“Health and medical services are aimed at assuring the entire population of good health and of care on equal terms… Priority for health and medical care shall be given to the person whose need of care is the greatest.”

The Health and Medical Services Act, 1:II

Overview

Sweden’s government is divided into three levels: central government, county councils, and municipal governments. Each shares the responsibility of maintaining the health of and providing medical care to Sweden’s citizens through the nation’s three-part health care delivery system which consists of national, regional (organized through county councils), and local care. Generally speaking, the central government sets the health care policies, while the local governments organize the delivery of services to ensure that their own residents receive the medical care they need.

Sweden is organized into six regions, which are broken down into 21 counties, which are further divided into 290 municipalities. Different levels of care are provided at the three regions: municipalities provide mostly primary care, counties provide secondary care, and regions provide tertiary level care.

Seventy percent of health care services is paid for through local government taxes. Sweden’s county councils and municipalities provide 90% of the health care in Sweden; the remaining 10% of services are provided by private practices.


The Organizational System


National

The central government’s Ministry of Health and Social Affairs is responsible for, among other services, medical and health care. The Ministry is primarily responsible for drafting health policy legislation. It also works with the county councils and municipalities to determine how to best finance and deliver health care to the citizens of Sweden.

The Ministry supervises a total of 17 agencies, of which eight are directly involved with health care at the national level. The central government distributes money and resources to each of the agencies and establishes the general role of each; the agencies are then free to act independently, deciding on their own how to address particular cases.

(1) The National Board of Health and Welfare: The central government’s primary authority for the social services, public health, infectious disease prevention, and the health services. The National Board of Health and Welfare evaluates the legislation of and supervises the activities of the county councils and municipalities, issues guidelines for health care, and is the chief authority over all health and medical services staff.

(2) The Swedish Council of Technology Assessment in Health Care: Carries out cost:benefit analysis of all medical innovations and medical treatments so as to ensure that only the most beneficial therapies are used on patients and so that the available resources are used most advantageously.

(3) The Medical Products Agency: Regulates the development, safety, manufacturing, and marketing of all new drugs and medical products. The Medical Products Agency guarantees that all patients and health services have adequate access to high quality medical products, and that the use of these products is cost-effective.

(4) The Dental and Pharmaceutical Benefits Agency: Determines whether new pharmaceutical products should be subsidized by the state; and, if so, at what price these products should be sold.

(5) The Medical Responsibility Board: Investigates malpractice claims and complaints made by patients that involve examination, care, and treatment of patients.

(6) National Institute of Public Health: Promotes heath and disease prevention by helping to ensure that all Swedes have equal access to health care.

(7) National Corporation of Swedish Pharmacies: Owns all pharmacies and ensures that all pharmacies carry all approved pharmaceutical products and sells the each drug at the standard, national price. The corporation also provides to the public and physicians updated information about every drug.

(8) National Social Insurance Board: Maintains a branch in every county council so that cases can be processed at the local and regional levels. The board supervises local insurance offices so as to ensure that each claim is processed without bias.


Regional

Sweden’s 21 county councils provide health care at the regional level. The Health and Medical Service Act of 1982 outlines very broadly the responsibilities of the county councils, and requires only that the county “offer good health and medical services to persons living within its boundaries.” Thus, the county councils are free to structure their hospitals and to decide how deliver health services based on the specific needs of the surrounding community.

County councils have a different number of health care service districts depending on the size of the county population, which range in size from 133,000 to 1.8 million people. Districts are typically comprised of one hospital and several primary care facilities. Primary care facilities provide general medical care and preventative and rehabilitative services. The citizens elect a hospital board, whose job it is to manage the health care district. Each hospital board appoints some of its members to an administrative group, whose job it is to ensure that health care is distributed equally within the district.

Every county is grouped into one of six regions. Should a patient require tertiary level care (i.e., highly specialized care to treat a severe, complicated, or unusual medical problem) he will go to one of the country’s eight regional hospitals, Sweden’s most advance health care facilities, which also serve as centers for research and teaching.


