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At 450,295 square kilometres (173,860 sq mi), Sweden is the third largest country in the European Union by area Sweden has a relatively low population density of 21 inhabitants per square kilometre (54/sq mi) with the population concentrated to the southern half of the country Sweden is an export-oriented mixed economy featuring a modern distribution system, excellent internal and external communications, and a skilled labor force. Timber, hydropower and iron ore constitute the resource base of an economy heavily oriented toward foreign trade. Country Population Life Expectancy Global Average 9,059,651 Male 79 71 66 Female 83 79 71 Both 81 75 68 61 146 176 3 13 60 5 21 260 1 4 8 8 63 201 Adult Mortality Rate (per 1000 adults 15 – 59 years) Under 5 Mortality Rate (per 1000 adults 15 – 59 years) Maternal Mortality Rate (per 100000 live births) Prevalence of HIV (per 1000 adults 15 – 59 years) Prevalence of Tuberculosis (per 100000 population) Regional Average WHO, 2009 Country Regional Average Global Average Population Living in Urban Area (%) 85 70 50 Gross Nationa income per capita (PPP int. $) 38050 23530 10599 WHO, 2009 Country World Rank 0.98 125 Population 0 – 14 15.7% 167 Population 15 – 64 65.5% 90 Population 65+ 18.8% 6 Birth Rate 10.13 167 10.21 58 Fertility Rate 1.67 151 Infant Mortality Rate 2.75 190 Sex Ratio M/F (per 1000 population) Death Rate (per 1000 population) (per 1000 population) WHO, 2009 Country World Rank Sex ratio at birth 1.06 57 Sex ratio under 15 1.06 42 Sex ratio 15 - 64 1.03 46 Sex ratio 65+ 0.79 82 Net Migration 1.66 35 Population Growth Rate 0.16 158 Life Expectancy/Birth 80.9 6 GDP per capita USD $38,500 17 WHO, 2009 Strong sense of societal solidarity The care of an elderly is not only a familial but is also a societal concern Democratic polity Long period of economic affluence with periods of crises Long tradition of publicly sponsored health care Collegium Medicum 1660 district MDs- Local Government 1752 Crown hospitals; care parishes * 1864 Local Boards of Health, Public Health System 1874 Regionalization 1958 1960 Economic crisis Prototype welfare state 1970-1980 Present The Swedish health-care system is taxpayerfunded and largely decentralized. Responsibility for health and medical care is shared by the central government, county councils and municipalities. The Health and Medical Service Act (Hälsooch sjukvårdslagen, HSL) regulates the responsibilities of the county councils and municipalities. The central government establishes principles and guidelines for care to set the political agenda for health and medical care by reaching agreements with the Swedish Association of Local Authorities and Regions (SALAR), which represents the county councils and municipalities. Structure District County Hospitals Local District Health Services Function Inpatient Outpatient services Med, Sx, Rad, Anes 60k-90k Primary Care, Public Health, MNCHN, School/Industry 2k to 50k Regional Hospitals Tertiary care Medschool, research 1M Central County Hospitals Specialized wards (500-1,000 beds) and clinics 200k-300k Structure Ministry of Health and Social Affairs National Board of Health and Welfare Planning Rationalization Institute County Councils Federation Function National Hospitals/Medical Centres Regulation Stewardship/ Planning Policy Evaluation Training Research National level Federation of Swedish County Councils Regional level 18 county councils, 2 regions and 1 municipality (regional authority) 8 regional hospitals in 6 medical care regions Approx. 20 county hospitals and approx. 40 district county hospitals Approx. 1100 health centres Parliament Government Swedish Association of Local Authorities Ministry of Health and Social Affairs Local level 290 municipalities (local authorities Special housing and home care for elderly and disabled people •Swedish Medical Association/ Professional Organizations •Social Democratic Party •Blue collar unions •White collar unions •Royal Commissions “Whenever health systems are ranked, Sweden always seems to come top or at the very least a close runner-up” --BBC News, 28 November 2005 Country Life expectancy Infant Nurses Per capita Physicians per mortality per 1000 expenditure on 1000 people rate people health (USD) Healthcare costs as a percent of GDP % of government revenue spent on health % of health costs paid by government Canada 81.3 5.0 2.2 9.0 3,895 10.1 16.7 69.8 Japan 82.6 2.6 2.1 9.4 2,581 8.1 16.8 81.3 Sweden 81.0 2.5 3.6 10.8 3,323 9.2 13.6 81.7 UK 79.1 4.8 2.5 10.0 2,992 8.4 15.8 81.7 USA 78.1 6.7 2.4 10.6 7,290 16.0 18.5 45.4 Life Expectancy vs Health Care Spending in 2007 for OECD Countries Source: http://www.oecd.org. “The national guarantee of care states that a patient should be able to get an appointment with a primary care physician within 3 days of contacting the clinic. If referred to a dietician by the GP, they should get an appointment within 14 days, and if treatment is deemed necessary by the specialist, it should be given within 10 days.” http://en.wikipedia.org/wiki/Healthcare_in_Sweden Physicians- interns/residency training, specialist consultants, district physicians, and administrators Nurses Pharmacist Midlevel- physiotherapist, nurse midwives 1. 2. 3. 4. 5. 6. 