Social support systems
Organisation and financing of social support to people with dementia and carers
Background information on the social/healthcare system in Switzerland
The first Swiss health insurance act was passed by the Federal Government in 1911. This obliged insurers to register with the Federal Social Insurance Office. The insurances were individually contracted (i.e. not employer based) and the funds were not allowed to make a profit. Individual cantons could decide whether the insurance was obligatory but by 1990, nearly 98% of the population had purchased such an insurance.
The revised Health Insurance Law of 1994 significantly changed the system and made health insurance obligatory for all residents in Switzerland. Insurance companies are obliged to accept all applications for insurance cover and the insured are allowed to change insurer once or twice a year (Civitas, 2002).
The organisation of social support for people with dementia and carers
Financial support is mainly organised at federal level. Support is also organised by the cantons and the communes but organisation differs from one canton to the other. There are no special provisions for people with dementia.
The Federal Department of Home Affairs (especially the Federal Social Insurance Office and the Federal Office of Public Health) of the Swiss Confederation is responsible for creating the legal framework and organising support to people with dementia and their carers at federal level. Various organisations at cantonal level are also involved. Private initiatives and voluntary associations are quite important as the State does not cover everything.
Organisations which provide support to the elderly and to sick people receive grants from the Federal Social Insurance Office. The Swiss Alzheimer Association benefits from State support. It receives a subsidy (of a fixed amount) and money for the services it provides e.g. the helpline and respite care at home (also for its branches). Other associations like Pro Senectute also receive subsidies.
The overall funding of social support for people with dementia and carers
Support for people with dementia and carers is financed by different sources: social insurances for old age and incapacity, obligatory health insurance, income taxes and of course the private income and fortune of the people concerned.
Social insurances (Old Age and Survivors insurance and Incapacity insurance) cover the costs for the “vital minimum” for all residents in Switzerland. They are financed by obligatory payroll deduction (under the AHVG and IVG laws – please see below).
The obligatory health insurance contributions (premiums) are set according to age, gender and rates applied in each region of the country (costs vary from one region to another and health politics are largely the responsibility of the cantons). They are not linked to earnings or income. Each person is insured individually. People whose contributions represent 8 to 10% of their income may be entitled to means-tested tax-based subsidies from the State and the cantons. The cantons have the power to define the criteria for the granting of such subsidies.
The obligatory health insurance covers part of the cost of home care (provided by the home care organisation Spitex) or residential care (based on prices that are determined by the cantons). Patients/service users must pay an annual franchise and make a further contribution towards costs. The remainder of the cost is covered by the cantons. People may opt for a higher franchise in order to reduce their health insurance premium.
People who have difficulty coping with daily life activities may apply for an incapacity allocation from the State. Private insurance offers the possibility to take out a special insurance for this kind of costs.
The legal framework surrounding the provision of social support
The main legislation of relevance to the provision of support to people with dementia and their carers is as follows:
- Bundesverfassung (Constitution SR 101;18.4.99, which came into force on 1.1.2000) Art. 41: social support and care for all people is guaranteed by the Confederation and the Cantons.
- Bundesgesetz über die Alters- und Hinterlassenenversicherung AHVG (Federal law on old age and survivors insurance) (SR 831.10; 20.12. 46 which came into force on 1.1.49, with various revisions). This assures a minimum income for elderly people including complementary financial support if needed (Bundesgesetz über Ergänzungsleistungen zur Alters-, Hinterlassenen- und Invalidenversicherung ELG, SR 831.3). Art. 43bis covers an allocation for incapacity - “eine Hilflosenentschädigung”.
- Bundesgesetz über die Invalidenversicherung IVG (Federal law on incapacity insurance) (SR 831.20; 19.6.59 which came into force on 15.10.59, with various revisions). This assures a pension and other financial help in case of incapacity. It also foresees an allocation for people with an incapacity who have not yet reached the age of retirement.
- Bundesgesetz über die berufliche Alters- , Hinterlassenen- und Invalidenvorsorge (Federal law on professional insurance for old age, survivors and invalids) (SR 831.40, 25.6.1982, which came into force on 1.1.85) including various important revisions. It introduced an obligatory insurance for employees (payroll deduction). This assures an old-age pension and an invalidity pension.
- Bundesgesetz über die Krankenversicherung (Federal law on health insurance) (SR 832.10; 18.3.94, which came into force on 1.1.96). It concerns the basic obligatory insurance which covers the cost of medical treatment, drugs and care (also partly long-term care).
The laws are completed by a series of regulations, such as the Krankenpflege-Leistungsverordnung (KLV) RS 832.112.3, which determines the nature of the care acts, organisation of care in institutions and home care services. However, there are also many cantonal laws and regulations because in Switzerland health care is a cantonal matter (i.e. there are 26 different legislations).