Local

Municipalities negotiate with the county councils to determine for what services each will be responsible. Among other responsibilities, municipalities provide social welfare services, including: childcare; social health services; environmental hygiene; care of the elderly (public nursing homes and home care), disabled, and mentally ill; and support for those recently discharged from the hospital. Like county councils, municipalities are managed by elected executive board; the board coordinates the business and finances of the municipality and supervises the municipal committees. Each municipality also has a municipal council, which has the power to levy taxes, and several committees, some of which are patient committees that work to improve the quality of the health system from the patients’ perspective (i.e., improve access to and quality of care; promote good patient-provider relationships; provide patients with health-related resources; connect patients to support groups; report to providers regarding inconsistencies noted in patient care).

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Source: European Observatory on Health Care Systems. Health Care Systems in Transition: Sweden. N.p.: n.p., 2001. Written by Catharina Hjortsberg and Ola Ghatnekar; edited by Ana Rico, Wendy Wisbaum, and Teresa Cetani


The Delivery System

The Health and Medical Services Act outlines how health care should be organized and delivered in Sweden. The Act ensures that all Swedish citizens are covered under the country’s health care system. Emphasis is placed on “assuring the entire population of good health and of care on equal terms.” Interestingly, nowhere in the 16 page document—where everything from quality assurance to health and medical services in times of war is stipulated—does there appear an outline for a basic health of prescription drug plan. Instead, the Act provides only a list of loose requirements:
  • Medical care must be readily available and of good quality

  • The system must be dedicated to protecting patient privacy and patients’ right to be involved in and consulted regarding the course of their treatment

  • The system must facilitate the establishment and maintenance patient-provider relationships

  • Providers must ensure that their patients understand their diagnosis and are informed of the availability of the existing treatment options

  • Preventative health care must be provided

  • Medical personnel much show respect for the deceased, and empathy for the survivors

  • Medical facilities must be well-staffed and well-equipped so as to provide the best possible care for the patients


The overarching goal of Sweden’s medical system is to provide care “with respect for the equal dignity of all human beings and for the dignity of the individual” and to give priority to “the persons whose need of care is greatest” (1:II). As long as these conditions as fulfilled, the Act entrusts the local governments to determine how to appropriately organize and deliver health care services to their residents.

Under the Swedish system, the municipalities and county councils are self-governing and are each responsible for providing different services:

County Council
  • Habilitation and rehabilitation services wiki.jpg
  • Assistive devices for persons with functional impairment
  • Interpreting services for the deaf, deaf-blind, and hearing impaired
  • Disposable articles required to treat chronic illnesses involving urinary or intestinal incontinence and/or urine retention
  • Free prescription drugs to patients receiving home care
  • Dental care for children up to age 19
  • Inpatient and outpatient hospital care
  • Psychiatric outpatient care
  • Specialty care facilities (which employ a range of specialists, particularly surgeons)

Municipal
  • Care for the elderly (home care and nursing home care)
  • Disability support services
  • Mental health care
  • School health care
  • Support and services for people released from hospital care
  • Public health and preventative services
  • Primary health care
  • Inpatient and outpatient Rx drugs
  • Patient transport support services

It should be noted that because the county councils and municipalities decide among each other what services will be provided by which level of local government, the above lists are meant only to reveal, in general, which services are provided by what organization; the specific services provided by counties versus municipalities vary throughout the country.


The Swedes pay into a socialized health care system through taxes levied by the central government and local governments. Only about 2% of the health care financing is paid for out of pocket by the patients. The central government covers about 10% of health care costs in the form of grants to county councils. The government reallocates the tax money to county councils and municipalities based on the type of people that live in the area (i.e., old or young, sickly or healthy) so that similar health care standards are maintained throughout the country. About 20% of health care funding comes from a mandatory payroll tax levied on employees and employers; this money funds the Swedish Social Insurance Agency, which uses the tax money to pay private health care providers, and to subsidize dental care and prescription drugs. The remaining 68% of the health care is financed by taxes charged by county councils and municipalities to their citizens.

Most hospitals are public hospitals owned by county councils, although with the introduction of the Stockholm Model in the early 1990s, privatized medicine is on the rise. Long waiting lists—especially for elective care—plague the system, which sparked the introduction of competition in the form of private providers into the health care system. Private hospitals specialize primarily in elective surgery and are contracted by county councils. Thus, the county councils still exert a certain authority over private practitioners. While they cannot prevent a clinician from setting up a private practice, the county council must approve the provider if he wishes to receive county council funding and to be reimbursed by Sweden’s social insurance system. If the provider does not get paid through the national insurance system, he must require his patients to pay out of pocket; and since all Swedes are covered under the national health system, very few patients are willing to pay for their care out of pocket. Thus, very few physicians who are unaffiliated with the county councils exist.

