A fundamental principle of the health care system is that it is a public sector responsibility to provide and finance health services for the entire population. Responsibility for these services rests primarily with the county councils which levy taxes to raise the financial resources required and also operate almost all the services provided. Thus it is mainly local politicians, in 26 geographical areas, who are responsibile for health services in Sweden. Two characteristics of the Swedish system are that it is decentralised and it is run on democratic principles.
The health situation
By international standards, health in Sweden is relatively good. Infant mortality is low, at 4.8
deaths per 1,000 in the first year of life. Of the predominant diseases, cardiovascular conditions
account for half of all deaths. However, deaths attributable to these diseases diminished
substantially during the 1980s, and this has contributed to an increased average life expectancy.
For men average life expectancy is 75.5 years and for women 80.8 years. The incidence of
suicide has decreased in recent years, particularly among young people. Fatal accidents
decreased by some 10% during the 1980s. In recent decades the number of cancer cases has
increased by an average of 1.7% per year. However, the increase in the average age of the
population accounts for 1% of this increase. The number of elderly people has risen
substantially and this trend will continue to the end of the centurywith the greatest rise in the
age group 85 years and older. Sweden is seen as having the world's oldest population, with
18% aged 65 or over. There are marked differences in health between different social groups,
and these differences are growing.
The health services
The primary level is the level of the health care system to which people shall be able to turn
with all their health problems. The primary care sector has the aim of improving the general
health of the people and treats diseases and injuries which do not require hospitalisation. This
sector employs many different professional categoriesphysicians, nurses, auxiliary nurses,
midwives and physiotherapists. Their work has been organised in health centres, which has
facilitated team-work. During recent years there has been a structural change in the work of the
doctors in primary caretoday everyone may choose a doctor, who has qualified as a general
practitioner, as their own family doctor (formerly called district doctors).
In addition to local health centres and family doctor surgeries, primary care is also provided by private doctors and physiotherapists; at district nurse clinics; and at clinics for child and maternity health care. At the children's clinics, vaccinations, health checks and consultations as well as certain types of treatment are provided free of charge to all children under school age. At the maternity clinics there are both midwives and doctors. These clinics are visited by expectant mothers for regular check-ups which are free of charge during the entire pregnancy. The district nurses give medical treatment as well as advice and support, both at their clinics and when visiting patients in their homes. Industrial health services and school health services are other services provided.
By adapting housing, using technical aids, and providing medical services and nursing in the homes of patients, it is both possible and easier for elderly and disabled people to stay in their own homes. People in hospitals for long-term patients, in nursing homes and those living in service apartments have access to medical and nursing services 24-hours a day. Great importance is attached to making these places as much like home as possible. Most of the patients in nursing homes, for example, have their own room.
For conditions which require hospital treatment, medical services are provided at county level and regional level. County medical services are available at some 80 central county hospitals and district county hospitals. Here, somatic care is provided in a number of specialist fields, partly as in-patient care and partly at clinics (out-patient care). The county medical services also include psychiatric care, which is provided to an increasing extent in out-patient forms. The regional medical system is operated at 10 regional hospitals which have a greater range of specialist and sub-specialist fields than at county level, for example neurosurgery, thoracic surgery, plastic surgery and highly specialised laboratories.
In Sweden a relatively large proportion of the resources available for medical services have traditionally been allocated to the provision of care and treatment at the hospitals. This can be seen, for example, in the low number of visits per person and year to doctors in the primary care services. The number of general practitioners is also low in relation to the total number of doctors (approximately 20 per cent).
The number of days of short-term care per person and year has decreased during the last few years for all age groups. In long-term care also, the number of in-patient days has decreased per person and year in most age groups. Extensive changes have been made in the area of psychiatric care during the last ten years. People with mental handicaps have, to a great extent, left the institutions and now live in the community. At the same time as reductions have been made in in-patient care, more out-patient and so-called alternative forms of care have been established.
The developments which have taken place in in-patient care must be seen in relation to the deliberate emphasis given to various forms of out-patient care. An increasing proportion of visits to doctors are made outside the hospitals and the nature of these visits has also changed. An increasing amount of treatment is given and operations performed without the patient needing to be taken into hospital. The introduction of day surgery, for example, can illustrate the changes which are taking place. The deliberate emphasis on out-patient forms of care also means that visits to medical staff other than doctors is encouraged. The number of visits to district nurses, nurses and auxiliary nurses has more than doubled since 1980.
