OECD Reviews of Health Systems 2 0 1 1 SWITZERLAND 2011 OECD Reviews of Health Systems Contents Chapter 1. Key features of the Swiss health system SWITZERLAND Chapter 2. Health insurance Chapter 3. Health workforce Chapter 4. Recent health system reforms and progress since the 2006 review Chapter 5. Reforms and governance of the Swiss health system 2011 O E C D R e v ie w s o f H e a lt h S y s t e m s S W IT Z Please cite this publication as: E R OECD/WHO (2011), OECD Reviews of Health Systems: Switzerland 2011, OECD Publishing. L A http://dx.doi.org/10.1787/9789264120914-en N D This work is published on the OECD iLibrary, which gathers all OECD books, periodicals and statistical databases. Visit www.oecd-ilibrary.org, and do not hesitate to contact us for more information. ISBN 978-92-64-12090-7 -:HSTCQE=VWU^U\: 81 2011 16 1 P OECD Reviews of Health Systems: Switzerland 2011 This work is published on the responsibility of the Secretary-General of the OECD. The opinions expressed and arguments employed herein do not necessarily reflect the official views of the Organisation or of the governments of its member countries or those of the World Health Organization. This document and any map included herein are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area. Please cite this publication as: OECD/WHO (2011), OECD Reviews of Health Systems: Switzerland 2011, OECDPublishing. http://dx.doi.org/10.1787/9789264120914-en ISBN 978-92-64-12090-7 (print) ISBN 978-92-64-12091-4 (PDF) Series: OECD Reviews of Health Systems ISSN1990-1429 (print) ISSN 1990-1410 (online) The statistical data for Israel are supplied by and under the responsibility of the relevant Israeli authorities. The use of such data by the OECD is without prejudice to the status of the Golan Heights, East Jerusalem and Israeli settlements in the West Bank under the terms of international law. Photo credits: Cover © Tomi/PhotoLink/Photodisc/Getty Images, © Tomi/PhotoLink/Photodisc/Getty Images, ©JimArbogast/Digital Vision/Getty Images, © Don Tremain/Photodisc/Getty Images, © GeoStock/Photodisc/ GettyImages, © Tomi/PhotoLink/Photodisc/Getty Images. Corrigenda to OECD publications may be found on line at: www.oecd.org/publishing/corrigenda. © OECD/World Health Organization 2011 You can copy, download or print OECD content for your own use, and you can include excerpts from OECD publications, databases and multimedia products in your own documents, presentations, blogs, websites and teaching materials, provided that suitable acknowledgment of OECD and WHO as source and copyright owner is given. All requests for public or commercial use and translation rights should be submitted to [email protected]. Requests for permission to photocopy portions of this material for public or commercial use shall be addressed directly to the Copyright Clearance Center (CCC) at [email protected] or the Centre français d’exploitation du droit de copie (CFC) at [email protected]. FOREWORD Foreword T his review of the Swiss health system was undertaken jointly by the OECD Secretariat and the World Health Organization (WHO) at the request of the Swiss Federal Office of Public Health. It follows the OECD reviews of the health systems of Korea (2003), Mexico (2005), Finland (2005) and Turkey (2008, in co-operation with the World Bank) and updates the first review of the Swiss health system, published in2006. The review assesses the institutional arrangements and the performance of the Swiss health system. It particularly focuses on the issue of solidarity and efficiency of health insurance, the health workforce, and the reforms and governance of the Swiss health system. It also discusses the factors affecting performance and offers an assessment of the challenges the system faces for the future and the need for reform. In so doing, it aims at furthering the debate on health reforms in Switzerland through a review of the strengths and weaknesses of the current system and an evaluation of alternative paths of reform. Francesca Colombo (OECD) and Pascal Zurn (WHO, Geneva) managed and co-ordinated the review of the Swiss health system. The main authors of this report are, in alphabetical order, Francesca Colombo (OECD), Ann-Lise Guisset (WHO Regional Office for Europe), Elke Jakubowski (WHO consultant, Department of Epidemiology, Social Medicine, and Health System Research at the Hannover Medical School), Ankit Kumar (OECD), Inke Mathauer (WHO, Geneva), Howard Oxley (OECD), Valérie Paris (OECD) and Pascal Zurn (WHO, Geneva), with significant contributions from Peter Donnelly (University of St Andrews) and Laura Stormont (WHO, Geneva). The authors wish to thank for their comments and suggestions John Martin, Stefano Scarpetta, Mark Pearson and Michael Schönstein from the OECD Secretariat; Jean-Marc Braichet, Manuel Dayrit, David Evans, and Jean Perrot from WHO, Geneva; as well as Hans Kluge, Joseph Kutzin, and Galina Perfilieva from the WHO Regional Office for Europe. They also wish to thank, from the OECD Secretariat, Margarita