With regard to legislative reforms, a revision of health insurance is planned, particularly regarding long-term care. It is proposed that the insurance should only pay part of the cost. According to the law in force, dating back to 1994, all costs should be paid by the obligatory insurance but, due to the increase in costs, lower tariffs have been applied to calculate the part of the insurance. The new law aims to fix the part of total costs to be covered by the obligatory insurance. The remaining costs will have to be paid by the patients and the cantons.
The suitability of social support for people with dementia and carers
Adequacy and accessibility in general
Obtaining the necessary information requires a lot of personal effort. The Swiss Alzheimer Association with 20 branches in the Cantons and some other organisations (e.g. Pro Senectute) offer information and some services.
Homecare provided by Spitex (an organisation specialising in homecare services) is very well developed, also in rural areas.
There are not enough day and night care centres (a study carried out by Swiss Alzheimer Association stated that only 12% of needs are covered by the existing 124 centres). Financial support is insufficient.
More and more residential care settings are introducing specific dementia units but there are not enough to cover needs.
The services that the Swiss Alzheimer Association (and some other organisations) offers respond to the specific needs of people with dementia and their carers.
People living in rural areas
As stated above, Spitex offers homecare services in rural areas as well as in agglomerations but day and night care centres are scarce and the few that exist are mostly located in larger agglomerations. Transportation services provided by the Red Cross and volunteers are not well developed in rural areas.
People from ethnic minorities
A special nursing home for people with dementia from Latin countries was set up in Zurich 2 years ago and there is also a Jewish nursing home near Zurich.
Younger people with dementia
The Swiss Alzheimer Association offers support groups for carers (and children) of younger people with dementia and is planning to organise holiday weeks for younger people with dementia (with/without their carers).
Services and support for people with dementia and their carers
Types of care
Day care centres exist but they are insufficient as they only cover about 12% of actual demand. Fairly often they are operated by nursing homes. Some are partly subsidised by the Cantons or communes but there are also centres which do not receive any funding from the State. Some centres also offer night-time care.
Some branches of Alzheimer Switzerland offer private respite care at home on a one-to-one basis. This service is possible by the hour and also for whole days and nights. It is financed by the family and so far some subsidies have been received from the State. The respite carers receive a small remuneration.
Nursing homes offer short-term stays to relieve carers (as long as the bed is not occupied by a long-term resident…). These can be partly funded by the State and partly by service users.
Long-term residential care
Long-term residential care is funded by service users and the health insurance. Service users pay for hotel costs, which means the actual cost of accommodation and the health insurance covers care costs but only up to a maximum of FR 80 per day. There may also be additional out-of-pocket expenses such as materials for care, various services and small personal expenses. The state/canton/commune may pay the amount that is not covered by the health insurance if the service user does not have sufficient resources. The price for long-term residential care is the same for all residents. It is not means tested.
Palliative care services at home and in centres are mostly available. They are funded by the State, the health insurance and the patients themselves. Some NGOs, volunteers and churches also offer such services. According to the European Association for Palliative Care (2005), there are some hospices that are funded privately. The Swiss homecare association (Spitex) states that it provides support to the dying and their families (Spitex, 2007).
Monitoring in the home via alarm systems
A tele-alarm system is available but people must pay for it themselves. The State does not contribute towards the cost.
Personal assistance and home help
The following services are available in Switzerland:
- Assistance with personal hygiene
- Supervision/assistance taking medication
- Assistance eating and drinking
- Assistance with mobility e.g. lifting, moving and walking
- Assistance with incontinence
- Assistance with skin care
- Companionship/social activities
- Occupation therapy/ergotherapy
- Assistive devices
- Home adaptation/transformation
The first four services are provided by Spitex (the homecare services organisation) and are considered sufficient. Spitex may also provide assistance with incontinence and skin care. These services are partly funded by the State and partly by the obligatory health insurance. Patients must pay the remainder themselves. Volunteers also provide assistance with personal hygiene and mobility and it is possible that other associations offer assistance with eating and drinking. Spitex is limited in the time that it can spend on assistance with mobility.
The Swiss Alzheimer Association and some volunteers provide companionship and social activities. This is insufficient. Service users must pay for these services completely.
Occupational therapy/ergotherapy is mainly provided in day care centres/homes. Spitex also provides this service in peoples’ homes. The service is partly financed by the health insurance if the person has a medical prescription and partly by the person him/herself.
Assistive devices are available and some are funded by the health insurance or incapacity insurance but many people do not know about them.
Home adaptations are partly funded by the State and partly by the person who needs them. It is possible to obtain funding from an incapacity insurance.
