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The life expectancy of the Swedish population continues to rise. In 2005 the life expectancy was 78 years for men and 82.8 years for women. This can be attributed to falling mortality risks for both heart attacks and strokes. A little more than 5 percent of the population is 80 years or older, which means that Sweden has proportionally Europe’s largest elder population.

Chronic diseases that require monitoring and treatment – and usually a lifetime of medication – place high demands on the system. One positive development is that fewer people smoke; almost 85 percent of the population are non-smokers. However, the increasing number of overweight and obese children and teenagers is a problem that the health care system is examining more closely.

Swedes tend to live long in comparison with people in many other countries and the country now has proportionally the largest elderly population in Europe. Photo: Hans Bjurling/www.imagebank.sweden.se

Management
In Sweden the responsibility for providing health care is decentralized to the county councils and, in some cases, the municipalities. A county council is a political body whose representatives are elected by the public every four years on the same day as the national general election. According to the Swedish health and medical care policy, every county council must provide residents with good-quality health services and medical care and work toward promoting good health in the entire population.

Sweden is divided into 20 county councils. One municipality, the island of Gotland, carries the same responsibilities as the county councils for health care. Around 90 percent of the Swedish county councils’ work involves health care but they are also involved in other areas, such as culture and infrastructure.

The population in these 21 areas ranges from 60,000 to 1,900,000. The county councils have considerable leeway in deciding how care should be planned and delivered. This explains the wide regional variations.

Similarly, Sweden’s 290 municipalities are responsible for care for elderly people in the home or in specially adapted housing. This includes people with physical or psychological disabilities. Services provided by doctors are not included in the care for which municipalities are responsible.

The role of central government is to establish principles and guidelines for care and to set the political agenda for health and medical care. This is achieved by means of laws and ordinances or by reaching agreements with the Swedish Association of Local Authorities and Regions (Sveriges Kommuner och Landsting, SKL), which represents the county councils and municipalities.

At national level there are a number of authorities within the area of health care. The National Board of Health and Welfare (Socialstyrelsen) plays a fundamental role as the central government’s expert and supervisory authority. The others are The Medical Responsibility Board (Hälso- och sjukvårdens ansvarsnämnd, HAS), The Swedish Council on Technology Assessment in Health Care (Statens beredning för medicinsk utvärdering, SBU), The Pharmaceutical Benefits Board (Läkemedelsförmånsnämnden, LFN), The Medical Products Agency (Läkemedelsverket) and state-owned Apoteket AB, a national chain of pharmacies.

Organization
Primary care has traditionally played a less important role in Sweden than in many other European countries. However, the aim is now to make it the basis of the health and medical care system. Today most health care is provided in health centers where a variety of health professionals – doctors, nurses, midwives, physiotherapists and others – work. This should simplify things for patients and foster teamwork. Patients should be able to choose their own doctor. Around 25 percent of health centers are privately run by enterprises commissioned by county councils. There are special clinics for children and expectant mothers as well as family planning clinics for teenagers.

Sixty hospitals provide specialist care with emergency room services 24 hours a day. Eight are regional hospitals where highly specialized care is offered and where most teaching and research is located. Since many county councils have small service areas, six health care regions have been set up for more advanced care. Furthermore, as Sweden only has nine million inhabitants, the entire country must serve as one service area for the most advanced specialist care. This is coordinated by a newly formed committee, Rikssjukvårdsnämnden, within the National Board of Health and Welfare.

The county councils own all emergency hospitals, but health care services can be outsourced to contractors. For pre-planned care there are several private clinics from which county councils can purchase certain services to complement care offered within their own units. This is an important element of the effort to increase accessibility. 

Financing
Costs for health and medical care amount to approximately 9 percent of Sweden’s gross domestic product (GDP), a figure that has remained fairly stable since the early 1980s. In 2005 care and services provided by the county councils, including the subsidization of pharmaceuticals, cost SEK 175 billion (USD 25.4 billion). Seventy-one percent of health care is funded through local taxation, and county councils have the right to collect income tax, the average level being 11 percent. Contributions from the state are another source of funding, representing 16 percent, while patient fees only account for 3 percent. The remaining 10 percent come from other contributions, sales and other sources.

