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By international standards, Sweden has a very good health status. Health care in
Sweden makes up a significant portion of the welfare state and is based on the
fundamental principle of equality. Under this system, all citizens, regardless of
economic status, have the right to health care. This paper will take a more in depth
look at the Swedish health care system (Kronstrom, 1999). The history and the
evolution of health care, health indicators and the role of the government will be
explored. Also, differences between the Swedish and Canadian will be discussed
followed by the advantages and disadvantages of the current system. Finally, Swedish
health management practices will be explore and analyzed in order to determine
whether or not they would beneficial to the Canadian health care system.
History of Health Care in Sweden
The modern system of universal health care in Sweden has a history that can
be traced back to medieval times. In the 1600’s, landowners and nobility took it upon
themselves to provide rudimentary health care to their respective subjects (Koblik,
1975). This system of health care was not created based on an ideology that health
should be accessible to all or social equity, but rather on a more pragmatic basis.
Those in power took an interest in the health of their subjects only because a healthy
individual can work much better than one plagued by illness. Although this system of
health care represented the beginning of health care in Sweden, it was by no means
universal and there were immense geographic disparities in the type and amount of
care that was provided.
The year 1847 marked the beginning of the contemporary system of universal
health care in Sweden. A series of “poor relief laws” were passed, these laws were not
based on the recognition of the need for social equality, but rater on “the idea of
Christian love, and to be put rather crudely, the idea of public cleanliness (that is it is
not sanitary to have people lying in the streets, possibly dying there”(Samuelsson,
p.336, 1968). These laws were only guidelines that were based on the prevalent
Christian values of the times. Those in need of medical care were to be treated, but it
was optional and there was no power to enforce it. Various discussions were held and
it was decreed that only those who could not look after themselves were to receive
state assistance in medical care. Very little was done to change the content of social
policy until after World War II. Following World War II, Sweden embarked on a
course of radical social reforms that led to the institution of a compulsory medical care
program (Samuelsson, 1968).
Beginning in the 1940’s, a greater pressure was exerted on the Swedish
government by the increasingly dissatisfied public to institute a comprehensive
national health system. Through a series of debates and government task forces,
Sweden decided on a “landstingsmodell” (a county-based integrated health care
delivery system). This model was implemented in 1955 and mandatory health
insurance for Sweden takes root (www.lysator.liu.se).
Once implemented, the health care model underwent a continuous cycle of
reform until the present day. Some of the more important reforms to the original
model are as follows:
1960 - Private beds in hospitals were abolished. Counties were made responsible for
open care.
1970 - A single fee was decided on for public care. (Today there are different fees in
the range of 80-150 kroner)($20-$35 US). Publicly employed doctors were salaried.
All pharmacies were bought by the state and a state monopoly of pharmacies was
founded.
1975 - Private doctors were permitted to work for the social insurance system. The
fees they could charge and the number of patients they could see was regulated.
1983 - County councils were requested, by law, to take responsibility for all kinds of
health care (Health and Medical Services Act).
1985 - County councils were given the right to control the establishment of private
practices. (www.fraserinstitute.ca)
Currently, there is a debate raging over what types of reforms are needed to
keep Sweden’s national health care system alive in the face of an ever-tightening
budget. The health care system in Sweden will continue to change as the needs and
priorities of the population evolve. Health care policy is not static; it is a continual
process of evaluation, consultation, and implementation. Health in Sweden is geared
towards remaining sustainable in the 21st century.
Demographics of Sweden’s Health Care system
The demographics of Sweden's health care system are measured, as in every
country by a number of variables. Infant mortality rate, this first characteristic is based
on the number of deaths of children under 1 per 1000 of population depicted in
percentage form. As of 1995 data, this percentage is 0.4%, which has been on a steady
decline since the 1980's in Sweden. Closely associated with infant mortality rate is
birth rate, which is determined by the average number of children in each couple.
Sweden’s average is 1.3 children (Health in Sweden-Sweden's Public Health Report
2001).