Xydia-Charmanta for statistical assistance, Judy Zinnemann for assistance and Marlène Mohier for her editing work, as well as, from WHO headquarters in Geneva, Lawrence Loh and Jennifer Edge for their contribution to the review and, especially, for their statistical and editing support. The completion of this report would not have been possible without generous support from the Swiss authorities. The report benefited from the expertise of, and the material received from, many Swiss officials and health experts that the review team met during a mission to Switzerland in February2011. These included officials from different federal offices and agencies, in particular the Federal Office of Public Health and the Federal Office of Statistics; cantonal authorities; health insurers; hospitals, nursing homes and health professionals; consumer associations and non- governmental organisations; the pharmaceutical industry; and other health experts. René Schwendimann (University of Basel) provided useful information on RN4CAST study. The review team is especially thankful to the members of the International Affairs Division of the Swiss Federal Office of Public Health for their help in preparing the mission and co-ordinating the supply of data, in particular Delphine Sordat, Patrizia Sieber-Zuercher and Gaudenz Silberschmidt. A draft report was sent to Swiss authorities for comments. The final report has benefited from comments by Swiss health experts and Swiss authorities. OECD REVIEWS OF HEALTH SYSTEMS: SWITZERLAND 2011 © OECD/WORLD HEALTH ORGANIZATION 2011 3 TABLE OF CONTENTS Table of Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Assessment and Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Chapter 1. Key Features of the Swiss Health System. . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 1.1. Key features of Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 1.2. The economic size of the health sector. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32 1.3. Governance of the Swiss health system . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 1.4. Financing health care in Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 1.5. Delivering health services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 1.6. Provider payments, reimbursement and contracting . . . . . . . . . . . . . . . . . . . . . 49 1.7. The system’s efficiency: international benchmarking and future challenges. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Chapter 2. Health Insurance. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59 2.1. General trends in the Swiss health insurance market . . . . . . . . . . . . . . . . . . . . 60 2.2. The1996 Health Insurance Law has strengthened solidarity, but health financing inequalities remain. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 2.3. Competition in health insurance markets does not deliver all its promises. . 71 2.4. The reform agenda. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Chapter 3. Health Workforce. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 3.1. Health workforce distribution and evolution. . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 3.2. Trends shaping the health workforce . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 3.3. Education. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 3.4. International health worker migration and Switzerland . . . . . . . . . . . . . . . . . . 102 3.5. Not only a question of numbers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 3.6. The challenge of developing a national and long-term vision on health workforce issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110 Chapter 4. Recent Health System Reforms and Progress since the2006 Review. . . . 115 4.1. Public health and prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 4.2. Quality of care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 OECD REVIEWS OF HEALTH SYSTEMS: SWITZERLAND 2011 © OECD/WORLD HEALTH ORGANIZATION 2011 5 TABLE OF CONTENTS 4.3. Hospital financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123 4.4. Pharmaceuticals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135 Chapter 5. Reforms and Governance of the Swiss Health System . . . . . . . . . . . . . . . . 137 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138 5.1. Main issues in health system governance identified in2006. . . . . . . . . . . . . . . 139 5.2. Governance traditions and principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140 5.3. Dynamic governance or the political capacity for reform . . . . . . . . . . . . . . . . . 141 5.4. Key features and instruments of governance of the Swiss health system . . . 142 5.5. Looking at health system objectives through the governance lens . . . . . . . . . 148 5.6. Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150 Notes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152 Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Canton Abbreviations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Tables 1.1. Per capita national income by canton, 2005 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1.2. Basic demographic indicators in Switzerland, 2009. . . . . . . . . . . . . . . . . . . . . . . . . 