Health reforms in Switzerland require a particularly large consensus in order to be adopted and implemented. Reaching such a consensus is complicated – sometimes impossible – and almost always takes a very long time (Bolgiani, Crivelli & Domenighetti, 2006). However, the lengthy and difficult process of consensus seeking is also an important strength of the political system because it ensures that passed reforms are supported (or at least not opposed) by all relevant stakeholders.
Extensive consultations with cantons and other stakeholders, including with corporatist bodies and civil society organizations, during the early phases of reforms often lead to the incorporation of legitimate concerns into reform proposals. The possibility for the population (or pressure groups that are successful at mobilizing popular support) to veto reforms or demand change through public referendum imposes strong popular control. Therefore, the government has to make sure that it has good arguments in favour of proposed changes, meaning that reform proposals have to be based on solid policy analyses and implemented reforms will usually undergo rigorous evaluations.
Reforms or significant developments can be initiated in Switzerland by several actors and via different policy paths. Reforms of federal laws are usually proposed by the Federal Council or Parliament. However, other reforms or significant developments are initiated by cantons either independently or jointly via the GDK/CDS , while still others are started by corporatist bodies or via popular initiatives.
Table6.1 summarizes major reforms and reform attempts as well as other significant developments that occurred in the health system between 2000 and 2014. As KVG/LAMal is the most important federal law outlining the basic characteristics of the health system (see section 2.1), most reforms are, in fact, revisions of KVG/LAMal . The most important areas of reform were:
Before discussing these reforms in more detail, section 6.1.1 describes the context and origin of several of these reforms to illustrate the long, difficult and not always successful political processes of making health reforms in Switzerland.
One important trend across all reforms since 2000 (and even before that) has been a tendency towards more harmonization of national health policy-making (see section 2.4). Many reforms have strengthened the role of the federal government, which has obtained more influence on hospital inpatient care provision, insurance supervision and public health. In addition, cantons are increasingly coordinating their activities, leading to a stronger role for the GDK/CDS and the need for more formal collaboration with the federal government through the National Dialogue on Health Policy. Nevertheless, reforms leading to a stronger role for the federal government are often highly contested as cantons are reluctant to allow more federal intervention in one of their core competences.
10 October 2022 | Country Update
After the approval of the popular initiative “Yes to protecting children and young adults from tobacco advertising” adopted on 13 February 2022, the Federal Council decided on 31 August 2022 to conduct a consultation procedure for the revision of the Federal Law on Tobacco Products and Electronic Cigarettes to further protect young people.
Switzerland has one of the weakest federal tobacco control measures in place in Europe: advertising of tobacco products is permitted except for certain restrictions, although many cantons have more far-reaching bans in place. This initiative aims to ban tobacco advertising that reaches children and adolescents and to ban sponsoring events such as festivals by the tobacco and electronic cigarette industry that are accessible to minors.
The currently planned revision of tobacco advertising concerns the Tobacco Products Act, which was already adopted by Parliament on 1 October 2021, even before the vote on the popular initiative. It also regulates electronic cigarettes and herbal smoking products, including in particular hemp-based smoking products with a low THC content and containing CBD. The Act is expected to enter into force at the beginning of 2024.
16 May 2022 | Country Update
On 15 May 2022, in a national referendum about 60% of the Swiss population voted in favour of the presumed consent model for organ donation. This means that people who do not consent to organ, tissue and cell donation after death will have to express their preference while still alive. In the absence of any clear indication, relatives can make the decision while respecting the presumed preferences of the deceased.
The new regulation will enter into force in 2024 at the earliest, because the details of implementation will have to be regulated in ordinances. Moreover, a register will have to be set up, and a broad campaign will have to be developed to inform the population. Until then, the explicit consent model will continue to apply: this means that organs and tissues can only be taken if the person has given consent; relatives will be consulted in case of the absence of authorisation.