The second major characteristic that the Sweden’s government and health care
systems use to measure their health care is life expectancy. According to 1995 data,
the male life expectancy in years was 76 and the female life expectancy was 81 years.
Since the 1980's, "men's life expectancy has increased by 3.3 years and women's by
1.9 years" (Health in Sweden-Sweden's Public Health Report 2001). Another
characteristic that is used to determine the quality of the health care system is the
median age. This age to date is 38.4 years, which is determined by taking the sum of
the population and dividing by the total population (or a sample thereof).
Major causes of death statistics are useful because they can determine what are
the major causes and the corresponding percentages. For the society in general,
cardiovascular disease conditions account for nearly 50% of all deaths. However, in
particular, the three major causes of death for the population of 15-24 years old are:
accidents (mostly traffic), suicide, and cancer. Other statistics that are useful in
determining the quality of the health care system are to look at population dynamics,
in particular the demographics of the 15-24 years old age group. These include total
population, which in 1995 was 8,788,000 and in 2030 is expected to be 9,539,000.
Also, this percentage constitutes 12.4 % in 1995 and an expected 11.4 % in 2030 in
population as a whole. As we can see by this data, as in other areas in the world, the
youth percentage of the population will continue to decrease as the baby boom
generation gets older. (Health in Sweden-Sweden's Public Health Report 2001).
Currently in Sweden, there are 225,000 health care providers working in the
health care field. Of these, 1700 physicians and 2200 physiotherapists work in private
practices (see Appendix 1 – Health care workers). The problems of decreased financial
resources, nursing and doctor shortages and increase of the aging population have also
been felt in Sweden. As a result, people heading into the health care field have greatly
decreased. Also, health care is losing practitioners due mainly to lack of financial
support and the increasing amount of workload that the providers are expected to
complete.
Due to current problems the Swedish government is looking at Quality and Safety
programs in the health care system. Beginning in the 1990's, health care’s system has
increasingly quality oriented. "The aim of this work is to generate value added for the
people these services are intended for-patients, their relatives and the public in general
and to improve the health care system's ability to meet their needs” (www.si.se).
Under careful scrutiny the two main areas that need to be changed are the availability
and patient oriented health services. Furthermore, in 1997, the National Board of
Health/Welfare implemented a Continuous Quality Improvement (CQI) program.
Similar to Canada's CQI/Risk Management project, the government set up standards
that each area of patient care must adhere to in order to ensure that patients are
receiving the utmost in continuous care. Though Sweden's health care system is under
many constraints, through their Quality and Safety projects they are connecting the
different health providers together and making them accountable to each other.
The Role of Government Funding
Health care in Sweden is organized in three levels: Primary care, county care
and regional care. The primary care sector’s objective is to improve the health of the
population by treating disease and injury that does not require hospitalization. It is also
responsible for public and preventive care in given area. Primary care includes health
care centres, district nurses and maternity childcare.
County care is somatic care of patients, which is carried out in central and district
county hospitals. Care is given both in hospital wards and in outpatient clinics. Shortterm psychiatric care is a county medical care responsibility and is now increasingly
performed in an outpatient basis. Sweden is divided into 20 counties, each with a
council responsible for the administration of health care.
Finally, regional care is carried out at highly specialized regional hospitals in
six health care areas. County councils in each respective region govern this type of
health care. Regional hospitals have a more substantial number and degree of (sub)specialties compared to that of county hospitals, including neurology, pediatrics, as
well as thoracic and plastic surgery (National Health Care…1996/97).
Costs of Sweden’s health services, including pharmaceutical and dental care,
amounted to SEK 128 billion (28 billion US) in 1996. About 90% of these costs were
allotted to the county councils and the care they provide. Roughly 77% of these
operations are financed by taxes. Also, the central government provides the councils
with additional funds, in the form of grants and payments (Swedish Institute, May
1999).
In recent years, county councils and health services have experienced
reductions in the tax base with respect to the revenues they receive. As a result, the
county councils have had to reduce spending by 1.5% each year since 1992.
Consequently, length of patient stay has decreased while outpatient services have
increased (Swedish Institute, May 1999).
