SWITZERLAND'S HEALTHCARE SYSTEM IN BRIEF
Switzerland is located in central Europe with a population in 2006 of 7.5 million inhabitants. The economy is based on services (60 percent), followed by industry (35 percent), including pharmaceuticals. Switzerland is a federal state comprising twenty-six cantons. Federal authorities carry out their political power only in those areas explicitly delegated to them through the cantons but the twenty-six cantons have prime responsibility in health care and social welfare. Each canton has its own law on health care, hygiene, hospitals, and social welfare. These laws are not harmonized.
Switzerland has a mixed public and private healthcare system (Reference Cranovsky, Mattillon and Banta1). All citizens are enrolled in compulsory basic health insurance. The public is allowed to choose among different sickness funds, including managed care plans. The basic, so-called social (as distinct from private) insurance covers all costs resulting from disease, accidents, and disability as long the client is not enrolled in a managed care plan. Therefore, more then 80 percent of the population is covered by either the social insurance or by private health insurance. There is a mix of public (mainly hospitals) and private (mainly doctors' offices) providers. The health services are decentralized. Ambulatory care is still traditionally provided in doctors' offices. In the past decade, there is a tendency toward centers of hospitals for ambulatory care, group practices, and managed care plans because the financial attractiveness of doctors' offices gets smaller over time.
DEVELOPMENT OF HEALTH TECHNOLOGY ASSESSMENT IN SWITZERLAND
The continuous rises in healthcare costs for several decades led to the realization at the federal level that action was necessary. The development of health technology assessment (HTA) in the Swiss Federal Office of Social Security (SFOSS) was directly aimed at controlling such cost rises.
Under the patronage of SFOSS over the past two decades, remarkable work in the field of HTA was done. Different types of HTA Institutions and initiatives with different goals, private and governmental units, were set up. Since 1984, the principles of HTA and the way of introducing new medical technologies were continuously improved and adapted to the current knowledge (Reference von Bremen, Züllig and von Below2–Reference Koch4). Numerous publications about economic evaluation of health care technologies with comprehensive views on policy issues influenced the diffusion and use of new technologies. Membership in the International Society of Technology Assessment in Health Care opened the contact to the world of HTA and its continuous evolution. Later, Switzerland became a member of the International Network of Agencies for Health Technology Assessment and EUROSCAN. Because of these efforts, decisions for reimbursement became “scientifically acknowledged” and HTA analyses were successful.
The Federal Law of Sickness Funds (KVG) from 1994 introduced the principle that every procedure covered by social security has to be effective, appropriate, and efficient. For emerging technologies, the interpretation of the law allowed the introduction of a time-limited conditional coverage. The pioneering work was delivered to the HTA agendas and was recognized worldwide. The introduction of Evaluation Registries to monitor the temporary insurance coverage followed. In 2000, the Swiss Network for HTA (SNHTA: www.snhta.ch) to coordinate and promote HTA projects in Switzerland was founded.
The Coverage Process by the Federal Social Security Office (SFOSS)
The application procedure for reimbursement of a new medical service requires a minimum amount of information that will enable the Swiss Federal Office of Public Health (FOPH) to assess the procedure in terms of its effectiveness, appropriateness/safety, and efficiency (original terms Wirksamkeit, Zweckmässigkeit, Wirtschaftlichkeit) (Reference Cranovsky, Mattillon and Banta1;5). A new Handbook for reimbursement procedure was presented in May 2008 by Swiss Federal Office in Bern, Switzerland, and is in use since then.
The health insurers and the organizations of physicians are asked if the procedure is established or controversial. If both state that the procedure is established, it is generally covered. If either or both states that the procedure (the technology) is controversial, there is an organized process of assessment and gathering opinions before a coverage decision is made. An information synthesis on known efficacy, effectiveness, and safety is carried out, as well as collection of information on economic, legal, ethical aspects, drawn from the scientific literature and Swiss and foreign reports. If such information is available from Swiss registries, data on utilization, outcome, side effects, cost, manpower considerations, and technical aspects are also part of the process.
The Development of Other HTA Programs
In 2004, all federal HTA activities except for those directly related to coverage moved from SFOSS to the Swiss FOPH (5). The Office is principally involved in health protection and controlling activities. However, since 1980, the Office has a leading role in promoting preventive measures to stop the spread of the HIV/AIDS epidemic. Its overall mission is to ensure its population a healthy living standard. It measures the impact of its actions in terms of the overall development of the nation's health. An evaluation service was set up in the Medical Division 1993 to mandate, manage, and coordinate evaluation studies, attached to the Office's prevention and intervention sections in the fields of AIDS, illegal drugs, and legal drugs. Since then, the evaluation function has been institutionalized at the federal level (7).
