“The present structure of the Swedish health care system reflects a long history of public funding and ownership, together with the growing importance of local self-government. Developments until the late 1960s were characterized by a growth in the number, size and importance of hospitals, largely determined by an expanding medical profession. During the 1960s, county councils’ responsibility for hospital services became integrated with responsibility for mental health services and general outpatient services, previously a national government responsibility. By 1982, a new act formally handed over responsibility for the planning and provision of services to the county councils. During both the 1960s and the 1970s, health care expenditures and physical resources grew continuously. The chief concern at both the national and local government levels was to improve equal access to services. Since the late 1980s, attention has shifted to cost control and efficiency, and to a growing demand for performance and quality in more recent times.”

Source: Anell A, Glenngård AH, Merkur S. Sweden: Health system review. Health Systems in Transition, 2012, 14(5):1–159.

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“During the last two decades, a much more critical attitude towards health care and county councils and municipalities as providers of services, has developed. In addition to distributive justice, objectives related to cost control, efficiency, value and quality have become more prominent in the governance of health care services. In the late 1980s, the lack of choice for inhabitants was debated and, not least, county councils were criticized for a lack of cost control and poor efficiency in expert reports (Roos, 1985). This criticism paved the way for a number of New Public Management (NPM) reforms in the early 1990s, including a purchaser–provider split, new contracts for providers and increased choice for inhabitants. Comparison across county councils indicates a short-term improvement in efficiency in county councils that implemented a purchaser–provider split and payment based on diagnosis-related groups (DRGs) (Jonsson, 1994, 1995; Gerdtham et al., 1999). However, the sustainability of an internal and thereby weak split between purchasers and providers has been questioned (Anell, 1996).

“Many county councils indeed returned to a traditional mode of planning and control following the economic recession in the Swedish economy in 1993. The recession initiated an acute demand to contain and even cut costs in the public sector, including health care expenditures. Significant changes were introduced in the hospital sector between 1993 and 1996. The number of beds and the associated nursing staff decreased as well as the ALOS. Emergency care was concentrated as several small hospitals had to focus on elective treatment and/or more limited acute services (Harrison & Calltorp, 2000). As a consequence of developments towards tighter budgets and priorities across hospitals, the need for improved primary care services and services for older people provided by municipalities became clearer. In 2000, a national action plan with special government grants to support the development of primary care and care for older people was implemented.”

Source: Anell A, Glenngård AH, Merkur S. Sweden: Health system review. Health Systems in Transition, 2012, 14(5):1–159.

“A further important development during the late 1990s was the merger between county councils. In 1999, the Region Skåne and the Västra Götaland Region were established by merging two and three county councils respectively (Palme et al., 2002). Besides the main task of providing health care services, the new regions were also given increased responsibility for regional development previously managed by county administrative boards accountable to the national government. In the most recent decade, a discussion about the need for similar mergers across additional county councils and formation of additional regions has continued.

“NPM [New Public Management] and similar reforms have been initiated and implemented by individual county councils and regions rather than at the national level. This can be seen as a reflection of the decentralized nature of Swedish health care that developed during the 1970s and 1980s. The exceptions are choice of providers for inhabitants and privatization of services, which have been given clear support from the centre-right-wing national governments in 1991–1994 and the governments led by the Conservatives in the mid 1990s and since 2006. Since 1 January 2010, following a change in the Health and Medical Services Act, choice of primary care provider for the population and freedom of establishment for private care providers accredited by the local county councils has been mandatory. This also means that the previous focus on primary care providers’ responsibility for a geographical population has been formally abandoned. Several county councils and regions had already implemented similar reforms from 2007–2009.

“Another important and recent national decision was to re-regulate the Swedish pharmacy market by allowing new owners to operate pharmacies from 2009. This re-regulation of ownership was accompanied by a sale of about half of the state-owned pharmacies operated by the National Corporation of Swedish Pharmacies. The number of pharmacies has increased by about 20% since the reform (Swedish Competition Authority, 2010a). Government decisions related to the organization of primary care and pharmacy services can be seen, to some extent, as a return to the conditions prevailing before the “seven-crown reform” and the socialization of pharmacies in the early 1970s.”

Source: Anell A, Glenngård AH, Merkur S. Sweden: Health system review. Health Systems in Transition, 2012, 14(5):1–159.

“Attitudes toward health care services have been collected annually since 2001 through a national population survey (Vårdbarometern). Comparisons of results across county councils and over time are presented at the Health Care Barometer web site. Since sample sizes are small and only cover 1000 individuals in each county council, data from the population survey only allow for comparison at an aggregate level. Results from the 2010 survey showed that 65% of responders had a high confidence in health care services within their county council. Differences across county councils were significant, however. On average, 82% of responders (75–88% depending on county council) thought that they had access to health care according to their need. Among those who did not think they had adequate access to services, shorter waiting times were considered important to improve the situation. Only 40% agreed fully or in part that waiting times for a visit to hospital were reasonable, compared to 63% for primary care. Both confidence and attitudes towards whether waiting times are reasonable have improved slightly since 2005.

“Since 2009, patient experiences have been collected separately through a standardized National Patient Survey (Nationella Patientenkäten) every second year. Previously, the Vårdbarometern also registered patient experiences among those individuals in the population who had been in contact with health services. The National Patient Survey provides new opportunities for more detailed comparison of experiences at the provider level. Results from existing surveys are presented at www.indikator.org/publik. So far, patient surveys have been conducted for primary care, emergency departments and specialized care. Patients are generally very satisfied with how they are received by physicians and nurses in primary care but demanded improvements in areas such as questions about previous health status, information about waiting times, side-effects of medicines and what signals to look out for concerning their health condition. Specifically, patients in specialized care called for improved attention to previous diseases and the health status of the patient as well as more information about the expected progress of disease. For emergency departments, patients demanded information about expected time to see a physician. Among the responders, 68% had waited less than 4 hours in the emergency department, but 17% had waited 4–6 hours and as many as 15% had waited for 6 hours or more.

“A number of reforms and interventions targeted at strengthening responsiveness to patients’ needs in general and improving waiting times in particular have been implemented (see chapter 6). An important emerging issue concerns patient safety, particularly in the hospital setting. Developments of RCCs include plans to strengthen collaboration with patient organizations and facilitate input from patients when improving services. Although a positive trend can be noted in terms of both objective and subjective measures of overall confidence and waiting times, changes are not significant and linkages to the reforms introduced are uncertain.”

Source: Anell A, Glenngård AH, Merkur S. Sweden: Health system review. Health Systems in Transition, 2012, 14(5):1–159.

Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems in the US and several other nations.

Page last updated Dec. 6, 2020 by Doug McVay, Editor.