What Is Included In Health Insurance
A portion of these government funds constitutes the National Insurance
scheme of the country. This system is in place to cover medical expenses, hospital
care, sick benefits and the costs of dental care (Swedish Institute, May 1999).
Patients Fees
The fee charged for a stay in hospital is an average of SEK 80 per day. Outpatient
fees are set by the county council. The average fee for a physician consultation is
SEK 54 ($12. US). Also, fees for a physical therapy session is SEK 27 ($6 US), in
patient hospital care is SEK 36 ($8 US), and prescriptions are SEK 45 ($10 US). A
ceiling cap is in place in order limit the patient’s yearly expenditure on health care.
Once the cap is reached, patients can receive medical services at not additional cost for
the remainder of the year. However, children under the age of twenty are exempt from
these fees. (http://www.si.se/cse/cs3/html)
Differences Between the Swedish and Canadian Health Care Systems
The health status of both Canadian and Swedish citizens is very impressive in
comparison to that of other nations. While the health care systems of these two
countries share many similarities to one another, there are also a number of differences
that exist between the two. Health care administration, physician payment, financing
and the role of the physicians, are just four of the differences that will be explored in
this section.
As similar to Canada, Sweden has had to face the pressing issues of rising
costs, long waiting lists, and a decrease in the quality of health care. In an attempt to
remedy these problems, the Swedish government has encouraged the privatization of
some health care services, such as ambulatory care, custodial care for the elderly, lab
testing, nursing and surgery (Crowley, 2001; Lassey, 1997). In Sweden, private health
care operators are permitted to compete with their public counterparts but only under
very strict guidelines. This private system is very unique in that it is completely
dependent on its competitor, the public sector. Private centres are tightly regulated
and controlled by the county councils who have the authority to determine who can
practice privately (Livingston, 1994; Lassey, 1997). Also, and most importantly,
private practices/clinics are publicly funded. While patient fees do exist, a monthly
grant is awarded by the councils based on the services provided by the physicians
(Crowley, 2001; Lassey, 1997; Livingston, 1994). This competition between the two
sectors has resulted in a decrease in costs, shorter waiting lists and better quality of
health care (Lassey, 1997).
In contrast to the Swedish system, the current Canadian government does not
advocate for any form of privatized care. Health care, for the most part, is publicly
administrated which is one of the core principles of Medicare in Canada. As
Canadians, we believe that we have a very unique health care system that has resulted
in an impressive health status amongst citizens. However, the threat of a two-tiered
system hangs heavily over our heads. With the rising costs of health care, the long
waiting lists and the increased needs of an aging population, privatization may be the
only solution. This threat has already been realized in some locations across the
country where private surgery and ambulatory clinics are treating patients who can
afford their high costs. Canada’s version of privatization, however, is very different
from that of Sweden. In Canada, there is no public funding available for private
operators nor is there much governmental control over their practices (Lassey, 1997).
As a result, if Canada succumbs to privatization, and a two-tiered health care system
develops, a gross amount of inequity will exist which violates another principle of
Medicare.
Another difference that exists between the Canadian and Swedish health care
systems involves physician payment. Although historically financed through fee-forservice, the vast majority of doctors in Sweden are now paid on a salary basis. This
change in the payment schedule was the result of a government strategy to reduce the
income gap between general practitioners and specialists. Also, despite being world
renowned for their excellent training and their high quality care, Swedish doctors earn
considerably less money than other doctors around the world due to this payment
schedule. This is the result of another government strategy to create equity, this time
amongst all Swedish citizens (Lassey, 1997).
The Canadian physician payment situation differs from the Sweden’s system
as described above. The majority of physicians in Canada work on a fee-for-service
basis, that is, for each service they provide, the provincial health insurance is billed for
payment. Fee schedules for each service are set by negotiations between medical
associations and provincial health ministries. While this fee schedule has existed for a
long time in Canada, there are many problems associated with it. Since doctors are
paid for every service they provide, an emphasis is likely to be placed on quantity, not
quality of care. The more patients a doctor treats the more money they will earn.
