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«Sweden Health Care Systems in Transition i IONAL BA NAT NK ER T FO IN R WORLD BANK PLVS VLTR REC ENT ON PM ST O R L UC VE TI O N A N D DE The ...»

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Sweden 4 European Observatory on Health Care Systems In 1990, the focus of economic policy shifted from low unemployment to a stable exchange rate and low inflation. A tax reform was also initiated, but for various reasons the policies failed and, in 1992, Sweden had to abandon the fixed exchange rate policy. The Swedish Krona was immediately depreciated by 25%. Exports fell to a low of 22.6% of GNP in 1992 which, in turn, led to high unemployment rates. In particular, registered unemployment as a percentage of the labour force, which departed from very low levels at the start of the decade, jumped to almost 10% in 1993 (see Table 1). The population covered by labour policy measures (training courses, etc.) is not included within official registered unemployment figures. When these additional population groups are taken into account, total unemployment rates increase to approximately 15% in the mid-1990s.

In order to restore the Swedish economy, a programme of fiscal restraint was given high priority in the government’s economic policy. Great emphasis was also put on reducing unemployment. After the high levels of interest rates in the first half of the 1990s, interest rates started to fall in 1995. This was partially due to falling inflationary expectations. Since 1999, interest rates have tended to move upwards in response to the growth in the world economy. In 2000, exports of goods and services were equivalent to 47% of GDP.

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Source: Statistics Sweden, OECD HealthData2000.

Health status Like many other industrialized countries, Sweden has a low birth rate, 1.5 per woman in reproductive age. This results in a negative natural population growth, but due to a positive net migration flow, the total population increase per 1000 inhabitants in 1999 reached 0.74. Life expectancy is high, and of the Nordic countries, Sweden has among the longest life expectancy at birth: 77.5 for men and 81.1 for women (2000). Average life expectancy rose during the 1990s, and today Sweden has the world’s oldest population, with almost every fifth person aged 65 years or older (see Table 2). This ageing process has important

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Source: Statistics Sweden, a = Forecast Furthermore, infant mortality decreased substantially during the 1990s, from 6 to 3.2 deaths per 1000 live births in 1990 and 2000, respectively. Programmes to prevent diseases and injuries have been successful in some cases, e.g.

mortality due to cardiovascular diseases (CVD) has declined, although CVD accounted for approximately 50% of all deaths in 1998. The second largest cause of death was tumours, which amounted to 25% for men and 22% for women (1998). Deaths due to mental diseases and diseases in the nervous system, eyes and ears increased between 1987 and 1997 (see Table 3).

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During the 1990s, the number of daily smokers decreased substantially, to 15% and 22% for men and women, respectively, in 1999. In 1989, the corresponding figures were 25.5% for men and 26.2% for women. This reduction has been attained partly by non-smoking campaigns and tax increases on tobacco.

Local authorities, county councils and municipalities are responsible for the provision of health care. An advanced and extensive system of social security provides universal benefits for sickness, maternity and unemployment, child care, the elderly and the disabled. The Swedish health care system is a socially responsible system with an explicit public commitment to ensure the health of all citizens, and immigrants and residents qualify for the same health care as citizens. Health care is publicly financed and to a very high degree, publicly provided as well.

Historical background The present day structure of the Swedish health care system reflects its long history. In the seventeenth century, towns and cities employed physicians to provide publicly-provided care. In rural areas, where the majority of the population was living at the time, the central government employed physicians for the provision of basic medical care. The provision of health care has been a predominantly public responsibility since then, and public provision has accounted for a very high proportion of total health care provision.

Sweden’s first hospital, the Serafimerhospital, was set up in Stockholm in

1752. It had eight beds that were supposed to fulfil the need for hospital care of the entire Swedish population, including Finland (at the time ruled by Sweden).

In 1765, the “Diet of the four estates” paved the way for the establishment of a number of hospitals by permitting local authorities to spend locally-collected resources on the construction of a hospital. One hundred years later, Sweden had 50 hospitals and approximately 3000 beds. Most of the hospitals were small, with only 10–30 beds, and initially they only had one physician each.

As they did not provide any outpatient care, most health care services were provided by physicians outside the hospitals. Public health care provision was initially administered by the Collegium Medicum. In 1813, the Sundhetscollegium took over this responsibility and, in 1878,this body became the Royal Medical Board.

In 1862, the county councils were established, and health care was one of their principal duties. This was the beginning of the structure of today’s Swedish





SwedenHealth Care Systems in Transition 7

health care system. Responsibilities were gradually transferred from central government to the county councils. Only the acute care somatic hospitals shifted ownership in the 1860s, and it was not until the Hospital Act in 1928 that the county councils became legally responsible for providing hospital care to their residents. This act formed the basis for the present day responsibilities of the county councils. However, the responsibility of providing outpatient care was not included in the act and treatment of some patient groups, e.g. mental and long-term care patients, was excluded from the general rule. In the 1930s, the county councils were gradually given responsibility for various non-hospital health care services, such as maternity and paediatric health care, child dental care, etc. Ambulatory care was offered primarily by private practitioners in their own offices or at the hospital. At the end of the 1930s, less than one physician out of three held a hospital post. This situation drastically changed by the 1960s, at which time roughly 50% of all physicians were employed at hospitals.

