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. Short-term 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, sickbenefits 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.