Consequently, doctors may be motivated to perform unnecessary procedures in order
to raise their income level, which contributes to the rising costs of health care.
Another important difference between the two countries, in regards to health
care, is the methods in which health care is financed. In both countries, the majority
of funding comes from government and provincial sales tax, government funding and
private insurance plans (Lassey, 1997). Sweden, however, has an additional financing
mechanism for health care patient fees. (Kronstrom, 1994; Lassey, 1997; Livingston,
1994). These patient fees are designed to keep health expenditures down while
simultaneously preventing unnecessary use of the health care system. (Lassey, 1997).
Finally, the role of physicians in Canada and Sweden differ. Canadian
physicians have a great deal of power and authority within the health care system,
holding the greatly valued position of the “gatekeeper”. This means that the physician
is the first point of contact, with regards to care, for any patient. They determine what
services are necessary to deal with the patient’s problem, including the use of any
specialty medical service. In fact, primary care physicians control complete access to
all specialists, such as dermatologists, surgeons and psychologists. Without a doctor’s
referral, Canadian citizens do not have access to any of these health specialties. This
gatekeeper role however, does not exist in the Swedish system. If a patient wants to
see a cardiac specialist, for example, they are able to see them directly, avoiding a
consultation with a primary care physician (Kronstrom, 1994; Lassey, 1997;
Livingston, 1994).
Advantages and Disadvantages of Swedish Healthcare System
Advantages
Sweden is considered to have one of the most progressive health care systems by
international comparison. Perhaps the fact that Sweden only has to deliver healthcare
to a limited population of 8.9 million could be factor of its international ranking. Its
population size allows the country to provide more comprehensive health care services
and therefore obtains better national health outcomes.
Sweden offers universal access to health care for the entire population regardless
of financial circumstances. The country provides equity in health care to all residents,
including urban and rural communities (Lomax, 1996). The principle of Swedish
health care is that there should be “equal access” to social and health services
(Weisbrod, 1991). Sweden has established the fundamental human right of all citizens
to obtain adequate and equitable health care. The patient’s need determines access to
medical care, not their ability to pay. All residents are entitled to use the services at
subsidized prices, which are set by each county council. To limit the expenses
incurred by patients, there is a high cost ceiling. So, as mentioned earlier a patient
who has paid a total of SEK 900 ($200 US) is in titled to free medical care for the rest
of the twelve-month period. Comparative literature statistical analysis has shown that
a single payer system of health insurance significantly reduces administrative costs
(Eliason, 1995). Reduced aggregate legal fees and lower malpractice insurance for
surgeons are results of this social concept and provides more national revenue and
resources for patient care allocation (Lomax, 1996). Another benefit of this health
care policy is children and young adults under twenty receive health services at no
cost (Swedish Institute, May 1999).
Scandinavian health care policies emphasize preventative health, not just
traditional medicine. They have public education campaigns that are channeled
through out the schools. Their pre and postnatal care has contributed to one of the
highest infant survival rates internationally (Lomax, 1996). Part of this social policy
includes dental privileges. The county councils are responsible for ensuring that all
children and young people, up to the age of nineteen receive free dental care. The
dental health of this group has improved considerable since the 1970s and continues to
improve steadily. Adults receive subsidy from the National Dental Insurance system
for basic dental care. The county councils are responsible for ensuring that sufficient
specialist dental care is available to meet the needs of both children and adults.
In addition, there is a focus on preventative care due to the future demographics of
Sweden’s population. In 1999, 17.3% of the population were aged sixty-five and
older (European Centre for Health Policy, September 2000). This figure is
significantly higher than most countries. In future decades health care costs for the
older population will have to be monitored and contained while improving the quality
of life for elderly people.
Another advantage of Sweden’s healthcare system is the councils cover
prescription medicine. The patient is required to pay the cost of prescriptions up to
SEK 900 ($200 US). If a medicine costs more, patients will receive a discount.
Patients never pay more than SEK 1,800 ($400 US) over a 12-month period (Swedish
Institute, May 1999).
