In Switzerland, health care, disease prevention and health promotion policies are the responsibility of three government tiers: the federal authorities, the cantons, and the communes acting in a decentralized framework. During the 1990s and the first decade of the 21st century, the federal state elaborated strategic frameworks for disease prevention and health promotion. The lack of systematic data collection was partly alleviated by the creation of an Observatory of health (OBSAN) that produces reports for the cantons on the basis of a cyclic federal survey. A federal law on health promotion and prevention reached a very advanced stage, but closely failed to muster the consensus needed to pass. The trend towards more governance and coordination at the federal level is not univocal. On one hand, some recent or upcoming decisions, for example in the matter of the regulation of land use or fiscal policy, would tend to reinforce the centralized competencies. On the other hand, we can observe a definite trend of funding cuts at the federal level, along the lines of a more general intention to “untangle” financial and political responsibilities back to the Cantons. The development of equitable and sensible disease prevention and health promotion policies in a decentralized framework carries its unique set of risks and opportunities.