Decentralization and central and regional coordination of health services:The case of Switzerland

As part of reforms in the health care delivery sector, decentralization is currently promoted in many countries as a means to improve performance and outcomes of national health care systems. Switzerland is an example of a co untry with a long-standing tradition of decentralized organization for many purposes, including health care delivery. Apart from the few aspects where the responsibility is at the federal level, it is the task of the 26 canto ns to organize the provision of health services for the population of aroun d 7 million people. This permits the system to be responsive to local prior ities End interest as well as to new developments in medical and public hea lth know-how. However, the increasing and complex difficulties of most heal th care delivery systems raise questions about the need for mechanisms for coordination at federal level, as well as about the equity and the effectiv eness of the decentralized approach. The Swiss case shows that in a strongl y decentralized system, health policy and strategy elaboration, as well as coordination mechanisms among the regional components of the system, are ve ry hard to establish. This situation may lead to strong regional inequities in the financing of health care as well as to differences in the distribut ion of financial, human and material inputs into the health system. The stu dy of the Swiss health system reveals also that, within a decentralized fra mework, the promotion of cost-effective interventions through a well-balanc ed approach towards promotional, preventive and curative services, or towar ds ambulatory and hospital care, is difficult to achieve, as agreements bet ween relatively autonomous regions are difficult to obtain. Therefore, a de centralized system is not necessarily the most equitable and cost-effective way to deliver health care. Copyright (C) 2000 John Wiley & Sons, Ltd.