Sweden’s healthcare system also allows freedom for patients to choose where and
by whom they wish to be given medical attention. Patients are able to choose the
health centre and/or family doctor. The fact that they do not need a referral to obtain
specialist hospital care as previously mentioned. This method promotes patient
autonomy and encourages them to be responsible for their own health.
Disadvantages
Similar to the Canadian Health Care System, Sweden too is under financial
restrain. In an effort to reduce health care spending the government has made some
administration changes. For example long-term care is now the responsibility of the
local councils and not the county regions. When the acute care of a patient is
complete, it is the local council responsibility to pay if the patient still occupies a
hospital bed. As hospital beds are expensive, local councils are eager to move patients
out of hospitals to nursing homes or to home care. It has become apparent to the
Department of Social Affairs that elderly patients are often moved too fast from
hospitals and that the standard of care for these patients is not satisfactory (Swedish
Department of Social Affairs 1995 Annual Report.). This has enormous implications
because the number of elderly adults is significantly higher in Sweden and continues
to increase.
Another disadvantage is that workers in the health care field have been living with
turbulent working conditions for a long period of time. The motivations and morale of
health care personnel is falling. Recently, more that ten of the top managers of the
larger hospitals have resigned from their positions, as have many heads of clinical
departments, due to conflicts between financial demands and the ethics of the medical
profession (Gennser, 1999). Local health centres find it difficult to attract doctors in
spite of the good salaries. General practitioners have low status and doctors have little
control over their work. Of the 4,000 posts in the 800 centres in Sweden, only 2,000
are currently filled (Ekstrand, 1996). A continual systemic reduction in health care
staff in Sweden will eventually sacrifice health care quality.
Another emerging problem is some inequalities of health between Swedish
residents. Health differences between different socioeconomic groups are increasing.
A growing number of citizens, especially women of the working class and lower
middle class have social, financial and health related problems. Sweden’s population
is predicted to have increased injuries resulting from increased alcohol consumption
and drug addiction (Lomax, 1996).
In Swedish society today, with decreasing resources and demands for economic
measures, there is a concentration on getting “as much health as possible for the
money.” According the National Board of Health and Welfare, if achievements are
given priority exclusively with reference to cost efficiency, regardless of how
problems are distributed within the population, this can lead to an increase in
inequality (National Board of Health and Welfare 1994). With health care dollars
decreasing coupled with a reduced number of health care employees, the country has
many challenges to address.
Management Practices that can be applied to the Canadian Health Care System
Decentralization of Management to Counties
In Sweden, the health care system is managed at three different levels, the most
important and powerful of which is the county council. By dividing the country into
twenty geographical areas, twenty different elected county councils are responsible for
each area. Councils are responsible for providing health services and striving to meet
the health needs of their respective populations. They plan the services that are to be
offered, such as hospitals, as well as allocating funds to provide these services. This
makes for health delivery at the local level, unique to each region. It is a very
organized structure with each county being managed differently to best meet the
health needs of the people that it serves (Swedish Institute, May 1999).
In Canada, health is primarily a provincial objective, being managed by
ministries that are responsible for the whole province. Health is uniformly delivered
across the province without regard for variations among different areas. The
organizational structure as adopted by Sweden, in which management is decentralized
to local government would enable a more integrated, accountable system. Canada
could use the already existing municipal governments to act as the local management
systems and those delivering health care. Although Canada has shifted some
responsibility to the municipalities, they should be the primary and dominant decisionmakers regarding health care (Lassey, 1997).
The Role of the Physician in Health Care
The physician’s role in the Swedish health care system as a whole is salaried and
also more limited. The profession lost standing in the 1980’s because of various
reasons as mentioned earlier. Reforms lead to changes in the system where they are
no longer the primary entry point to the system as they are in Canada. Although they
remain essential to the operating of the system they do so more in collaboration with
other professionals as well as the patient (Gennser, 1999).
As already stated, the traditional “gate-keeper” role that the physician
occupies in other industrialized countries is not evident in the Swedish Health Care
system. A patient’s ability to see a specialist on his or her own accord, without the
referral of the physician, limits the power of the physician’s status in the system. In
Canada, where doctors are paid for referrals, can lead to health care professionals
teaming up to provide care when it is not necessary (Lassey, 1997).