05 January 2022 | Policy Analysis
As a measure to appeal to and maintain nurses and health workers in the profession, Switzerland adopted the so-called “Nursing Initiative” in a popular vote in November 2021, with in total 61% of votes. The Federal Constitution requires the federal government and cantons to recognize and promote nursing as a core component of health care. The objective of the initiative is threefold: first, to recognize the nursing profession as an essential and central component of health-care; second to train and educate more nurses and health workers to address the occurring needs of an ageing population and so the initiative thus aims to increase the number of nursing personnel in Switzerland; and, third to ensure that nurses have the ability to work according to their training and competencies and that they benefit from good working conditions to main quality care.
To achieve these ambitious goals, the nursing initiative is being implemented in two stages. The first stage comprises an education and training offensive campaign with an envelope of CHF 1 billion to be invested in education of nurses during the coming eight years.
At a second stage, the professional circumstances in health workforce professions shall be addressed by 1) providing working conditions that meet high requirements, 2) offering opportunities for professional development and 3) providing appropriate remuneration for care services. Throughout the implementation, close collaboration with all stakeholders, such as the Cantons, educational institutions and professional associations, is key.
An additional element which aims to address the needs of unpaid care work providers, which are mainly women, are various initiatives to improve compatibility of work and family life. For example, the provision of childcare services or modularized training and continuing education, shall allow professional development alongside the family. Various measures will also be put in place in order to develop certain skills and implement new digitalization tools. These measures should contribute to reduce workload and facilitate certain tasks.
14 April 2020 | Policy Analysis
On 6 December 2019, the Federal Council adopted the new Swiss health policy strategy “Health2030”, which sets the framework for priority activities at federal level.
Under the previous strategy “Health2020” over 36 measures have been pursued on the federal and cantonal level to ensure a resilient health system and affordable access to care for all. Since 2013, these measures were implemented through various projects of which many have shown positive effects. Health2030 builds on these experiences and achievements. It focuses on four key challenges:
Health2030 defines eight objectives and 16 lines of actions for the development of concrete measures:
Federal Office of Public Health (2019). Gesundheitspolitische Strategie des Bundesrats 2020 – 2030. [The Federal Council’s health policy strategy 2020 - 2030.] https://www.bag.admin.ch/bag/de/home/strategie-und-politik/gesundheit-2030/gesundheitspolitische-strategie-2030.html, last accessed: 13 March 2020
Many of the reforms and reform attempts included in Table6.1 were already proposed by the Federal Council as part of an attempted revision of the KVG/LAMal in 2000. Box6.1 shows a timeline from the introduction of KVG/LAMal until 2012, focusing on two reforms, which were part of this initial reform package: the hospital financing reform and the unsuccessful managed care reform.
| Table6.1 | Box6.1 |
|  |
After the implementation of KVG/LAMal in 1996, the Federal Council commissioned a package of 25 studies to evaluate whether the fundamental changes to the health system resulting from this reform had achieved the desired effects ( BSV/OFAS , 2001). The evaluation found that KVG/LAMal had been successful at improving solidarity of the insurance system (despite problems with risk adjustment) and ensuring good quality of care but had been unsuccessful at controlling the escalating costs. Reforms were recommended that should focus on increasing efficiency and quality through (amongst others) better coordination of care provision (managed care), and changes to the system of hospital financing and planning.
The package of reforms proposed by the Federal Council in 2000 contained a host of measures that took up the recommendations of this evaluation. Besides the hospital financing reform and the managed care proposal, the package included modifications to the system of long-term care financing and improvements to the system of risk adjustment. However, after prolonged discussions, the reform proposal was rejected by Parliament in 2003.
According to the Federal Council, each of the proposed measures had the support of the parliamentary majority but the reform package was rejected because opposition of minorities against individual parts of the proposal accumulated into a majority. Therefore, the Federal Council unbundled the original reform into six separate proposals (Crivelli, 2004).
The hospital financing reform was proposed again in 2004 with only minor revisions. Simultaneously, developments started at the level of the corporatist bodies ( MHI companies, hospitals, FMH ) and cantons. A foundation called Swiss DRG was created by these actors in April 2004 to start preparing the introduction of DRG s in Switzerland. In 2007, Parliament finally accepted the proposed reform, which led to the implementation of a DRG -based hospital payment system in 2012 – almost 12 years after the initial proposal in 2000.
