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N A N D DEThe European Observatory on Health Care Systems is a partnership between the World Health Organization Regional Office for Europe, the Government of Greece, the Government of Norway, the Government of Spain, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.
Health Care Systems in Transition Sweden 2001 Written by Catharina Hjortsberg and Ola Ghatnekar Edited by Ana Rico, Wendy Wisbaum and Teresa Cetani Swed
RESEARCH AND KNOWLEDGE FOR HEALTHBy the year 2005, all Member States should have health research, information and communication systems that better support the acquisition, effective utilization, and dissemination of knowledge to support health for all.
This document may be freely reviewed or abstracted, but not for commercial purposes. For rights of reproduction, in part or in whole, application should be made to the Secretariat of the European Observatory on Health Care Systems, WHO Regional Office for Europe, Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark. The European Observatory on Health Care Systems welcomes such applications.
The designations employed and the presentation of the material in this document do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Care Systems or its participating organizations concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The names of countries or areas used in this document are those which were obtained at the time the original language edition of the document was prepared.
The views expressed in this document are those of the contributors and do not necessarily represent the decisions or the stated policy of the European Observatory on Health Care Systems or its participating organizations. This disclaimer also applies to the Ministry of Health and Social Affairs of Sweden.
Introduction and historical background
Organizational structure and management
Organizational structure of the health care system
Planning, regulation and management
Decentralization of the health care system
Health care finance and expenditure
Main system of finance and coverage
Health care benefits and rationing
Complementary sources of finance
Health care expenditure
Health care delivery system
Primary health care and public health services
Public health services
Secondary and tertiary care
Human resources and training
Pharmaceuticals and health care technology assessment............. 64 Financial resource allocation
Third-party budget setting and resource allocation
Payment of hospitals
Payment of physicians
Health care reforms
Aims and objectives
Content of reforms and legislation
Foreword T he Health Care Systems in Transition (HiT) profiles are country-based reports that provide an analytical description of each health care system and of reform initiatives in progress or under development. The HiTs are a key element that underpins the work of the European Observatory on Health Care Systems.
The Observatory is a unique undertaking that brings together WHO Regional Office for Europe, the Governments of Greece, Norway and Spain, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. This partnership supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of the dynamics of health care systems in Europe.
The aim of the HiT initiative is to provide relevant comparative information to support policy-makers and analysts in the development of health care systems and reforms in the countries of Europe and beyond. The HiT profiles
are building blocks that can be used to:
• learn in detail about different approaches to the financing, organization and delivery of health care services;
• describe accurately the process and content of health care reform programmes and their implementation;
• highlight common challenges and areas that require more in-depth analysis;
• provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in the different countries of the European Region.
The HiT profiles are produced by country experts in collaboration with the research directors and staff of the European Observatory on Health Care Systems. In order to maximize comparability between countries, a standard template and questionnaire have been used. These provide detailed guidelines Sweden vi European Observatory on Health Care Systems and specific questions, definitions and examples to assist in the process of developing a HiT. Quantitative data on health services are based on a number of different sources in particular the WHO Regional Office for Europe health for all database, Organisation for Economic Cooperation and Development (OECD) Health Data and the World Bank.
Compiling the HiT profiles poses a number of methodological problems. In many countries, there is relatively little information available on the health care system and the impact of reforms. Most of the information in the HiTs is based on material submitted by individual experts in the respective countries, which is externally reviewed by experts in the field. Nonetheless, some statements and judgements may be coloured by personal interpretation. In addition, the absence of a single agreed terminology to cover the wide diversity of systems in the European Region means that variations in understanding and interpretation may occur. A set of common definitions has been developed in an attempt to overcome this, but some discrepancies may persist. These problems are inherent in any attempt to study health care systems on a comparative basis.
The HiT profiles provide a source of descriptive, up-to-date and comparative information on health care systems, which it is hoped will enable policy-makers to learn from key experiences relevant to their own national situation. They also constitute a comprehensive information source on which to base more indepth comparative analysis of reforms. This series is an ongoing initiative. It is being extended to cover all the countries of Europe and material will be updated at regular intervals, allowing reforms to be monitored in the longer term. HiTs are also available on the Observatory’s website at http://www.observatory.dk.
Acknowledgements T he HiT on Sweden was written by Catharina Hjortsberg and Ola Ghatnekar (both from The Swedish Institute for Health Economics).
The HiT was edited by Ana Rico, Wendy Wisbaum, and Teresa Cetani (European Observatory on Health Care Systems).
The European Observatory on Health Care Systems is grateful to The National Board of Health and Welfare of Sweden and to Richard Saltman (European Observatory on Health Care Systems) for reviewing the report, and to the Swedish Ministry of Health and Social Affairs for its support. The editors also thank Reinhard Busse for his special help in reviewing the report.