28 1.3. Indicators of public health risks in OECD countries, 2009 . . . . . . . . . . . . . . . . . . . 30 1.4. Financing of health expenditure in Switzerland, 2009 . . . . . . . . . . . . . . . . . . . . . . 35 1.5. Resources available in the Swiss health delivery system and other OECD countries, 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 1.6. Public and private hospitals in Switzerland, 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . 46 1.7. Distribution of health expenditure by type in OECD countries, 2008 . . . . . . . . . . 50 2.1. Types of insurance contracts within the mandatory health insurance (LAMal) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 2.2. Trend in premium subsidies since1999. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 3.1. Yearly number of nursing graduates and projected needs. . . . . . . . . . . . . . . . . . . 100 3.2. Medical studies: number of applicants and capacity in universities, academic year2010/11 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 3.3. Percentage of migrant practicing doctors and nurses in OECD countries (foreign-born). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102 4.1. Hospital financing amongst OECD countries with insurance-based systems, 2007. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Figures 1.1. GDP per capita in OECD countries, 2010 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 1.2. Life expectancy at birth in OECD countries, 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 1.3. The Swiss population by age group, 2010and2050. . . . . . . . . . . . . . . . . . . . . . . . . . 28 1.4. Share of the population considering their health to be good or very good in OECD countries, 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 1.5. Share of selected causes of mortality, 2007 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 1.6. Health expenditure in OECD countries as a percentage of GDP, 2009, and changes in per capita health spending, in real terms, 1999-2009 . . . . . . . . . . 32 6 OECD REVIEWS OF HEALTH SYSTEMS: SWITZERLAND 2011 © OECD/WORLD HEALTH ORGANIZATION 2011 TABLE OF CONTENTS 1.7. Per capita health expenditure and per capita GDP in OECD countries, 2009 (or latest year available) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 1.8. Spending on health by type of financing, 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 1.9. Expenditure on promotion and prevention as a share of current health expenditure in OECD countries, 2008 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 1.10. Funding of health promotion and prevention activities in Switzerland, by financing agent, 2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 1.11. Main health promotion and prevention programmes of the Swiss Federal Office of Public Health by level of funding, 2011 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 1.12. Acute care beds in Switzerland and in selected OECD countries, 1998-2008. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 1.13. Share of expenditure for out-patient pharmaceuticals paid by the government or social insurers in the OECD, 2009 . . . . . . . . . . . . . . . . . . . . . 48 1.14. Potential gains in life expectancy through improved efficiency. . . . . . . . . . . . . . . 54 2.1. Trends in the take-up of different types of health insurance plans among the insured population between1996 and2009 . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 2.2. Distribution of health insurance premiums paid for adults over 25, by canton of affiliation, 2011. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 2.3. Sum of cantons’ payments to providers, insurance premiums and cost-sharing on a per capita basis by canton, 2007. . . . . . . . . . . . . . . . . . . . . . 65 2.4. Share of population receiving premium subsidies and average level ofpremium subsidy per beneficiary by canton, 2009 . . . . . . . . . . . . . . . . . . . . . . . . 67 2.5. Average LAMal premium burden after the payment of premium-reduction subsidies, as a share of disposable income, for five types of households, in1998, 2002and2007. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 2.6. Households’ direct payments for health care in OECD countries, 2009 . . . . . . . . 70 2.7. Health care expenditures in2007 by income quintile (before and after adjustment for premium studies) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71 2.8. Comparison of trend in net risk equalisation volume and SHI expenditure over1996-2009. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 3.1. Nurse/doctor ratio in Switzerland and OECD average . . . . . . . . . . . . . . . . . . . . . . . 88 3.2. Number of physicians per 1000population per canton, 2009. . . . . . . . . . . . . . . . . 