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Great expectations: What can we learn from Sweden? Anders Anell, PhD, director The Swedish Institute for Health Economics (IHE), Lund Swedish Health Care • Cornerstone of the Swedish welfare state – Quality health care for all, distributive justice • Decentralised decision-making – 21 county councils responsible for hospitals and primary care services – 289 municipalities responsible for care of the elderly and mentally handicapped (home care, nursing homes) • Public ownership and political control – With local exceptions • Weak primary care services New policies introduced at different government levels • National government – Responsibility of local governments – Specific issues (focus on access, quality and equity) – Legislation or agreements + budget infusion • Local government – Experimentation with choice of providers, purchaserprovider split, contracting, privatisation, hospitals mergers and closure, new primary care models, integrated care and more Impact of new policies • Impact of local-government reforms and national agreements limited compared to new legislation • The formation of reforms can often be explained by a political logic (i.e. maintaining legitimacy) – Politicians produce rhetoric, plans and actual changes – Coherence not necessary for survival • Changes in welfare and advances in medical technology more important than both local and national government reform Development of GDP and total expenditure on health in Sweden, 1970-2004 (Index 1970=100, 2000 GDP price level) Index 280 260 240 220 200 180 160 140 Total expenditure on health GDP 120 19 70 19 72 19 74 19 76 19 78 19 80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04 100 Source: OECD Health Data 2005 Year Acute care bed days per capita and age group in Sweden, 1993 and 2004 9 1993 Bed days per capita 8 7 6 2004 5 4 3 2 1 0 0-14 15-24 25-44 Source: Sjukvårdsdata i Fokus, SKL, 2006 45-64 65-74 75-84 85+ Age Expenditures for county council health care and municipal care of the elderly and the handicapped. Constant 1999 prices. Billion SEK 140 120 100 80 60 40 20 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Year County council exp. Municipality exp. County council exp. (rev.) Pharmaceuticals Source: Nationell handlingsplan för äldrepolitiken. Lägesrapport 2001. Statistisk Årsbok för Landsting. Apoteket AB. Development of total health care expenditure in Sweden 1993-2004 (constant 2004 prices) Public share Pharmaceutical Total health Total health Health care of total expenditures as Year expenditure expenditure expenditure health % of total health billion SEK per capita (SEK) as % of GDP expenditure expenditure 1993 142.0 16 242 7.9% 82.5% 11.5% 1994 140.6 15 950 7.5% 82.0% 12.7% 1995 146.0 16 520 7.5% 81.2% 13.3% 1996 152.5 17 242 7.6% 81.6% 14.8% 1997 154.8 17 500 7.5% 80.3% 13.5% 1998 164.1 18 534 7.6% 80.4% 14.8% 1999 174.1 19 644 7.7% 79.7% 15.1% 2000 182.2 20 516 7.7% 79.8% 15.0% 2001 191.7 21 520 8.0% 80.0% 14.4% 2002 203.8 22 792 8.4% 80.2% 14.2% 2003 209.5 23 336 8.5% 80.4% 13.8% 2004 214.3 23 779 8.3% 80.3% 13.4% Source: Swedish National Accounts, SCB 2006 and own calculations Health care expenditure and GDP per capita in the EU (15) + US and Norway, 1975 Health care exp./capita, US$ PPP 700 DK 600 US DE SE 500 NL A 400 FR FI NO 300 IE BE L G ES 200 PT 100 0 2 000 3 000 4 000 5 000 GDP/capita, US$ PPP Source: OECD Health Data 2005 6 000 7 000 8 000 Health care expenditure and GDP per capita in the EU (15) + US and Norway, 2003 6000 US 5500 TEH/capita, US$ PPP 5000 4500 4000 NO LU 3500 NL BE DE 3000 FR 2500 DK SE GR IT 2000 ES AT FI IE GB PT 1500 1000 15 000 20 000 25 000 Source: OECD Health Data 2005 30 000 35 000 40 000 GDP/capita, US$ PPP 45 000 50 000 55 000 60 000 ”How would you assess health care services today compared to 10 years ago?” Better than 10 years ago 15,6% About the same as 10 years ago 17,6% Worse than 10 years ago 42,3% Don´t know/uncertain 24,5% Total 100% Source: Rosén P. Population survey in county council of Östergötland (Sample = 4 000 with 58% response rate, n = 2284, ages 18+). Why? • Cost-containment policies in mid 90s and increased pressure for explicit priority setting • Political rhetoric – Election every fourth year; shift of local government common. Opposition (and media) has an interest to highlight problems. • Increased transparency related to access and quality (absolute level and differences) • Demand for patient influence and less reliance on experts Waiting times and government policies • Important problem for politicians since late 1980s – Used as an argument for overall reform (privatisation) – Waiting time ’guarantees’, budget infusion from national level • Several explanations behind existing waiting times – Wider indications for treatment most important – Waiting list for cataract surgery doubled 1990-2000; the volume produced increased by 140% Number of procedures per 100 000 Number of hip replacements in Sweden per 100 000 population and age group 1994, 1999 and 2004 1200 1000 800 1994 600 1999 400 2004 200 0 45-64 65-74 Source: Sjukvårdsdata i Fokus, SKL, 2006 75-84 85+ Age Number of procedures per 100 000 Number of coronary bypass and PCI in Sweden per 100 000 population and age 1994, 1999 and 2004 700 600 500 1994 400 1999 300 2004 200 100 0 45-64 65-74 75-84 Coronary bypass Source: Sjukvårdsdata i Fokus, SKL, 2006 85+ 45-64 65-74 75-84 PCI 85+ Age Regional expenditure per capita in Sweden for five new oncology drugs1, 2005-01 – 2005-06 Stockholm region 21.44 SEK Uppsala/Örebro 20.16 SEK Northern region 19.31 SEK Southern region 16.99 SEK Southeastern region 16.34 SEK Western region 16.08 SEK Source: Dagens Medicin, 21 September 2005, p. 4-7. 1 Herceptin/trastuzumab, Erbitux/cetuximab, Avastin/bevacizumab, Mabthera/rituximab and Glivec/imatinib. Variation in access to cancer therapy • Local priorities not transparent and limited by budget criteria • Less acceptance by national government (and the population) of variation in access to treatment (’post-code rationing’) • Towards a national cancer-plan (= agreement + budget infusion)? – increased use of national guidelines, less discretion for decision-making at local level and additional funding? Expenditures for cancer drugs per capita in selected countries in 2002/2003 France 16 Euro Italy 13 Euro Sweden 12 Euro Germany 12 Euro Switzerland 11 Euro Spain 11 Euro Austria 10 Euro UK 10 Euro Norway 9 Euro Netherlands 9 Euro Finland 9 Euro Denmark 7 Euro Sweden identified as ’average’ in terms of uptake of new cancer drugs in pan-European study. (Austria, Spain and Switzerland = top three countries; Czech Republic, Hungary, Norway,Poland and UK below-average.) Source: Wilking, Jönsson (2005)A pan-European comparison regarding patient access to cancer drugs. Karolinska Institutet, Stockholm. Some challenges for the future • Balance between national and local decisionmaking – Ongoing parliamentary committee expected to suggest larger regions to replace county councils • Long-run financing of services (from 2015) – Alternatives to tax funding? • Recruitment of human resources – Both municipalities and county councils • Development of primary care and integration of services Inequity in distribution of physician visits in Sweden due to weak primary care services Fig. 5: Horizontal inequity (HI) indices for the annual mean number of visits to a doctor in 19 OECD countries van Doorslaer, E. et al. CMAJ 2006;174:177-183