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Brief analytical summaries or syntheses #43

Sweden – Health System Review

Summary

Published by the European Observatory on Health Systems and Policies, this report regards Sweden’s health system in detail. It describes the institutional framework, process, content, and implementation of Swedish health policies, highlighting challenges and areas that require further analysis.

Background

Sweden is a monarchy with a parliamentary form of government. The size of the population is about 9.4 million inhabitants and more than 80% of the population lives in urban areas. The GDP per capita, measured as purchasing power parity (PPP, current international US$), amounted to Swedish krona (SEK) 37 775 (€4200) in 2010. Life expectancy in Sweden is among the highest in the world. Diseases of the circulatory system are the leading cause of mortality, accounting for about 40% of all deaths in 2009. The second largest cause of death is cancer. There are three independent government levels – the national government, the 21 county councils/regions and the 290 municipalities. The main responsibility for the provision of health care services lies with the county councils and regions. The municipalities are responsible for care of older and disabled people.

The Swedish health care system is a socially responsible system with an explicit public commitment to ensure the health of all citizens. Three basic principles are intended to apply to health care in Sweden. The principle of human dignity means that all human beings have an equal entitlement to dignity, and should have the same rights, regardless of their status in the community. The principle of need and solidarity means that those in greatest need take precedence in medical care. The principle of cost–effectiveness means that when a choice has to be made between different health care options, there should be a reasonable relationship between the costs and the effects, measured in terms of improved health and improved quality of life.

Analysis and results

Organization and governance

The Health and Medical Services Act of 1982 specifies that the responsibility for ensuring that everyone living in Sweden has access to good health care lies with the county councils/regions and municipalities.

Financing

Health care expenditure as a share of GDP was 9.9% in Sweden in 2009. Health care is largely financed by tax in Sweden. About 80% of all expenditures on health are public. Both the county councils and the municipalities levy proportional income taxes on the population to cover the services that they provide. These two levels of government also generate income through state grants and user charges. About 4% of the population has voluntary health insurance (VHI), in most cases paid for by their employer. Funding from VHI constitutes about 0.2% of total funding.

Physical and human resources

There were about 25,500 hospital beds in Swedish hospitals in 2009, with slightly more than 4,400 in specialized psychiatric care and about 20,000 in specialized somatic care in county council hospitals, and about 1,100 in private hospitals.

In 2008, Sweden had 3.7 practicing physicians per 1000 population, compared to an EU average of 3.3. Also, the number of practicing nurses per 1000 population of 10.8 was above the EU average of 7.9.

Provision of services

Most of the work in public health as well as other health-related work is carried out at regional and local levels in Sweden.

Principal health reforms

Reforms in Swedish health care are often introduced by local authorities in county councils and municipalities. This means that the pattern of reform varies across local government, although mimicking behaviour usually occurs. During the past 10 years, reforms initiated by individual county councils have focused on developing primary care and coordinated care for older people.

Conclusion

Although Swedish health care ranks high in cross-country comparisons of population health, health care outcome measures and quality of care, the opposite is usually the case when it comes to technical efficiency. For specialized services, indications of poor technical efficiency are somewhat surprising since Sweden at the same time reports a low bed-rate per inhabitant and reasonably low average length of stay. More generally, however, studies suggest that there is no significant correlation between technical efficiency (measured by output and costs) and indicators reflecting quality of care across the 21 county councils. There is, however, no simple explanation behind the variation in quality and efficiency since no county councils perform well in all respects. The county councils that perform best in terms of quality of care, access, patient safety and costs seem to have accomplished this end in different ways.

Implications and recommendations

Assessment of the health system

Average life expectancy at birth in Sweden is among the highest in the world and has improved by 5.5 years over the last 30 years. Also, in terms of avoidable mortality, Sweden consistently ranks among the best OECD countries. Swedish health care also performs well compared to other countries with respect to disease-oriented indicators of health service outcomes and quality of care. The Achilles’ heel of Swedish health care has been the long waiting times for diagnosis and treatment in several areas. A number of initiatives at both national and local level have been implemented to reduce waiting times and improve access to providers. To improve access to diagnosis and treatment continues to be a key policy objective among both national and local politicians in order to improve the responsiveness to patients’ needs and maintain the legitimacy of the publicly financed health system.

In the past, regional equity and equity across socioeconomic groups in terms of quality of care was more or less taken for granted. As public comparison of indicators reflecting quality and efficiency across county councils and providers has revealed significant differences, this ideal has been challenged. Regional comparisons across county councils also suggest significant room for improvement, although Swedish health care performs well on average compared to most other countries.

The report also highlights the rather low level of investment in primary care and the possible detrimental effect on equity of access to services. In practice, priorities have been heavily influenced by past investments in health care, which have favoured hospital-based care. Policies have also been introduced at the national level to support the development of primary care, care for older people and psychiatric care. Mechanisms to support evidence-based and cost-effective vertical priorities have been introduced only in the last two decades.

Source

Sweden – Health System Review