Since the Middle Ages, hospitals have been charitable welfare institutions for all those in need of care. In the 19th and 20th century, they developed into larger institutions which play an increasingly important role in the welfare state.
Hospitals in the Middle Ages and Early Modern Period
In the Middle Ages and Early Modern Period, hospitals did not only help those with medical issues but also provided for those in need, whether they came from near or far. They thus served the sick as well as the infirm, elderly or poorer citizens who could not be tended by their relatives, as well as travellers and pilgrims. Hospitals resembled welfare institutions for the destitute and the marginalised. They were originally run by churches or monasteries. Around 1300, in many regions, communities and cities took over the administration of the hospitals, though the institutions themselves often continued to be run by members of religious orders. The hospitals typically held tracts of land and benefited from the secularisation of church property in Protestant regions; they also received donations from the upper classes in the 17th and 18th centuries. Many cities built new hospitals or renovated existing ones in the 18th century, and in the process, different groups of people in need – men and women, the healthy and the ill – were increasingly separated from one another. In Catholic hospitals, members of religious orders often cared for the sick.
Hospitals in the Institutional Landscape of the 19th Century
Hospitals continued to serve as welfare facilities for the old and needy, the ill and the mentally or physically disabled, until well into the 19th century. The number of care homes and asylums grew significantly during the 19th century. Shaped by middle-class debates about reform, increasingly specialised institutions were established for individual groups of people in need. Specialised asylums met the need for nursing and care of the afflicted, along with the felt need to control public order.
Throughout this development, hospitals continued to be responsible for patients in need of shorter or longer-term care. Clinics run by universities were established alongside public hospitals; they mainly served to train medical students. In these clinics, patient treatment was explicitly the responsibility of doctors, and the diagnoses made and the therapies tested here set new standards for hospitals as a whole. The clinics became specialised infirmaries, introduced the idea of having permanent physicians, and improved diagnoses as well as nursing and treatment methods. This allowed specialized disciplines such as surgery to made considerable progress. Spatial differentiation in the hospitals progressed, and departments were subdivided into functional wards. Beginning in the 1830s, hospitals were also set up in rural areas to satisfy the growing local demand for medical services; the cantons thereby became involved in the hospital sector for the first time.
Hospitals in the Welfare State
Despite these developments, hospitals still had less prestige in the early 20th century in terms of providing social assistance than did charitable organisations primarily serving the poor. Those who could afford home visits by a doctor did not go to hospital, and many hospitals remained financially dependent on private donations.
The financial situation of the hospitals gradually began to change after 1914 once the Health and Accident Insurance Act passed. Since the Confederation subsidized the health funds, insurance contributions became an increasingly important element in hospital financing. This was a rather drawn-out, slow process, as health insurance remained voluntary at the national level and in most cantons (even in 1945, only around 50 percent of the population were insured).
The composition of hospital staff also changed in the interwar period: there were more and more assistant doctors in training. The training of nurses was likewise professionalised, as they now received more specialized training, and nurses associated with religious orders were increasingly supplanted.
During the boom years in the 1950s and 1960s, technology used in the cantonal hospitals improved, and the cantons also founded additional regional and district hospitals. New treatment methods and medications were introduced. While the number of hospital beds and the duration of hospital stays increased only slightly, the frequency of hospital visits rose sharply. The doctors’ profession also benefited from an accelerated expansion of the healthcare sector in the decades following the Second World War. In particular, the group of employed doctors who worked in hospitals increased significantly compared to the rather slow growth among general practitioners in private practice.
These developments brought about sharp increases in hospital costs, driven especially by the rising cost of medications and of innovative medical equipment. The costs were assumed by the public authorities and by patients, more and more of whom benefited from health insurance. Health insurance coverage increased from around 50 per cent in 1945 to 80 per cent already by 1960. Although the cantons were the largest funders, they did not force the hospitals to coordinate their services or streamline how they were run. Despite the rising costs, the expansion of this sector was politically uncontroversial. The economic boom led to increasing affluence, and investing the new wealth in higher quality healthcare was popular among broad segments of the population. In 1964, the Confederation reorganised healthcare funding by linking federal subsidies for healthcare funds with their expenditure trends. This resulted in hospitals and healthcare funds expanding what they covered under their basic insurance scheme.
Hospital Reforms since the 1970s
The recession in 1974/1975 marked the end of the extraordinarily long period of economic growth. Consequently, a critical eye was increasingly cast on hospital and healthcare costs, with the cantons taking measures to limit rising costs, and restructuring hospital infrastructures to eliminate duplicated services. Since 1996, lists set out the hospitals in which patients may seek treatment that is covered by their mandatory health insurance. Though people in many areas opposed the closing of ‘their’ hospitals, the number of general hospitals and specialized clinics fell from 378 to 289 between 1998 and 2014, and in this same period, around 20 percent of the previously available hospital beds disappeared.
Further attempts to limit rising costs sought to change how hospitals worked. A new system of hospital financing meant to ensure that the available resources would be used more efficiently and that hospitals would compete with one another. Since 2012, funding no longer goes directly to the hospitals themselves, but is instead provided, through flat rate payments, for medical or other services provided. The level of the payments now depends on the diagnosis and treatment ordered for the patient. If treatment costs fall within the basic insurance cover, 45 percent (at most) is assumed by the insurance company and 55 percent (at least) by the public authorities. Ten percent of the flat-rate payments are earmarked for investment costs incurred by the hospitals. In 2009, the cantons pledged to coordinate ‘leading edge medicine’ (e.g., the highly specialised wards) across cantonal borders.
It remains difficult to assess whether the measures undertaken have actually had a cost-saving effect, or to determine what other effects they may have had.
Literatur / Bibliographie / Bibliografia / References: Donzé Pierre-Yves (2003), Bâtir, gérer, soigner: Histoire des établissements hospitaliers de Suisse romande, Genève ; Gilomen-Schenkel Elsanne (1999), Mittelalterliche Spitäler und Leprosorien im Gebiet der Schweiz, in Stadt- und Landmauern 3, 117-124 ; Lengwiler Martin, Rothenbühler Verena (2004), Macht und Ohnmacht der Ärzteschaft: Geschichte des Zürcher Ärzteverbands im 20. Jahrhundert, Zürich.