Management and planning
In Swedish society there are three political and administrative levelscentral government,
county council and local authority. All these levels have important roles in the welfare system
and are represented by directly elected political bodies which have the right to finance their
activities by levying taxes and fees.
One important role for central government is to lay down basic principles for the health services through laws and ordinances. The most important of these is the Health and Medical Services Act of 1982, which lays down that the people shall be offered health and medical services of good quality which shall be provided on equal terms and be easily accessible to all. The services provided shall be based on respect for the patient's integrity and his right to make his own decisions. They should also, as far as possible, be organised and performed in consultation with the patient. Other laws regulate the obligations and responsibility of personnel, professional confidentiality, patients' records and the qualifications required by personnel to practise in the health professions. The number of detailed rules has diminished during recent years. Today central government is more interested in the results and performance of the services rather than how they are organised. It is chiefly by means of systems for follow-up and evaluation that central government can exercise control over the health services.
The Ministry of Health and Social Affairs (Socialdepartementet) is responsible for developments in areas such as health care, social insurance and social issues. The Ministry draws up terms of reference for government commissions, drafts proposals for Parliament on new legislation, and prepares other government regulations.
The National Board of Health and Welfare (Socialstyrelsen) is the government's central advisory and supervisory agency in the field of health services, health protection and social services. The key task of this agency is to follow-up and evaluate the services provided to see whether they correspond with the goals laid down by central government.
Another government agency which is engaged in evaluation work is the Swedish Council of Technology Assessment in Health Care (SBU). The SBU shall contribute towards the rational utilisation of the resources allocated to the health services by evaluating both new and established methods from medical, social and ethical perspectives. Reviews of current knowledge in the field and syntheses of existing scientific material are produced with the aid of experts. Information on results is then disseminated to central and local government officials and medical staff to provide basic data for decision-making purposes.
Under the Health and Medical Services Act the county councils are responsible for providing health services and for striving to achieve a good standard of health in the population. In Sweden there are 23 county councils. Three large local authorities (Gothenburg, Malmö and Gotland) also have the same responsibilities as the county councils where health care is concerned. The population of these 26 areas varies between 60,000 and 1.7 million people. County council elections are held at the same time as central government electionsevery fourth year. The county councils decide on the allocation of resources to the health services and are responsible for the overall planning of the services offered. It is also the county councils which own and run the hospitals, health centres and other institutions, even if these institutions are supplemented by those of private organisations which, in certain cases, have contracts with the county councils.
The total domination of the county councils in the provision of health services enables them to make decisions on structural issues in the health services. During recent years considerable changes have taken place in this area, particularly the reduction in the number of beds but also where other hospital activities are concerned, such as the cut-backs in the number of casualty wards open 24-hours a day. The reduction in the number of beds has been achieved by increases in productivity generated by new medical technology, shrinking financial resources, and incentives resulting from the development of financial management systems. One example is in the field of maternity care, where at the end of the 1980s the number of beds was reduced by 19% even as the number of deliveries increased by 31%.
One significant change introduced by the county councils in recent years is the freedom for patients to choose where and by whom they wish to be given medical attention. Patients can choose the health centre and/or family doctor and even which hospital they wish to attend. If a patient wishes to receive medical care at a hospital outside the county council in which he or she resides, a referral may be required, but freedom of choice which covers the medical services of several county councils is available in several of the health care regions. A patient does not usually need a referral to obtain specialist hospital carehe/she can go directly to the hospital without going via the primary services. The primary level therefore does not always have a referral function; the way in which the county councils can influence patients decisions about which part of the health care system to approach first is to differentiate consultation fees
Where highly specialised care is concerned, and, to a certain extent, research and the training of doctors, the county councils cooperate in six medical care regions. The population of these regions varies from 900,000 to 1.9 million and in each region there is at least one university hospital. This collaboration is based on agreements between the county councils in the region, for example on the prices which shall be charged for highly specialised care. The county councils also collaborate at national level through the Federation of County Councils (Landstingsförbundet).