Patient Payment Schemes
Another management practice Sweden employs that would be beneficial to the
Canadian system is the fee the patient pays for using health services. This is a result
of the economic slump in the 1980’s where less funding was available for health
services, which lead to constraint in services and shortages in other areas. Patient fees
were implemented to help fill the service gap and to help offset the rising costs of
health care (Gennser, 1999). This fee is in reality quite minimal for the high quality of
care Swedish residents is accustomed to. The remainder of costs is billed to the
National Health Insurance system. Also, fees are subsidized for certain services such
as those for the disabled, counseling for birth control and contraceptive use, and
prescriptions that treat chronic illnesses. Swedish citizens are also reimbursed for
extra travel costs incurred while using health services (Lassey, 1997).
Reasons why these Practices were Chosen
Decentralization of Management
This management practice would be especially effective in Canada because of
its large geographical area and the diversity of the population. Every region of the
country varies so dramatically from the next. Different areas have different needs
with respect to culture, population density, geographical barriers and access to care.
By arranging the delivery of services by smaller regions, Canada could ensure the
unique needs of each region are being specifically met. For example, councils that are
sensitive to the unique needs of this culture would manage health care for the
Aboriginal population.
This type of management also makes the health care system more accountable
to the populations it serves. It would be closer to the level of the citizens so they could
ensure they were receiving the care they desire. It is a method of community
empowerment, where citizens would be more directly involved in the care and
services they acquire. It should increase the overall satisfaction with the health care
system because people feel it is extremely important to have a say in their health care
(Eisemann, 1999). It also means resources could be allocated more appropriately, in
varying degrees based on the demand in each area.
The Role of the Physician in the Health Care System
This management practice has several main advantages and reasons why it
would be beneficial in the Canadian context. Primarily, by allowing patients to access
care without the referral of a physician promotes greater patient autonomy. This
system enables the patient to have greater choice in the services they use and who are
to deliver these services to them. Patients play a greater role in their own health,
which leads to a sense of personal accountability and healthier attitudes.
In addition to have physicians salaried in Canada, as they are in Sweden, is a
method of promoting greater equality among specialists and other health care
practitioners. Although their incomes are generally lower than they are in Canada, this
payment method also means physicians can concentrate more on quality of care rather
that quantity of care as is the case with fee-for-service.
Finally, this payment method prevents the duplication of services and
procedures. Often, a patient might see more than one health care provider for the
same ailment. Unnecessary visits to the doctor are also prevented because the doctor
does not get paid per visit.
Patient Payment Schemes
This change in the system of financing health care would be beneficial in the
Canada because of the tremendous health care rising costs that exist. Patient fees help
to offset the costs the government must pay for health. Although they are quite
modest fees, the total amount paid by Canadian citizen would be a substantial relief to
the already overburdened system.
It would also help to fill gaps in service delivery so resources could be concentrated on
preventing the barriers to access to care. This is especially true of Canada’s large rural
and aboriginal population. Services are not equally distributed in Canada and the
extra revenue would even this distribution. It is also important to note that these rural
populations often have to travel long distances to health care facilities and should be
reimbursed as they are in Sweden.
If patients are required to pay for health they become consumers in the health care
system. As consumers, they would be more inclined to make wiser decisions about
health, such as where and when they use the system. They have the right to choose
between different hospitals and county services as well as physicians and specialists.
It promotes patient autonomy as well as personal responsibility about health. Patients
would be inclined to use the system only when it is necessary, reducing waste of
services and unnecessary strain on the health care system. It would also be important
for the Canadian government to offset costs for those on social assistance, the disabled
and those under the age of eighteen.
Sweden has a truly exemplary system of health in the way it is managed and
distributed amongst its population. It sets international standards in regards to quality
of care and administration. Although there are benefits and drawbacks to the Swedish
system, it is overall one of the most effective in the world. Canada could reform its
own Health Care system with respect to the Swedish example in order to improve
health in this country.
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