruckstuhl, 2010).
5.1.3 Health promotion
A wide variety of state and non-state institutions and organizations are active in health, including the federal government, cantons, health insurers, SUVA and foundations. One of the main actors in health promotion is the Swiss Foundation for Health Promotion, which is financed through compulsory contributions by the insured. Besides occupational health, the foundation focuses on promoting healthy body weight and promoting health promotion, e.g. development of standards, participation in national and international networks.
Tobacco control policies are relatively weak in Switzerland, when compared with other European countries: tobacco taxes are relatively low, there are cantonal variations in the protection of people against passive smoking, and regulations controlling tobacco advertising are insufficient (Joossens & Raw, 2014; FOPH, 2012e). Switzerland has still not ratified WHO’s Framework Convention on Tobacco Control (WHO, 2014). Tobacco consumption remains relatively high in Switzerland, when compared to several other European countries, for which data are available (OECD Health, 2014).
5.1.4 Prevention (vaccination and screening)
There is no national immunization programme, and cantonal programmes may differ considerably, for example concerning the availability of school immunization programmes. In most cantons, paediatricians are responsible for immunization of children. The FOPH publishes domestic vaccination guidelines as well as vaccination recommendations for international travel. Recommended child immunizations are fully covered by MHI. For certain recommended adult vaccinations, co-payments may also be waived, for example, in 2013, for vaccination against measles or human papilloma virus (FOPH, 2013e).
Vaccination rates of children aged 1 year old are slightly below EU28 averages for measles (92% in Switzerland versus 94% in the EU28) and for diphtheria, tetanus and pertussis (95% in Switzerland versus 96% in the EU28) (OECD, 2014a). Between November 2006 and September 2009, three outbreak waves and 4415 cases of measles were confirmed in Switzerland, and measles outbreaks in Austria, Germany and the United States in 2008 could be linked to measles strains originating from Switzerland (Lang et al., 2011).
Antenatal services in Switzerland are mainly offered by gynaecologists in individual practices and by midwives. The standard benefits package of MHI (see section 2.8.1) includes a broad range of antenatal check-ups as well as birth preparation and breastfeeding courses. Most antenatal services do not require cost-sharing by the mother (see section 3.4.1).
Screening programmes exist for metabolic diseases for newborns, for cervical cancer, breast cancer and colon cancer. While screening rates for cervical cancer in 2012 were around 75%, which was comparable to neighbouring European countries (OECD, 2014a), those for breast cancer were much lower, i.e. around 45% in Switzerland compared to above 80% in Finland, Denmark, Austria and the Netherlands (OECD, 2014a). Responsibility for the design and implementation of screening programmes lies with the cantons. Only two cantons have a colon cancer screening programme and several cantons do not have structured screening programmes for breast cancer.