7. Distribution to areas and fields of specialties Supply of doctors Compensation and work stress Role of private sectors Education, training and research opportunities Cost for the government Market-reform initiatives were vulnerable to the whims of politicians According to OECD data, total expenditure on health as a percentage of GDP in Sweden amounted to 8.4% in 1998, slightly less than the EU average of 8.6%. Public health care expenditures amounted to 7.4% of GDP in 1998. In 1999, approximately 85% (99 billion SEK or 10.9 billion Euros) of total county council net expenditure was spent on health care (excluding dental care and pharmaceuticals), while the remaining 15% was for expenditure on other services, including social welfare, culture and public transportation. Of the total expenditures of 127 billion SEK spent on health care by the county councils, 99 billion was financed by taxes and not earmarked state grants (78%). Acute secondary and tertiary health care consumed 62.3% of these revenues, psychiatric care 9.5% and geriatric care 5.8%, while the remainder (22.4%) was spent on primary health care. MAIN SOURCES OF HEALTH CARE FINANCES, million SEK EXTERNAL REVENUES Drug Benefit Scheme Other Patient earmarked Fees subsidies Sales of services Other TOTAL 14 710 2 933 7 979 3 92 28 533 2 519 LOCAL TAXES AND STATE GRANTS 99 139 TOTAL REVENUES 127 672 The social insurance system, managed by the National Social Insurance Board, provides financial security in case of sickness and disability. • Insurance is mandatory and covers part of individual income losses due to illness and health care services. • The insurance also covers individual expenditure for prescribed drugs and outpatient care over a high cost-protection limit. • BENEFIT SERVICES Medical expenses Outpatient services Hospital treatment Paramedical treatment Pharmaceuticals Counseling on Birth control Dental care Medical devices for rehabilitation Travel Expenses Sickness Payments while ill Subsidization of salary while caring for a close relative Maternity Before and after birth Parental benefit For care of a child under age 8 2008 2009 Total Expenditure on Health (% of GDP) 9.4 9.9 General Government Expenditure on Health (% of THE) 78.1 78.6 Private Expenditure on Health (% of THE) 16.8 16.6 GGHE as % of General Government Expenditure 13.8 13.8 Private Insurance as % of PHE 1.2 1.2 Out of Pocket Expenditure as % of PHE 92.8 92.8 PAYING THE PHYSICIANS The counties employ most physicians on a salaried basis. Incomes are relatively less than in other industrialized nations at about 2x the average personal income. Financed largely from country budgets, although the national government makes contribution for special facilities such as university training institutions HOSPITALS 47% PRIMARY CARE SERVICES 18% DRUGS 8% LONG-TERM CARE, SERVICES FOR THE ELDERLY 27% 1930’s – Legislations passed focusing on maternal and child health low infant mortality rate 1947-1960 – Universal insurance and regionalization of services primary care were provided thru government sickness insurance agency, counties retain hospital services 1960-present – Decentralization health services shifted from central to small counties regional level take full responsibility Government Type: Democratic Parliament Ministry of Health and Social Services National Board of Health and Welfare -- responsible for establishing legal and developmental framework for county implementation of health care -- county is required by central govt to develop 5 yr plans for health care Health care, health, social issues/ insurance Dental treatment eHealth Elderly care Health and medical care Public health Sickness insurance The Ministry of Health and Social Affairs is responsible for the whole of the policy The objective of public health policy is to create social conditions to ensure good health on equal terms for the entire population The objective of health and medical care policy is that people must be offered good quality health care that is adapted to needs, accessible and effective “Semashko” Almost negative population growth rate High burden of diseases of old age High burden of mental illnesses Although the health system is decentralized, there is system of coordination among the different levels of the system. Referral systems local health districts and hospitals Sweden has to cope with rising healthcare costs and shrinking productivity (taxable population) Local taxes are the basis for funding health and medical care, which means opportunities for economic expansion are strictly limited Cost effectiveness/Equity Rationing is severely limited in times of crisis, a more efficient financing scheme is in order 1. almost nil chances of private practice 2. Oversupply of doctors, nurses, allied medical professions 3. Maldistribution to areas and fields of specialties 4. Compensation and work stress 5. Limited role of private sector 6. Education, training and research opportunities 7. Cost for the government None really, fairly modern information network A central quality assurance board and medical responsibility board Tendency for institutions to be “arrogant” for they have a virtual monopoly of services Insight: there is always some trade off, for the stellar health indices of Sweden, it entails considerable costs, tight regulation and governance. References: Genser, M. The Swedish Health Care System, The Fraser Institute http://oldfraser.lexi.net/publications/books/health_reform/sweden.html 2011 Blomqvst A International Health Care Models http://www.parl.gc.ca/Content/SEN/Committee/371/soci/rep/volume3ver5-e.pdf Saltman R. Renovating the Commons, http://jhppl.dukejournals.org/cgi/content/abstract/30/1-2/253 Jamlikhet (equality) And Tryghett (security) Aging population, changing medical technology, integration into the European common market Adaptation to a stronger primary care network, allow patients to choose doctors, health centers and hospitals within the public system Reforms more focused on fiscal management, cost effectiveness and organizational changes Government remains as the major provider and consumer of health care Limited competition physician distribution program- similar to DTTBP opening of opportunities for foreign physicians. Assigning of slots per field of specialty Encouraging private health centers and practitioners Professional organizations serve as venue for lobbying for compensation and benefits Setting of enrollment limits Providing opportunities for post graduate training, subspecialty, education and research. Swedish Association of Local Authorities and Regions (SALAR); Swedish Health Care in an International Context - a comparison of care needs, costs, and outcomes; June 2005 http://www.oecd.org. David Hogberg, Ph.D. “Sweden's Single-Payer Health System Provides a Warning to Other Nations”. National Policy Analysis.” May 2007. http://en.wikipedia.org/wiki/Healthcare_in_Swe den