Certain services are available but are not funded by the health insurance. Consequently, service users have to pay for them themselves. This includes assistance with housework (can be provided by Spitex), help with the preparation of meals including meals-on-wheels (provided by the Swiss Red Cross and Pro Senectute), assistance with shopping (provided by volunteers), transportation (provided by the Swiss Red Cross and volunteers but not well developed in rural areas) and laundry services (provided by Spitex).
Psychosocial support and training for people with dementia and carers
The State does not have a service to inform the public of the availability of various services but it does finance the helpline of the Swiss Alzheimer Association and certain other organisations which provide information about services. NGOs and volunteers are also involved in providing this service. However, these services need to be developed further.
Counselling services for people with dementia are being set up in different places but, at the moment, they are insufficient. Those that exist are partly funded by the State and partly by service users. NGOs receive financial support from the State for these services in the form of grants. Counselling services for carers are sufficient and partly financed by the State (e.g. in the form of grants to NGOs) but carers also have to partly pay for counselling themselves. However, the Swiss Alzheimer Association and the organisation Pro Senectute both offer counselling services for carers.
Services to enable people with dementia to take holidays are under construction and being extended. There are currently eight branches of the Swiss Alzheimer Association and some Pro Senectute organisations offering this kind of service. They are partly funded by the State (the Federal Social Insurance Office to be precise) in order to cover the costs of the assisting volunteers. Service users (people with dementia and carers) must pay their own hotel costs. There are also nursing homes that offer holiday stays for people with dementia. Costs are paid by the service users.
There are currently no official services designed to give carers a holiday (i.e. a substitute carer or holiday money). When a carer is unable to take care of the person with dementia because of his/her own health problems, the person with dementia can be taken into a hospital or a nursing home. The sick carer is entitled to the necessary treatment and drugs through the health insurance. Short stays in spas or similar centres for relaxation on medical prescription are very rare. Private insurance arrangements may offer cover for a substitute carer.
As the State does not contribute towards the cost of training, carers must pay for it themselves. The Swiss Alzheimer Association and a few other organisations such as memory clinics, Pro Senctute and the Swiss Red Cross may occasionally organise training for carers.
Work/tax related support for people with dementia
The Employment Law in the Code of Obligations contains limited provisions to protect people against dismissal on the grounds of illness. It does not specifically mention dementia. However, there are some regulations for blocking periods (“Sperrfristen”) in case of illness during which time a person cannot be dismissed.
The Federal Law on Old Age and Survivors Insurance (AHVG) and the Federal Law on Incapacity Insurance (IVG) contain provisions for an incapacity allocation.
A tax deduction for costs incurred due to an illness is granted on the basis of federal and cantonal laws. There is no tax refund for employing someone to provide home care services.
People with dementia are entitled to financial assistance to make home adaptations. This is covered by the Law on Incapacity Insurance (IVG) and the Decree on the provision of Means of Assistance through the Invalidity Insurance of 29.11.1976.
Work/tax related support for carers and carer allowances
Carers do not have any legal right to paid or unpaid time off work for caring. However, the law (the Employment Law in the Code of Obligations, Art. 329) has been extended by jurisprudence. It is therefore possible to have paid time off work to care for a terminally ill person but otherwise people are dependent on the goodwill of their employer.
Art 36 of the Employment Law of 13/3/1964 states that employers have to take family responsibilities (including the care of a sick relative) into account when fixing working hours. Employees do not have a legal right to flexible working hours but a lot of companies in Switzerland offer flexible working hours to all their staff.
The State does not offer free or subsidised pension contributions to carers. The AHV- contribution is deducted from the income. Carers who have a paid activity pay the normal contribution. Carers who do not have a professional paid activity do not pay contributions but at the end, they have less credit. In accordance with the Federal Law on Old Age and Survivors Insurance (AHVG), carers who cannot work and thus pay their contributions to the State pension fund are entitled to some kind of compensation. This may take the form of credits towards their pension (AHV-Betreuungsgutschriften) or in some cantons, a direct payment.
Unless otherwise stated, information provided by Marianne Wolfensberger (the Swiss Alzheimer Society) in September 2007.
- Website containing texts of relevant laws in French and German: http://www.admin.ch/ch/f/rs/831_10/index.html
- European Association for Palliative Care (2005), Report on palliative care in Switzerland: http://www.eapcnet.org/download/forPolicy/Switzerland.pdfl
- Pro Senectute (an organisation for seniors): http://www.pro-senectute.ch/f/index.cfm
- Spitex (2007), website of the Swiss homecare association: http://www.spitexch.ch
- The Swiss Healthcare System 2002: http://www.civitas.org.uk/pdf/Switzerland.pdf
- Federal Office of Public Health: http://www.bag.admin.ch
 The information in this report on social support for people with dementia and their carers in Switzerland was provided by Marianne Wolfensberger from the Association Alzheimer Suisse.
Last Updated: mercredi 15 juillet 2009