One example of the management of the health services is the introduction of a guarantee for patients which has been in force since 1992. This guarantee was the result of an agreement concluded at national level by the Ministry of Health and Social Affairs and the Federation of County Councils to reduce the waiting time for certain forms of treatment for which there were long waiting lists. The content of the guarantee is that, after an opinion has been given by a specialist, no patient needs to wait more than three months for treatment. If the waiting time is expected to be longer at the hospital selected, it is the duty of the hospital concerned to ensure that the patient receives treatment at another hospital within three months. In 1996 , this guarantee has been extended to cover accessibility. Patients are now guaranteed to be able to make initial contact with the primary care services the same day, to get an appointment with a doctor in the primary care services within eight days and an appointment with a specialist within four weeks. The aim of these new criteria for accessibility is to reinforce the position of the patient vis à vis the care services. This aim is to be further emphasised by the extension of the care guarantee to patients with severe chronic illnesses, such as diabetes, who will be ensured an agreed standard of care.
Where cooperation between central government and the Federation of County Councils is concerned, mention can be made of the jointly owned Swedish Institute for Health Services Development (Spri), which works with research and development in health care administration and economics, documentation and data processing of health services, and methods and systems for quality development.
The local authorities also have their own area of responsibility within the field of health services, namely the care of elderly and disabled people in the places in which they live. In 1992 the responsibility for, among other things, nursing homes was transferred to the local authorities from the county councils. At the same time the local authorities also assumed the obligation to pay for patients who had been treated in a hospital and who were obliged to remain in hospital since the local authority could not offer a suitable place in, for example, a nursing home. A similar change in responsibility came into force in 1995, this time concerning the living arrangements, employment and support for those suffering from long-term mental illnesses.
Finances
Sweden's costs for its health services amounted in 1993 to SEK 110 billion. This figure
includes costs for pharmaceutical preparations and dental care. This corresponded to 7.6% of
GNP, a proportion which has since decreased and which is expected to decrease further in the
future. Ninety percent of the costs were spent on care provided or financed by the county
councils and the three local councils (in future referred to as county councils).
The health services account for some 74% of the operations of the county councils. The main part of these operations, or 74% (1994), are financed by tax revenues. The county councils are entitled to levy a proportional tax on the incomes of their residents. On average the tax rate is 11.4%. Other incomes of significance for the county councils are grants and payments for certain services received from central government, in total 12%. Patients' fees amount to 4% of county council revenue.
The incomes of the county councils, and thus the health services, have diminished in recent years due to reductions in the tax base and cut-backs in the grants received from central government. To counteract this deterioration in their finances, the county councils have reduced their expenditure in real terms by some 2% per year since 1992, a trend which is expected to continue until the year 2,000, when a return to zero growth may be possible. It is generally felt that it has hitherto been possible to meet these reductions by rationalisation, without a reduction in the number of patients treated. Instead patients have spent less time in hospital and have been treated more often as out-patients. The number of beds in short-term somatic care has been reduced from 4.4 per 1,000 inhabitants in 1985 to 2.8 per 1,000 inhabitants in 1994. The corresponding figures for psychiatric care are 2.5 in 1985 and 1.1 in 1994. There is a danger that patients will become more aware of the reductions in the future, when the potential for rationalisation in the health services has been exhauasted.
One method for the county councils to promote rationalisation in the health services has been to introduce a new financial control system. In the early 1990s, most county councils introduced some form of purchaser-provider model in their medical services. Under this model the traditional system of fixed annual allocations to hospitals and primary care services has been abandoned. Instead, payment is made according to results or performance, i e the funds received by a hospital depend on the number of patients it treats. An attempt has also been made to create competition between hospitals with the aim of improving the quality and reducing the price of each service provided. In some county councils, competition with the private sector has been encouraged. The new control systems have resulted in the establishment of special purchasing functions, normally under the leadership of a committee of politicians, with the task of formulating the requirements which should be made of the hospitals by the county councils and of evaluating quality and prices. The hospitals for their part have become more independent in relation to the political bodies.
It is still too early to evaluate the total effect of the purchaser-provider model on Swedish health care. It is clear that it has led to greater interest in the performance of the health services, in the costs of performance, and in the quality of the services provided. In parallel with the development of new financial control systems patients have been given greater opportunities to choose between the variety of medical services available.
Patients' fees
Those entitled to use the Swedish health services at subsidised prices are all those resident in
Sweden regardless of nationality, as well as patients seeking emergency attention from
EU/EEA countries and seven other countries with which Sweden has a special convention.
The fee charged for a stay in hospital is SEK 80 per day. Hospital care is free of charge for children under the age of 16 years.
