What drives regional heterogeneity in hospital capacity planning? A qualitative study investigating the perspectives of Swiss cantons

Background: Hospital capacity planning can help to balance quality, cost-effectiveness, and accessibility of inpatient services. Achieving all three objectives equally is complex and requires a balanced and targeted approach. Moreover, the implementation of a national reform in this field in decentralized health systems is challenging. Objectives: This study explores how Swiss cantons (federal states) have implemented the national reform of hospital capacity planning, focusing on the factors that contribute to regional variation. As hospital capacity planning is attracting attention internationally, we aim to inform other countries on possible implementation approaches for centrally mandated reforms carried out within decentralized health systems. Methods: We conducted a document analysis of official cantonal materials, including hospital lists and mandates from 2012-2025. Additionally, 25 semi-structured interviews with cantonal representatives and experts were transcribed and analysed using inductive and deductive coding techniques. Results: Swiss cantons have mostly aligned their hospital capacity planning methods, especially in defining service groups and assessing need for care, following the model developed in Zurich. Differences still exist in how they apply specific requirements, such as minimum volume thresholds, which are affected by political pressures and cantonal priorities. While some cantons adopted the reform to boost quality and centralize services, others faced challenges like limited inter-cantonal collaboration, resource constraints, and the dual role of cantons as regulators and hospital owners. Conclusion: Despite formal autonomy, the widespread adoption of Zurich's planning tools has standardized key aspects of hospital capacity planning across cantons. The Swiss experience demonstrates that decentralized systems can achieve methodological convergence without strict national mandates, provided strong regional models exist. For other decentralized health systems, these findings highlight the importance of balancing national guidance with evidence-based regional flexibility, standardizing quality requirements, reducing political influence on decisions, and fostering collaboration to ensure equitable, high-quality hospital services.