89 3.3. Number of physicians in independent practice per 1000population and per canton, 1980, 1990, 2000 and 2009. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 3.4. General practitioner density in OECD countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 3.5. Practicing physician age distribution, 1980-2010. . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 3.6. Nurse age distribution, 2010. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94 3.7. Physician age distribution per gender, 2010. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 3.8. Medical specialty and gender distribution. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95 3.9. Number of medical and nursing graduates in Switzerland, 1980-2009 . . . . . . . . . 99 3.10. Number of medical graduates per 100000population, 1995-2008, OECD average and Switzerland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 3.11. Requests for assistance for reintegration into the profession (nurse) per year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108 4.1. Prevalence of overweight and obesity amongst Swiss children aged 6years to 12/13years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 4.2. Average length of stay for acute care across OECD countries, 2009 . . . . . . . . . . . . 124 OECD REVIEWS OF HEALTH SYSTEMS: SWITZERLAND 2011 © OECD/WORLD HEALTH ORGANIZATION 2011 7 TABLE OF CONTENTS 4.3. Day cases as a proportion of total surgical procedures delivered inhospitals, 2008. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 4.4. Relative retail pharmaceutical price levels in OECD countries, 2005 . . . . . . . . . . . 129 4.5. Trends in generic market share since2002 (share of total market sales, at ex-factory prices). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 8 OECD REVIEWS OF HEALTH SYSTEMS: SWITZERLAND 2011 © OECD/WORLD HEALTH ORGANIZATION 2011 INTRODUCTION Introduction T his report reviews Switzerland’s health system. It provides an update to the information and analysis presented in the OECD Reviews of Health Systems: Switzerland published by the OECD and the WHO in2006. In addition, it discusses three central policy issues for Swiss authorities: health insurance, the health workforce and governance of the Swiss health system. The report seeks to examine key aspects of Switzerland’s health system with a view to suggesting priorities for reform and providing insights from which other countries can learn. The Swiss health system is high performing and responsive, reflected in high levels of patient satisfaction and one of the longest life expectancies in the world. Switzerland has combined a highly decentralised health care system with an almost unconstrained choice of providers and a comparatively high availability of health care services. However, this comes at a significant cost, with Switzerland spending more than most OECD countries on health care. The demands on the health system, and the economic pressures that are likely to accompany them, will only continue to increase as technology advances, the population ages and persons living with chronic disease become more common. These changes will bring new challenges for policy and necessitate ongoing reforms. Health insurance through managed competition in Switzerland has delivered comprehensive coverage and choice. Improving the quality of care (particularly for those people who will need care with greater frequency and across multiple settings) while constraining costs, should be the focus for future reforms. This could begin with a more systematic use of cost-effectiveness criteria to determine what services should be available under the manadatory health insurance benefit package. Addressing costs and quality will also demand that Switzerland overcome co-ordination problems to define national policies for prevention and health promotion –where evidence already suggests value for money lies. So as to ensure that future reforms are well targeted, Switzerland should focus on improving health information and information technologies that can help drive improvements in the quality of care. These reforms ought to be undertaken along side the development of a long term national view on how to train more health personnel and make the most of Switzerland’s exisiting health workforce. Reforms undertaken over the past half decade should bring dividends over the years ahead. In particular, reforms to the financing of hospitals that are currently being implemented hold the potential to reduce the utilisation of hospitals in Switzerland. Reforms to pharmaceutical pricing have already begun to deliver rewards, and there is potential for future reforms to further increase value for money in pharmaceutical spending. Driving future health policy reforms will require that the unique structures of governance in the Swiss health system continue to encourage services to be locally responsive and innovative. But they are also likely to demand that the governance OECD REVIEWS OF HEALTH SYSTEMS: SWITZERLAND 2011 © OECD/WORLD HEALTH ORGANIZATION 2011 9