Also, the managed care reform was launched again in 2004. After lengthy discussions in Parliament, which considerably changed the original proposal of the Federal Council, the reform was ultimately approved by Parliament in 2011. However, a popular referendum – supported (for different reasons) by the FMH and the Socialist Party – rejected it in 2012 (see section 6.1.3).
The hospital financing reform of 2007 has considerably increased the role of the federal government in defining the conditions of inpatient care delivery in Switzerland. The reform has had far-reaching consequences on the hospital sector that are linked with – but go far beyond – the introduction of the Swiss DRG system for the payment of acute inpatient care. First, DRG -based payment has increased transparency and is expected to lead to higher efficiency; second, the reform has increased competition between public and private hospitals by specifying that the same payment system applies to both; third, the reform has increased choice for patients (and competition for hospitals) by expanding options for obtaining care outside the canton of residence; and finally, it has improved cantonal planning of inpatient care provision and coordination of planning across cantons.
Transparency has improved because DRG s enable comparisons of inpatient activity and facilitate benchmarking of costs across hospitals and cantons. Efficiency is thought to increase because hospital payment now depends on the treatment of cases independent of (or less dependent on) the costs of provision. Also, insurers are increasingly attempting to negotiate lower base rates based on information about negotiated payments for DRG s in other hospitals. In addition, DRG s make transparent the costs of local political decisions. DRG -based payments have to cover the full costs of service provision (capital and running costs) but explicitly exclude the costs of “public interest functions of hospitals”. According to KVG/LAMal , public interest functions, such as university education, research, or ensuring regional accessibility, have to be funded separately by cantons.
However, university hospitals claimed that they need higher DRG -based payments (base rates) because Swiss DRG s did not adequately reflect service provision in university hospitals, and most cantons have approved higher base rates for university hospitals. The national price watchdog (Surveillant des Prix) monitors negotiated base rates and can recommend reducing base rates if they are found to be higher than in other parts of the country or higher than the costs of service provision (see section 3.3.4). This puts pressure on cantons as they have to justify if they approve higher base rates.
Increasing competition between public and private hospitals was one of the aims of the hospital financing reform. Prior to the reform of inpatient financing, public hospitals received subsidies from cantons for investments and parts of their running costs, while MHI covered a maximum of 50% of the eligible running costs, which excluded, for example, costs of teaching and research. Private hospitals were partly financed by MHI and partly by VHI . Since the reform, cantons pay between 51% and 55% of each DRG -based payment (although this proportion will increase to at least 55% by 2017) to all hospitals included in cantonal hospital lists, independent of hospital ownership (see section 3.7). Therefore, private hospitals can now (at least in theory) compete on a level playing field with public hospitals, and patients can freely choose to be treated in private hospitals included in cantonal hospital lists.
However, a recent study found that large differences existed in 2012 (the first year of the new financing rules) concerning the degree to which cantonal regulatory arrangements actually allowed competition between public and private hospitals (Widmer & Telser, 2013). Although regulations are likely to have changed in the subsequent years, private hospitals continue to feel disadvantaged by cantonal regulations and subsidies (PKS, 2014).
Hospital competition has also increased because patients can now choose to be treated in hospitals outside their canton of residence (see section 5.4.2). Prior to the reform, out-of-canton services were covered by MHI and cantons only in the case of emergency or if the services were not available in the insured’s canton of residence. Patients wishing to have choice of provider in other cantons had to take out supplementary VHI or pay directly.
Since the reform, an insured can choose any hospital in Switzerland as long as it is included in the hospital list of the canton of treatment. Hospitals are paid by cantons and insurers on the basis of DRG s, but reimbursement (except in emergencies or medically indicated cases) is limited to the price (base rate) that would have been paid in the canton of residence for the same service. The rest has to be covered by patients out of pocket or by supplementary insurance. This is unproblematic for patients living in cantons with high base rates but can impose considerable costs on patients living in cantons with low base rates and with no supplementary insurance.