After the second world war, the first important step towards universal coverage for physician consultations, prescription drugs, and sickness compensation was taken (1946), when a National Health Insurance Act was voted by the parliament. The plan was for expenditures on physician consultations, prescribed drugs and inpatient care to be reimbursed up to a certain level but, due to financial constraints and to the desire to achieve consensus among all involved parties, especially the physicians, the act was not implemented until 1955.

In the post-war era, a considerable expansion of the Swedish health care sector began, particularly in the hospital sector. New therapeutic and diagnostic procedures created new sub-specialties both among the physicians and hospital structures. As technology improved, so did the health status among the Swedish population and the eradication of some diseases began, e.g tuberculosis. Like most other western European countries during this period, the Swedish health care delivery system became hospital-based and approximately 90% of health care expenditures were consumed by the hospitals. In 1963, the county councils assumed responsibility for the provision of somatic outpatient care in addition to hospital care, which was a means for improving coordination of health care provision.

In 1968, the Royal Medical Board was transformed into the National Board of Health and Welfare, which still today is responsible for the supervision of both health and social services. It is also responsible for health- and social services statistics. The National Corporation of Swedish Pharmacies was founded in 1971 when private retail distribution was nationalized.

Sweden 8 European Observatory on Health Care Systems In 1970, as part of the “seven-crown reform”, outpatient services in public hospitals were taken over by the county councils. The patients paid seven crowns to the county council for each outpatient consultation and the county council was compensated directly by the national health insurance authority for the remainder of the cost. The considerably reduced fee incurred by the patient made health care more accessible for low income groups. The reform also meant that physicians in hospital outpatient departments became salaried employees of the county councils. In addition, physicians were no longer allowed to treat private patients seeking outpatient care in county council facilities.

During the 1980s, responsibility for the health care planning was decentralized from the national level to the county councils. The overall objective of the public health services was stated in the 1982 Health Care Act as providing “good health care on equal terms for the entire population”. According to the act: “Every county council shall offer good health and medical services to persons living within its boundaries. [...] In other respects too, the county council shall endeavour to promote the health of all residents. […]”. The Act gave the county councils full responsibility for health care delivery related matters, i.e.

they were not only responsible for providing health care, but also health promotion and disease prevention, for their residents. As a consequence, the two university hospitals (the Karolinska Hospital of Stockholm and the Academic Hospital of Uppsala) came under the ownership of the county councils in the early 1980s, as did responsibility for the public vaccination programmes.

In 1985, a reform of the health insurance system, the Dagmar Reform, was introduced. Health insurance reimbursement for ambulatory care was no longer transferred to the county council according to the number of outpatient visits.

Instead, a capitated reimbursement formula adjusted by needs-related social and medical criteria was adopted. Regarding reimbursement to private providers, previously, social insurance reimbursements were made directly to them on a fee-for-service basis. Through the Dagmar Reform, the county councils were made cost-liable; they had the authority to approve which private practices should be reimbursed by national insurance, as well as the number of patients the practices could see per year. The payments were still made from national insurance to private practitioners, but only to those who had an agreement with the county council. Payments were balanced according to a fixed capitationbased budget for each county council. If the national insurance payments exceeded the fixed capitation budget, the county councils had to balance the expenditures.

SwedenHealth Care Systems in Transition 9

Agreements were made every year between central government and the federation of county councils as regards the amount of money to be transferred from central government to the county councils.

The county councils were fully responsible for the financing and provision of health care between 1983 and 1992. In 1992, a major change was introduced through the ÄDEL-reform, whereby the responsibility for long-term inpatient health care and social welfare services to disabled and elderly individuals was transferred from the county councils to the local municipalities. As a result of this reform, one fifth of total county council health care expenditure was transferred to the municipalities. A few years later, the municipalities took over the responsibility of the physically disabled (“Handikapp-reformen,” 1994) and of those suffering from long-term mental illnesses (“Psykiatri-reformen,” 1995). This development meant that about 30–40% of hospital beds were transformed into nursing home beds for those needing less technologicallyadvanced care. With this reform, the responsibilities in terms of health care between county councils and municipalities became even clearer.

In an attempt to curb the increasing cost for pharmaceutical products, a “drug reform” was initiated in 1998 when the county councils took over responsibility for drug reimbursement from the state. This was intended to focus the control of the entire health production as well as the costs to the counties, which would facilitate feedback. In addition, the patients’ share of the drug costs was increased, due to a reformed Drug Benefit Scheme.

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Organizational structure and management Organizational structure of the health care system T he Swedish health care system is a regionally-based, publicly operated health service. It is organized on three levels: national, regional and local. The regional level, through the county councils, together with central government, form the basis of the health care system. Overall responsibility of the health care sector rests at the national level, with the Ministry of Health and Social Affairs.

National level The principal responsibility of the Ministry of Health and Social Affairs (Socialdepartementet) is to ensure that the health care system runs efficiently and according to its fundamental objectives. It prepares cabinet business and deals with policy matters and legislation in health care, social welfare services and health insurance. It allocates financial assistance directed at very specific treatments, and acts as a supervisor of the activities in the county councils, e.g.

the government may legislate for temporary ceilings on county council and local municipality tax rates.

The National Board of Health and Welfare (Socialstyrelsen) has a supervisory function over the county councils, acting as the government’s central advisory and supervisory agency for health and social services. The board supervises implementation of public policy matters and legislation in health care and social welfare services. Its most important duty is to follow and evaluate the services provided to see if they correspond to the goals laid down by the central government. The board also keeps official statistics on health and health care. It is assisted by the Centre for Epidemiology (Epidemiologiskt Centrum),

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