Each county council sets its own fees for out-patient care. The fee for consulting a doctor in the primary health services, that is to say a family doctor or a district doctor, varies between county councils from SEK 60 to SEK 140. For consulting a specialist at a hospital or a doctor in private practice, the fees vary from SEK 100 to SEK 260.
The county councils also set patients' fees for other medical treatmentfor example for visits to physiotherapists, occupational therapists and nurses, both in the public health services and, should the occasion arise, in private care. The fees vary from SEK 50 to SEK 80 per visit, depending on the county council.
To limit the costs incurred by patients there is a high cost ceiling. A patient who has paid at least SEK 1,800 for medical care and for pharmaceutical preparations is entitled to free care and free medicines for the remainder of the twelve month period, which is calculated from the first visit to a doctor or the first purchase of medicines.
Sweden has an extensive system of benefits for the sick. The main component of this system is sickness benefit, but it also includes compensation for participation in labour market rehabilitation schemes, compensation payable to persons with infectious diseases who are obliged to stay in quarantine, and benefits payable to expectant mothers who are unable to work due to pregnancy.
Pharmaceutical preparations
Before a medicine may be sold in Sweden it must be registered at the Medical Products Agency
(Läkemedelsverket), which is a government agency responsible for the control of
pharmaceutical preparations. The activities of this agency are regulated in a new law governing
medical products which has been adapted to EU regulations. The number of registered
pharmaceutical preparations is approximately 3,300.
Under the social insurance scheme the patient is only obliged to pay a limited part of the costs for pharmaceutical preparations. The patient pays a certain fee for each prescribed medicine which he purchases on one and the same occasion. For the first item on the prescription the patient pays a maximum fee of SEK 160 and for each of any additional medicines a maximum of SEK 60.
The National Corporation of Swedish Pharmacies (Apoteksbolaget), in which the state is the majority shareholder, has the sole and exclusive right to retail medicines, both to the general public and to the hospitals. This is done via just over 800 pharmacies. The pharmaceutical companies have an insurance which provides compensation to patients who are injured by a medicine.
Dental care
The county councils are responsible for ensuring that all children and young people up to the
age of 19 years receive free dental care. Here the emphasis is placed on preventive care. The
dental health of this group has improved considerably since the 1970s and continues to
improve steadily. For adults there is a public dental insurance which subsidises dental care
exceeding a cost of SEK 700 in any one year. Approximately half of all dentists work in the
national dental service, which is run by the county councils; the remainder are private dentists.
The national dental service also treats adult patients on the same conditions as the private
dentists. The county councils are responsible for ensuring that sufficient specialist dental care is
available to meet the needs of both children and adults.
Staff
Just over 300,000 people are employed in the health services, i e about 10% of all employees in
the country. This number has diminished in recent years, partly due to the financial squeeze
and changes in the work done by the services. There is a tendency for the numbers of doctors
and nurses to increase at the expense of less qualified staff. There is a certain shortage of
nurses, especially nurses with specialist training. Where doctors are concerned, a small surplus
has started to appear. However, at the same time it is difficult to recruit doctors to certain
geographical areas and to certain specialist fields. In Sweden there is one physician (i e doctor
qualified to practise and resident in Sweden under the age of 68 years) per 340 inhabitants.
In addition to the above there are some 2,100 physicians and 2,300 physiotherapists working in private practices (of whom, however, quite a number are not in full-time employment). They are paid by the county councils by fees per visit/call in accordance with a scale of fees determined by central government.
The average salary of a hospital doctor with a specialist qualification is SEK 34,00 per month. The salary of a nurse is approximately SEK 14,600 per month.
The head of a department is, almost without exception, a doctor with the overall responsibility for the management of the clinic. This includes responsibility for medical services as well as administration, finance, and personnel.
Training and research
Doctors are trained at the universities of Lund, Gothenburg, Linköping, Stockholm (Karolinska
Institute), Uppsala and Umeå. The training programmes are linked to the operations of the
university hospitals and other relevant parts of the health services, for example the primary
health service. To become a registered doctor a student must successfully complete a study
programme of five and a half years and a 21-month pre-registration period as a house officer.
On registration a doctor is authorised to practise medicine, but almost all doctors continue their
studies in order to qualify as a specialist after five years' service in one of the 60 recognized
specialist fields. Every year some 900 students start medical training programmes. The study
programme for nurses lasts three years and is available at some thirty colleges of nursing,
which are normally run by the county councils and which admit some 3,500 new students each
year.