Finally, the law has considerably improved planning of inpatient care. On the one hand, it has specified that planning has to be based on objective criteria (see section 2.5.2) and should also include private hospitals in the planning exercise. The Canton of Zurich has been very influential in promoting objective planning criteria. It has developed a methodology for estimating future care needs, length of stay, etc., on the basis of epidemiological extrapolations to the year 2020. This methodology was adopted by most cantons for their hospital planning activities for the year 2015.
On the other hand, the reform mandated cantons to coordinate their planning activities, in particular in the area of highly specialized medical care (see section 2.5.2). Joint planning has been successful in so far as there is increasing collaboration between rural and urban cantons, and between cantons with and without university hospitals. The introduction of Swiss DRG s has facilitated joint planning by providing a common measure for the analysis of hospital activity.
However, planning of highly specialized medical care has been difficult and highly controversial, and the federal government has declared that it might intervene if cantons fail to reach an agreement. Since 2009, the GDK/CDS has engaged in joint planning of highly specialized medical care based on an inter-cantonal agreement, allowing the GDK/CDS to take binding decisions about which hospitals would be allowed to provide which services. However, it has met with considerable resistance from some smaller cantons and small or mid-size hospitals, and disputes have resulted in appeals to the Federal Administrative Court. In March 2014, the court decided that a few of the 39 GDK/CDS planning decisions (i.e. concerning paediatric oncology and rare visceral surgery) had to be revised, although many others were confirmed. Nevertheless, it can be expected that actors will ultimately come to an agreement and concentration of highly specialized medicine will continue.
An important positive development in the hospital sector has been the increasing focus and activity of different actors on quality improvement and patient safety. The ANQ (see sections 2.3 and 2.8.2) has promoted the collection of data in order to improve the quality of acute, rehabilitation and psychiatric hospitals. Results of specific indicators are monitored and published on the website of the association. Indicators for acute care hospitals include readmission rates, reintervention rates, surgical infections, patient satisfaction, falls and pressure ulcers (see section 5.4.3). Data collection for psychiatric hospitals started in 2012 and for rehabilitation hospitals in 2013 (see section 5.7).
In addition, the hospital planning methodology developed by the Canton of Zurich has led to an increasing focus on structural quality of care provision as it makes the presence of, for example, intensive care units and qualified staff, as well as minimum volume thresholds, preconditions for allowing hospitals to provide particular services. Finally, the FOPH has introduced the CH-IQI , with a focus on mortality rates (see section 5.4.3).
The three most important successful reforms in the area of health insurance since the year 2000 have been: (1) two rounds of changes to the system of risk adjustment; (2) new rules for the co-financing of premium subsidies by the federal government and cantons; and (3) the strengthening of the federal government in the supervision of MHI companies. Several other reform attempts, such as the attempted managed care reform and the popular initiative for a single public sickness fund, were unsuccessful.
Improved risk adjustment had been on the political agenda right from the initial impact evaluation of KVG/LAMal (see section 6.1.1). Risk adjustment at the time was based purely on the age and sex of the insured and insurers had been found to engage in risk selection by attempting to attract healthy individuals while avoiding the sick ( BSV/OFAS , 2001). When the reform package of 2000 proposing changes to the risk-adjustment system was rejected by Parliament in 2003 (see Box6.1), it took another four years for improved risk adjustment to be incorporated into KVG/LAMal in 2007, and then another five years before it was finally implemented in 2012. The reform added a third criterion (in addition to age and sex) to the risk-adjustment formula, which now also compensates insurers for the higher average costs of insured who have had at least one inpatient stay of more than three nights during the previous year.
The managed care reform rejected in 2012 would have led to improvements in risk adjustment. However, when this failed, a further reform was passed in 2014 comparatively quickly giving the right to the Federal Council to further improve the risk-adjustment system. This was possible because the popular initiative in favour of a single public sickness fund put pressure on Parliament to improve risk adjustment. As a result, the Federal Council has already defined a fourth criterion, i.e. expenditure for pharmaceuticals exceeding Sw.fr.5000 in the previous year, which will be used from 2017. Further criteria can be defined by the Federal Council if necessary.