Publicly employed physicians are paid mostly by capitation rates; some are paid on a fee-for-service basis. Private primary care providers are typically paid on a fee-for-service basis. Hospitals are paid based on diagnosis-related groups (DRGs) and global budgets.

Public providers and government-contracted providers must charge all of their patients the same amount and according to the rates set by the county council or municipality. Public or government-contracted hospitals that provide inpatient or long-term psychiatric care and/or provide disposable articles (mentioned previously) may charge patients based on their income so that “the charges [do] not… amount to so much that the individual does not retain sufficient of his charge base to cover personal needs and other normal living costs” and so the “spouse or partner of the care recipient does not incur an oppressive impairment of his or her financial situation” (1:XXVI).

Patients are typically charged about $12 USD per day for inpatient care (this includes medical treatments and all medicines). The cost of outpatient care for patients varies among county councils. Patients are charged about $18 USD to see a primary care physician, and $30 USD or more to see a specialist, depending on the specialty. Patients are responsible for paying for all prescription drugs in full up to $131 USD, after which the price is increasingly subsidized by the local government. Sweden has in place two caps so that no patient must pay more than $131 annually for medical care and/or more than $263 USD annually for prescription drugs. Once the maximum(s) has (have) been reached, the patient will receive free medical care and/or prescription medications for the remainder of the year.


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Source: Works Cited The European Observatory on Health Systems and Policies. Health Systems in Transition: Sweden, 2005

The Patient’s Journey

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Source: OECD health data, 1999. Note: more recent data regarding Sweden's medical resources not available.
While Sweden generally invests more resources in health care than other OECD countries, much of the technology is available only at Sweden’s eight regional hospitals. In an effort to limit costs, Sweden reserves admission to the regional care centers for those who require the most advanced diagnostic tools and the most experienced specialists. Indeed, there are several levels of care through which a patient must proceed before being referred to a regional center.

First, a patient will seek care by appointment at the primary care level, often from a general practitioner employed at one of the county council’s primary care centers. There, the patient can receive preventative services (i.e., routine physicals, vaccinations), treatments for common ailments (i.e., ear infections, common cold), and/or medical advice. Also at the primary care level are nurses, midwives, physiotherapists, gynecologists, and pediatricians. In fact, nurses are often the ones to perform the initial assessment of the patient; and, if necessary, refer the patient to the general practitioner or to a county hospital. Also available in each county are “telemedicine” hotlines, which patients may call 24-hours a day to ask a registered nurse medical advice and, if necessary, where to seek care.

Most primary care providers are publicly employed, although private physicians and clinics do exist and are relatively common in urban areas. As of 2003, there were about 1,100 primary care health centers, of which 300 were privately run. Additionally, of the 12 million total primary care provider visits made by patients in 2003, only 27% were conducted at private facilities. And, as discussed previously, private physicians are still tied to the state, as the county council must approve the provider if he wishes to receive county council funding and to be reimbursed by Sweden’s social insurance system.

Should the primary care providers fail to diagnose and treat the patient, the patient will be referred to a specialist of his choice at one of Sweden’s 40 district county hospitals. The general practitioner can call the specialist himself, or he can give the patient a referral letter so that the patient can schedule the appointment. It should be noted that while there is no formal “gatekeeping” system in effect, allowing the patient to seek care directly at a hospital, the waiting times for the patient are significantly longer without a referral from a general practitioner. And, while the patient is free to choose their specialist and hospital, the patient cannot choose at what level of care he will be treated (county versus regional)--the care level is determined based solely on the degree of specialty required to treat the patient.

Every district county hospital employs physicians in at least four specialty areas: internal medicine, general surgery, radiology, and anesthesiology. District county hospitals are capable of treating most ailments, including mental health problems. As of 2002, each district county hospitals had about 151 hospital beds available for inpatient care.
If the patient requires still more advanced care, he will be referred to one of Sweden’s 20 central county hospitals. These hospitals are quite a big larger and more specialized than district county hospitals, having, on average, 458 hospital beds and employing 15-20 different kinds of specialists.