The Swiss Centre for Technology Assessment (TA-SWISS) was founded in 1992 (6). TA-SWISS analyses chances and risks of new technological developments. Special attention is given to the fields of “biotechnology and medicine” and “the information society and nanotechnologies.” TA-SWISS fulfils its task of providing advice to policy makers by means of expert studies and participative methods (participation with the general public). Its interdisciplinary studies are authored by experts and easy to understand: summaries are elaborated and addressed to decision makers and the general public. The same applies to the recommendations and results obtained from participative methods (6,8).
PRIVATE INSTITUTES AND EXAMPLES
In the absence of a publicly funded system for assessing and reporting new health technologies, the Swiss healthcare market commonly uses reports from externally funded HTA agencies of high reputation (e.g., Ontario Health Technology Advisory Committee, National Institute for Clinical Excellence, etc.), together with reports from Swiss independent private organizations for decision-making processes. ICHI (www.ichi.ch), is an example of an organization that creates a forum for solving reimbursement issues where dialogue between companies who have developed new medical technologies and the respective medical societies leads to successful reimbursement strategies through HTA. A main goal is bringing all stakeholders together to find solutions to transfer innovative medical devices to the market. ICHI GmbH offers an integrated team of experts that regularly prepares HTAs together with reimbursement dossiers for submission to the Swiss FOPH (9).
As an example, in 1998 the Federal Department of Home Affairs requested a program for the evaluation of complementary medicine (10). Five complementary therapies such as traditional Chinese methods, homeopathy, or herbal therapy were included for a limited time for reimbursement (July 1, 1999, until June 30, 2005). In a difficult process, seeking consensus among representatives of different interest groups, a basic evaluation procedure was defined, comprising two parts: The evaluation conducted empirical studies and HTA (literature analysis including efficacy, appropriateness, safety, utilization, and cost-effectiveness). Despite positive results for some complementary methods, all of them were omitted from reimbursement at the end of the program by a political decision of the Swiss FOPH. The Ministerial decision was not accepted either by Swiss citizens or by the Swiss parliament. It is expected to be changed due to public pressure in 2009.
DISCUSSION
All healthcare systems are managed to some extent, and access to health technology is directly influenced by pricing decisions of governments. However, whatever technology appears and is used, eventually coverage will be given as long as peer—and public—pressure is present. Therefore, HTA may play a secondary role in coverage decisions.
Most probably because of an organizational change within governmental structures over the past 5 years, knowledge in the field of HTA is perhaps still present, but innovation has been transferred to private initiatives. The hidden consequences, if ignored by policy makers and healthcare professionals, may be crucial. In a regulated market driven without respect for HTA, different influences may seriously damage public health.
With the move of most Federal HTA activities to FOPH, the broad perspective of HTA seen in earlier days was somewhat lost. The FOPH activities, as stated, concern themselves mainly with HIV/AIDS and legal and illegal drugs. The implications of health technology in general are not visibly assessed, because if such assessments are done, they are done in a less visible way.
The main point is, that because health care is mainly an issue for the Swiss cantons, the federal government is largely not involved with most health technology. Earlier, the program in SFOSS concerned itself with all HTA and acted as a kind of force for coordination. There also were some Cantonal HTAs. However, cantons no longer do HTAs.
Switzerland probably needs a national agency of HTA such as those developed in most members of INAHTA. As seen also in the Netherlands (see study in this issue), the lack of a national approach and a requirement for coordination and communication of all HTA results has led to some duplication and considerable gaps in the concerns for health technology, at least as far as is known. Hopefully, this problem can be addressed during the next few years.
CONTACT INFORMATION
Pedro Koch, MD (pedro.koch@viterio-schweiz.ch), CEO and Owner, Viterio-Schweiz, Martinsbruggstrasse 65, 9016 St. Gallen, Switzerland
Julian Schilling, MD, PD (med@travelclinic.ch), Owner and Chief, Travel Clinic Zürich, Forchstr. 92, 8008 Zürich, Switzerland
Marlene Läubli, PhD, Head of Evaluation and Research Management, Swiss Federal Office of Public Health, 3003 Bern, Switzerland
Florian Mitscherlich, lic. Iur, CEO, ICHI, Adelbändli 10, 5000 Aarau, Switzerland
Dieter Melchart, MD, Professor, Technische Universität München; Director of Zentrum für Naturheilkunde Forschung ZnF, ZnF at TU München, Kaiserstrasse 9, 80801 Munich, Germany
Sergio Bellucci, Ing. Agr. ETHZ, CEO, TA-Swiss, Brunngassse 36, 3011 Bern, Switzerland