The system of co-financing of public subsidies to low- and middle-income households for the purchase of MHI (see sections 3.3.2 and 3.3.3) was reformed as a result of a new Federal Law on Fiscal Equalization (FiLaG/PFCC), passed in 2003 and implemented in 2005. The law aimed at reducing general economic and fiscal disparities across cantons and this provided an opportunity for also reforming the co-financing of MHI subsidies. Public subsidies are managed by cantons but about half of the resources are provided by the federal level and cantons have to follow the rules defined in the KVG/LAMal . Prior to the reform, the Confederation paid two thirds of the total subsidies at the national level but required a matching grant of one third from cantons. Consequently, cantons paying more subsidies also received more funding from the Confederation.
Under the new system, the Confederation pays an amount that is equal to 7.5% of the estimated MHI gross expenditure of the cantonal population and cantons have to use this money to subsidize premiums of the insured. Compared with the previous system, the total funding of premium subsidies by the Confederation has decreased, but this reduction was compensated by an increase in general fiscal equalization measures (independent of premium subsidies). As a result of the reform, cantons have more autonomy in their expenditure decisions (because they are no longer required to match federal subsidy contributions) but this can lead to large differences in premium subsidies across cantons (see section 7.2.1).
Also, the adoption of the new KVAG/LSAMal by Parliament in September 2014 was helped by the popular initiative “For a single public sickness fund”. The proposed law had been under discussion since early 2012 and a parliamentary majority appeared unlikely because of resistance against more state intervention. However, the proposal was ultimately approved because of fears that a rejection of the law would strengthen arguments of the popular initiative. The proposed law remedied two concerns of proponents of the popular initiative: one was a lack of transparency when insurers offered both MHI and supplementary VHI , potentially using information gathered from MHI to offer better (or worse) conditions for VHI to the healthy (or sick); the other was a concern about unjustified premium increases. The new KVAG/LSAMal mandates insurers to clearly separate MHI from VHI activities and strengthens coordination of supervisory activities of the FOPH with FINMA , which is in charge of supervision of VHI (Federal Council, 2012a). The law also makes clear that premiums of insurers will not be approved by the FOPH if they are found to be too high or too low, and insurers can be mandated to reimburse premiums to insured if they were set too high. In addition, the law introduces new accounting criteria and guidelines for managing insolvencies of insurers.
The popular initiative “For a public sickness fund” was similar to two other initiatives that had already proposed radical reform of the MHI system in 2003 and 2007. Both initiatives had been rejected by more than 70% of voters and the most recent initiative was rejected by 62% in September 2014 (De Pietro & Crivelli, 2015). The initiative proposed replacing the existing 61 MHI companies with a single public sickness fund. Besides inadequate risk adjustment and lack of transparency, proponents of the initiative criticized the current system for several reasons, including: (1) the high per capita health expenditure; (2) the lack of involvement of public authorities in negotiating payments with providers; (3) the lack of incentives to develop prevention programmes; (4) the malfunctioning of the MHI market exhibited by large differences in premium levels across insurers; (5) high administrative costs of the system for marketing, switching insurers, duplicate paperwork, etc.
However, opponents effectively campaigned against the initiative with two main messages: (1) “Public systems cost more than private ones and reduce the freedom of choice”; and (2) “We know what we lose, but we cannot even imagine what we would find”. In view of the liberal values of Swiss society, broad coverage of the standard MHI package, good access to health care services, very high level of choice, and substantial premium subsidies for low-income households, it is no surprise that the initiative was rejected. Nevertheless, the referendum also showed that 38% of the electorate was willing to radically reform the existing system.
Another major reform attempt in the area of health insurance since 2000 was the managed care reform. The first managed care reform was proposed as part of the reform package in 2000 and rejected by Parliament in 2003 (see section 6.1.1). The subsequent Federal Council proposal of 2004 suggested introducing integrated networks of providers, where the network would be responsible for coordination of the full set of services offered by MHI and would carry budget responsibility for subscribed patients.