The most specialized level of care is provided at regional hospitals, of which there are only eight in the country. Patients referred here are those who present with particularly challenging diagnoses or rare disease and thus require the combined efforts of multiple specialists and the most high-tech equipment. By regionalizing care, Sweden controls costs by minimizing the amount of specialized machinery in which the country must invest. Furthermore, concentrating the most difficult patients cases and the most highly skilled specialists and subspecialists into only eight regional facilities brings together the expertise required to ensure coordination and continuity of care. Regional hospitals are owned and administered by the county council in which the hospital resides; the surrounding county councils pay the first county council so that their residents can also seek care at the regional facility. Regional hospitals are the largest hospitals, with approximately 1,025 hospital beds as of 2001.

When a patient is ready to be discharged from a hospital—whether from a county or regional hospital—a team comprised of the patient, his hospitalist, representatives from social care and the outpatient staff develop a care-plan, outlining the medications, rehabilitative services and support the patient will require following his discharge from the hospital. Upon discharge, primary care providers (general practitioners or nurses) at the municipality level resume responsibility for the patient’s care. The patient will receive necessary medical services through outpatient or home-based care as outlined in the care plan until he is medically cleared by the municipality.

The following graphic outlines the journey through Sweden’s health care system of a hypothetical patient in need of surgery:


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Adopted from the text of Glenngard, Anna H, Frida Hjalte, Marianne Svensson, et al. “Health Systems in Transition: Sweden.” The European Observatory on Health Systems and Policies, in partnership between the World Health Organization Regional Office for Europe 2005: 73-93.


New Developments

Prior to January 2003, Swedes were bound by law to seek care only within their own county. Now, under Sweden’s “freedom of choice” policy, patients are allowed to seek care at any hospital in the country. This law was passed in an effort to reduce wait times and to increase patient autonomy.

In an effort to increase patient satisfaction, Sweden enacted a “health-care guarantee” in November 2005. Under the new policy, county councils must ensure that patients receive medical care within 90 days after an initial diagnosis has been made. If the county council fails to offer treatment within 90 days, the county council must refer the patient to another hospital and pay for the total costs (including travel costs) incurred by the patient. As of December 31, 2008, 75% of county councils had provided patients with treatment within the 90 days deadline.

Between 2010 and 2012, the Swedish Association of Local Authorities and Regions will allot a share of $140 million to county councils that meet the 90 day treatment deadline with 80% of their patients.



References
Glenngard, Anna H, Frida Hjalte, Marianne Svensson, et al. “Health Systems in Transition: Sweden.” The European Observatory on Health Systems and Policies, in partnership between the World Health Organization Regional Office for Europe 2005: 73-93.

The Health and Medical Service Act
. Government Offices of Sweden, 2003. The Health and Medical Service Act. Aug. 2003. Web. 22 Nov. 2009. <http://www.sweden.gov.se/sb/d/3873/a/23125>.

"Health care in Sweden - SWEDEN.SE." Health care in Sweden SWEDEN.SE - The official gateway to Sweden ? features, facts, news, weather. The Swedish Institute (SI), 12 Nov. 2009. Web. 30 Nov. 2009. <http://www.sweden.se/eng/Home/Work-live/Society-welfare/Health-care/Facts/Health-care-in-Sweden/>.

"Sweden's Single-Payer Health System Provides a Warning to Other Nations." National Center for Public Policy Research - A Conservative Think Tank. The National Center for Public Policy Research, May 2007. Web. 30 Nov. 2009. <http://www.nationalcenter.org/NPA555_Sweden_Health_Care.html>.

"Swedish health care - SWEDEN.SE." Swedish health care SWEDEN.SE - The official gateway to Sweden ? features, facts, news, weather. The Swedish Institute (SI), Jan. 2007. Web. 22 Nov. 2009. <http://www.sweden.se/eng/Home/Work-live/Society-welfare/Health-care/Facts/Swedish-health-care/>.

"Swedish Health Care System." Swedish Health Care - We specialize in - Healthcare Management - Biomedical Engineering - Elderly Care. Web. 30 Nov. 2009. <http://www.swedishhealthcare.se/swedenshealthcaresystem.html>.