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 country 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 cantons to organize the provision of health services for the population of around 7 million people. This permits the system to be responsive to local priorities and interest as well as to new developments in medical and public health know-how. However, the increasing and complex difficulties of most health care delivery systems raise questions about the need for mechanisms for coordination at federal level, as well as about the equity and the effectiveness of the decentralized approach. The Swiss case shows that in a strongly decentralized system, health policy and strategy elaboration, as well as coordination mechanisms among the regional components of the system, are very hard to establish. This situation may lead to strong regional inequities in the financing of health care as well as to differences in the distribution of financial, human and material inputs into the health system. The study of the Swiss health system reveals also that, within a decentralized framework, the promotion of cost-effective interventions through a well-balanced approach towards promotional, preventive and curative services, or towards ambulatory and hospital care, is difficult to achieve, as agreements between relatively autonomous regions are difficult to obtain. Therefore, a decentralized system is not necessarily the most equitable and cost-effective way to deliver health care.