In the subsequent parliamentary debate, the original proposal was abandoned in favour of a more liberal version, where the network would not have had to offer the full set of services but would just coordinate patients on their way through the health care system, while carrying partial budget responsibility. The reform adopted by Parliament in 2011 would have introduced higher financial penalties for traditional forms of insurance to make it comparatively more attractive for insured to opt for managed care plans and MHI companies would have been obliged to offer such plans throughout the country.
However, opponents (notably physicians and the Socialist Party) demanded a popular referendum. Physicians (except for family doctors) criticized the reform on the grounds that it would reduce the choice of physician, while the Socialist Party was against higher user charges for patients in traditional forms of insurance. Ultimately, the reform proposal was rejected by 76% of voters. Nevertheless, despite the failed reform, the idea of managed care is increasingly successful. In 2014, almost 60% of Swiss residents were insured by so-called alternative insurance plans, which always include some elements of managed care (see section 5.2.2).
The general – although contested – trend towards a stronger role for the federal government in determining health policies is particularly evident in the area of public health. The two most important initiatives in this area, i.e. the revision of the EpG/LEp and the proposed Federal Prevention Law, aimed to improve coordination between the different levels of government and strengthen the role of the federal level. Nevertheless, the failed Prevention Law, and the long history preceding the proposal, illustrate that such reforms are difficult in Switzerland and almost always take a very long time.
Box6.2 shows a timeline of attempts aimed at strengthening the role of the federal government in disease prevention and health promotion. In 1976, a popular initiative aimed to ban advertising for cigarettes and alcohol by adding an article to the Federal Constitution. Despite its rejection in 1979, the initiative kicked off federal activities in the area of disease prevention and health promotion, such as the establishment of committees and the publication of reports. One early result of these developments was the establishment of the foundation Health Promotion Switzerland in 1989.
Almost 20 years later, a draft Federal Prevention Law was proposed by the Federal Council in 2009 (Federal Council, 2009). The law aimed to clearly define the responsibilities of the federal level and cantons; to improve coordination of different activities; and to introduce a Swiss Institute for Disease Prevention and Health Promotion, which would have been affiliated with the federal government. When the reform was proposed, the majority of the cantons initially accepted a greater federal role.
However, some (particularly small) cantons later associated themselves with the opponents of the law, consisting of right-wing parties, business sector lobby groups, as well as some insurers. The opponents strongly criticized the establishment of a new Institute for Disease Prevention and Health Promotion as they viewed this as a “state monopoly on prevention”. Instead, they favoured strengthening the role of the existing multi-stakeholder foundation Health Promotion Switzerland. After several years of fierce negotiations and a highly politicized debate (fuelled by support from the tobacco and alcohol industries) on the antagonism between public and individual responsibility (Mattig, 2013), the law was ultimately rejected by Parliament in 2012.
By contrast, the reform of the EpG/LEp was initiated at the request of the cantons in 2006 and was passed comparatively quickly. All stakeholders seemed to agree that the existing EpG/LEp dating back to 1970 had to be adjusted to enable effective interventions against health threats posed by new epidemics and increased international mobility. The new law more clearly specifies the responsibilities in case of emergencies, where the federal level is responsible for coordination, supervision and monitoring, while cantons are responsible for implementation of measures ( FOPH , 2013i).
In addition, the law adjusts the national reporting system to changes in information technology and improves international collaboration. Furthermore, the federal government now has the power to initiate national programmes in the area of antibiotic resistance and hospital-acquired infections. In 2012, the law was approved by a large majority in Parliament and was confirmed by popular referendum in 2013.
Other important reforms in the area of public health were the introduction of a smoking ban for public buildings or workplaces (including public administrative buildings, hospitals and restaurants) as a result of the implementation of the Federal Law on the Prevention of Passive Smoking in 2010, and amendments to the Road Traffic Act passed in 2001, with stricter rules for alcohol consumption, speed, etc. (see section 7.4.1).
There have been numerous other areas of reform, which can not be discussed in detail. However, four areas were particularly important.