Most county councils use some form of purchaser–provider system, in which a council negotiates compensation agreements with health care units – for example, performance-based compensation determined by diagnosis-related group (DRG), that is, a system to classify hospital cases into one of approximately 500 groups expected to have similar hospital resource use. This allows hospitals to become more independent of political bodies. In some cases hospitals have become corporations owned by the council. It is now more common for county councils to buy health care services – 10 percent of health care is financed by county councils but carried out by private health care providers.

Patient fees
The fee for staying in a hospital is SEK 80 per day. Fees for outpatient care are decided by each county council. Fees to consult a primary care physician range from SEK 100 to 150. An appointment with a specialist will cost more. To limit costs for the individual there is a high-cost ceiling, which means that after a patient has paid a total of SEK 900, medical consultations in the twelve months following the date of the first consultation are free of charge. A similar ceiling exists for prescribed medication, so no one pays more than SEK 1,800 per twelve-month period.


The care guarantee that was established in Sweden at the end of 2005 means that no patient should have to wait for more than three months once it has been determined what care is needed. Photo: Ulf Owenede/www.imagebank.sweden.se

Accessibility
Waiting times for pre-planned care, such as cataract or a hip replacement surgery, have long been a weakness that has caused dissatisfaction. Despite a major increase in productivity – the number of operations in relation to population size is higher in Sweden than in other countries – there are still long waiting lists. Therefore the county councils and the government agreed to establish a care guarantee at the end of 2005, stating that no patient should have to wait for more than three months once it has been determined what care is needed. If the time limit expires, the patient is offered care elsewhere, which is paid for by his or her own county council, including any travel costs.

Generally, patients are free to choose where to go for care. Referrals may be necessary, for example for treatment outside the region where the patient lives. No referral is usually necessary for specialist care. This is different from many other countries where such “gatekeeper functions” are more common.
 
Integrated care
Providing health care for a growing elder population is a great challenge. It requires better cooperation between the county councils’ health care services and the elder care that is the responsibility of the municipalities.

One way to achieve this is within the framework of a relatively new concept, “integrated care.” This involves a variety of care providers, such as local hospitals, health centers and social services, which coordinate their services in order to meet patients’ needs.

In the future, integrated care will take care of most everyday health care needs – particularly common and recurring conditions – as well as the needs of those who have multiple chronic conditions.

Efficiency and improvement
The basis for funding health and medical care is local taxation, which means that opportunities for economic expansion are greatly limited. Cost restrictions are a must, and it is necessary to maximize existing resources. Benchmarking with other county councils may lead to improvements, but heavy decentralization has meant that national data are frequently lacking. However, there will soon be an improvement here because the National Board of Health and Welfare and the Swedish Association of Local Authorities and Regions have agreed to establish a model for comparing and evaluating achieved goals and results. There are many reasons for this:

• to provide a better platform for public debate and political decisions,
• to make it easier for county councils and municipalities to manage and streamline health care and
• to provide the general population and patients with more easily accessible information.

Statistics based on national research have already been produced on issues such as health effects, quality, patient security, waiting times, patient opinions and costs. This type of benchmarking enables county councils to be evaluated in relation to each other.

Related links
www.sweden.gov.se – The Government Offices of Sweden
www.sos.se – The National Board of Health and Welfare
www.skl.se – The Swedish Association of Local Authorities and Regions
www.sbu.se – The Swedish Council on Technology Assessment in Health Care
www.fhi.se – The Swedish National Institute of Public Health
www.smittskyddsinstitutet.se – The Swedish Institute for Infectious Disease Control
www.lfn.se – The Pharmaceutical Benefits Board
www.lakemedelsverket.se – The Medical Products Agency

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