Swedish medical research has a prominent international position in many fields. It is characterised by strong links between basic research and clinical research and by the integration of research and development into the health services, particularly at the university hospitals. Medical research is mostly financed by government funds, but the county councils also provide resources for clinical research which is closely connected to patient care. The strong position occupied by medical research in Sweden is demonstrated by the fact that almost one third of university research spending goes to the medical field.
Quality and safety
The interest of staff working in the medical services in issues relating to quality has increased
considerably during recent years. Improving quality is considered urgent in a situation in which
resources are limited and where it has become all the more important to be able to demonstrate
quality in the services which are offered, for example if there is a purchaser-provider
relationship and elements of competition. Quality committees at management level, sometimes
with special officers responsible for quality, are working to produce systems to develop and
improve quality
. Regulations produced by the National Board of Health and Welfare have been in force since 1994. These lay down that regular, systematic and documented work to ensure quality shall take place in the health services. All registered staff are obliged to participate in programmes of quality assurance. It is the responsibility of management to organise these programmes and to ensure that they take place. The needs of patients shall be the decisive factor when the goals for these programmes are established.
If, in connection with medical care or treatment, a patient suffers a serious injury or illness, or is exposed to the risk of injury or illness, the institution providing the care or treatment is obliged to report this fact to the National Board of Health and Welfare. Where faults or negligence are attributable to members of staff, the matter can be referred to the National Medical Disciplinary Board (Hälso- och sjukvårdens ansvarsnämnd), a government agency whose organisation is somewhat similar to that of a court. A patient or a relative of a patient can approach the Board if he considers that health service staff have acted incorrectly. The Board can decide on disciplinary measures (warning or admonition) or remove the person from the professional register.
The matter of financial compensation for a patient who has suffered an injury is not dealt with by the Board. There is a patients' insurance scheme which covers such claims. The issue of holding staff responsible for their actions and deciding on sanctions is therefore kept separate from the issue of financial compensation for the patient.
Since the mid 1970s, the county councils and other institutions providing health care services have voluntarily assumed responsibility to grant financial compensation to patients who have suffered injuries during treatment. A patient who has been injured, infected or has met with an accident in connection with an examination or treatment can be compensated, regardless of whether it is the responsibility of the medical services or not. From 1997, every institution organising health care will have a legal obligation to provide compensation for injuries which occur in the course of these services. The institutions are insured to meet demands for compensation from patients.
Current issues
A Parliamentary commission was appointed in 1992 to address general issues concerning the
organisation and finance of medical care. Among those issues which the Commission is
considering are how the position of the patient can be reinforced, resource needs in the medical
services, forms of steering, pharmaceutical preparations, public health, and clinical research
and development. The Commission, which is to report in 1997, is not expected to recommend
any radical changes, since it is working on the basic assumption that the present system (with
the county councils and local authorities being both providers of and financially responsible for
medical services), will continue.
The discussion about how the medical services can be made more efficient has begun to concentrate on the structure of the servicesand how they can be changed. Sweden has relatively few hospitals, but many beds: the hospitals are thus relatively large. At the same time some of the small hospitals serve a very small population. There are a number of reasons why the structure needs to be changed and there is great interest in this question. Finance is naturally one reason, but issues of quality and safety are nevertheless in the foreground in the ongoing discussions. Examples of issues which are being studied and discussed are the closing of hospitals, care of the acutely ill and severely injured, division of responsibilities and collaboration between hospitals, and the interaction between hospitals and other parts of the health services.
Distribution of public health care costs, 1994
somatic short-term care 61%
long-term care 5%
psychiatric care 10%
primary care 17%
dental care 5%
other 2%
Employees in the public health services.
Certain professional categories, 1994
Doctors 23,000
Nurses 85,000
Auxiliary nurses 81,000
Physiotherapists 6,000
Occupational therapists 5,000
SEK1 (Swedish krona) = USD 0.15 or GBP 0.10
The table on organisation of the Swedish health services is not included in the Internet edition of this fact sheet.
This fact sheet is part of SI´s information service. It can be used as background
information on condition that the source is acknowledged.
May 1996
Classification: FS 76 v Vpb
ISSN 1101-6124
Fact Sheets on Sweden