The current series of Health Care Systems in Transition profiles has been prepared by the research directors and staff of the European Observatory on Health Care Systems.
The European Observatory on Health Care Systems is a partnership between the WHO Regional Office for Europe, the Governments of Greece, Norway and Spain, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.
The Observatory team working on the HiT profiles is led by Josep Figueras, Head of the Secretariat and the research directors Martin McKee, Elias Mossialos and Richard Saltman. Technical coordination is by Suszy Lessof.
The series editors are Reinhard Busse, Anna Dixon, Judith Healy, Laura MacLehose, Ana Rico, Sarah Thomson and Ellie Tragakes.
Administrative support, design and production of the HiTs has been undertaken by a team led by Myriam Andersen, and comprising Anna Maresso, Caroline White, Wendy Wisbaum and Shirley and Johannes Frederiksen.
Special thanks are extended to the Regional Office for Europe health for all database from which data on health services were extracted; to the OECD for
the data on health services in western Europe, and to the World Bank for the data on health expenditure in central and eastern European (CEE) countries.
Thanks are also due to national statistical offices which have provided national data.
Introduction and historical background Introductory overview Political and economic background S weden is situated on the Scandinavian peninsula, in the northern part of Europe (see Fig. 1). The country covers an area of 449 964 km2, of which 54% is covered by forest. The population is 8.9 million (1999) and Stockholm, the capital, is the largest city, with 1.1 million habitants. On average, the country has 22 persons per km2 but it is unevenly populated, as 84% of the population live in urban areas. There is a high concentration of inhabitants in the coastal regions and in the south. Swedes are the predominant ethnic group (about 90% of the population). Other residents include immigrants from Finland, South America, the Middle East, Asia and the Balkans. Sweden has two minority groups of native inhabitants in the north: the Finnish-speaking people of the northeast and the Sami (Lapp) population. The main language is Swedish and 85% of the population belongs to the Church of Sweden, which is Lutheran.
The educational system reaches the entire population and the literacy rate is 99%. In 1999, 24% of the population aged 16–74 years had a university education of at least two years. The corresponding figure among 25–49 year olds was 31%. Female participation in the workforce is also high, constituting 48% of the labour force in 1998. However, part-time work is more frequent among women than men.
Living standards are among the highest in the world and the GDP per capita, measured as purchasing power parity adjusted Euros, amounted to 20 798 in
1999. In the 2000 United Nations Human Development Index Sweden was ranked sixth.
Sweden is a monarchy with a parliamentary form of government. The King is the head of state, but his position is only symbolic and the power rests with the parliament (Riksdag). The governing process in Sweden works on three democratically elected levels: the Riksdag at national level, the 21 county councils (landsting) at regional level, and the 289 municipalities at local level, each with different spheres of responsibility. Elections at all three levels are held every fourth year.
The Riksdag is the legislative assembly and has 349 seats, of which 310 are directly elected and the rest are divided among political parties on the basis of votes received nationally. The Riksdag elects the Prime Minister and the Prime Minister, in turn, appoints the government. At regional level, the state is represented by the County Administrative Board (Länsstyrelsen), which can be described as the prolonged arm of the state. The members of the County Administrative Board are appointed by the county council, which is democratically elected at the local level. Their main responsibility is health and medical care, but also dental care, public transport, tourism and cultural life in the region.
The municipalities are responsible for local issues in the immediate environment of the citizens, e.g. education, childcare, care of the elderly, roads, water, sewage, energy, etc. Both the county councils and the municipalities levy separate proportional income taxes on their residents to pay for the services that they provide.
Sweden has a mixed state and private economy based on services, heavy industries and international trade. Sweden’s natural resources include forests, iron ore, copper, lead zinc, silver, uranium and water power. In 1998, the agriculture, forestry and fishing sectors together accounted for approximately 2% of GDP, whereas the manufacturing sector accounted for 21%. The services sector accounted for 43.5% of GDP this same year, and the fastest growing sector is the electrical and optical equipment industry. Private and public consumption amounted to 54% and 28%, respectively, of the gross domestic final consumption in 1998 (the remainder were investments).
The Swedish economy expanded rapidly during the 1950s and 1960s, with annual GDP growth averaging 3.4 and 4.6%, respectively. This development was broken during the 1970s both due to tight monetary policy and the oil crisis. Sweden reacted to the resulting recession by expansionary economic policy and large wage increases. The results of this economic policy, however, were not positive and Sweden did not enjoy growth in the 1980s at the same level as its neighbours. A series of devaluations were made during the late 1970s and beginning of 1980s in order to boost exports. A deregulation of financial markets also led to growing domestic demand. In spite of this, average GDP growth remained at 2% during the 1980s, while the inflation rate surged.