Deinstitutionalization in Switzerland: The Incrementalist Model

Abstract

Processes of deinstitutionalization of mental health care are particularly difficult to assess in Switzerland because of the complexity of the country's health care delivery system. Each of the 26 states, or cantons, that make up the Swiss Confederation is fully autonomous in structuring its health care facilities. Administration and financing of hospitals are a cantonal responsibility; most psychiatric hospitals are publicly owned. It is only a terms of federal financing, health insurance subsidies, and issues of consensus of the medical profession that some nationwide parameters impinge upon the diverse policies of the cantons. Deinstitutionalization of psychiatric services is precisely one of the processes in which cantonal differences have manifested themselves in the extreme. Six cantons have no psychiatric hospitals and rely on service agreements with neighboring ones; the five cantons with medical schools Geneva, Vaud, Berne, Basel City, and Zurich have university psychiatric hospitals in addition to state psychiatric hospitals. These five cantons together supplied 47.5% of Swiss psychiatric beds in 1975 [1]. The number of beds for psychiatric care per 1,000 inhabitants ranges from a high of over 6, in Appenzell (because of high out-of-state utilization), to a low of 1.2, in the Valais; the average is 2.4. There are similar variations in the distribution of psychiatrists, the national average in 1979 be-