Creating competent health-care specialists: the Swiss school of public health.

The Swiss health-care system (the second most expensive worldwide) is fragmented into 26 cantonal authorities for a population of 7.5 million. Cantons differ in policy, legislation and structure. Health insurance is compulsory although contributions vary greatly between cantons. A recent report by the Organization for Economic Cooperation and Development (OECD) pointed out that weak governance has led to a system in which "efficiency can be improved", "a broader legal framework for health promotion and disease prevention is overdue", and "equity is not guaranteed". To a certain extent, this situation is due to the scarcity of specialists who know how to judge and respond to health needs and who also understand the complexities of financial flows and the effect of policy interventions in complex systems. As in most countries, health economics and public health have developed independent training programmes, mostly without any coordination or cooperation. Health services therefore are often managed by lawyers or business economists who apply free-market instruments to this regulated system. In the Swiss context, this leads to ever-increasing costs and inequalities without evaluation of potential health gains.