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[Public health, prevention and federalism: insights from the implementation of the federal law on health insurance].

OBJECTIVES
In 1996, the new Swiss law on health care insurance (KVG) introduced the coverage of certain preventive measures. This provided an opportunity to include research-based public health issues in federal health policy. The present article examines the problems with which the realization of those goals in a Federalist health care system with strong cantonal autonomy as it is found in Switzerland was confronted.


METHOD
Comparative qualitative case studies design (vaccination of school age children and screening-mammography).


RESULTS
Switzerland's federalist health care system strongly hinders the realisation of the Confederation's public health goals. Prevention falls into the cantons' autonomy and the federal KVG (Krankenversicherungsgesetz; Health insurance law) only regulates the coverage of the services provided, but does not contain any instruments to assure implementation in consistency with the policy goals. Under those circumstances, conflicts of interest between the implementing actors, varying cantonal preferences, and scarce resources block the implementation of public health goals.


CONCLUSIONS
The results imply stronger leadership of the Confederation in prevention policy and an improved consideration of implementation aspects in approving new measures to obligatory insurance coverage.