5. Provision of services
ost welfare services are carried out at regional and local levels in Sweden. The county councils manage the health care services, while the municipalities manage areas such as compulsory and upper secondary education, pre-school, care for older people, roads, water, waste and energy. Sweden adopted a national public health policy in 2003, which states that public authorities should be guided by the 11 objective domains of the policy, covering the most important determinants of Swedish health.
Since 2005, there has been a new care guarantee in Sweden, which aims at strengthening the patient’s position, improving accessibility and ensuring equal access to elective care in different parts of the country. The guarantee is based on the “0–7–90–90” rule – meaning instant contact (zero delay) with the health care system for consultation; seeing a GP within 7 days; consulting a specialist within 90 days; and waiting for no more than 90 days after being diagnosed to receive treatment. The guarantee applies to the whole country and also includes all elective care in the county councils.
One important aim behind structural changes in Swedish health care since the 1990s has been a shift from hospital inpatient care towards outpatient care and primary care. Primary health care involves services that do not require advanced medical equipment and is responsible for guiding the patient to the right level within the health system. Choice of primary care provider for the population and freedom of establishment for primary care providers accredited by the local county councils is mandatory in Sweden, since January 2010.
Specialized somatic care involves health care services provided at hospitals requiring medical equipment or other technologies that cannot be provided in the primary care setting. In Sweden, a relatively large proportion of the resources available for medical services have been allocated to the provision of care and treatment at hospital level. Hospitals are grouped into county council hospitals and regional/university hospitals. There are 7 regional/university hospitals and about 70 county council hospitals, offering specialized inpatient and outpatient somatic and psychiatric care. About two-thirds of the county council hospitals are acute care hospitals, where care is offered 24 hours a day and a larger number of clinical expert competences are represented than in local hospitals. Highly specialized care is provided at regional/university hospitals. Swedish counties are grouped into six medical care regions with seven regional/university hospitals to facilitate cooperation and to maintain a high level of advanced medical care.
There are about 1200 pharmacies throughout the country, distributing prescription and non-prescription drugs to the population and to hospitals and other health services. Since October 2002, the TLV has had the responsibility of deciding whether a prescription drug or specific product should be subsidized and included in the reimbursement scheme. The TLV makes its decisions primarily based on the cost–effectiveness of various products. Moreover, generic substitution for prescription drugs was introduced in 2002. It is the MPA that decides which drugs are interchangeable.
5.1 Public health
Most welfare services, including public health initiatives, are produced in the public sector. The county councils and regions manage the health care services, while the municipalities manage areas such as compulsory and upper secondary education, pre-school, care for older people, roads and water, waste and energy. Sweden adopted a national public health policy in 2003, which states that public authorities should be guided by the 11 objective domains of the policy, covering the most important determinants of Swedish health (see section 2.6). These include:
- participation and influence in society
- economic and social prerequisites
- conditions during childhood and adolescence
- health in working life
- environments and products
- health-promoting health services
- protection against communicable diseases
- sexuality and reproductive health
- physical activity
- eating habits and food
- tobacco, alcohol, illicit drugs, doping and gambling.
The policy was updated in 2008 (Act on the System of Choice in the Public Sector), adding greater elements of individual choice and responsibility. The renewed public health bill focuses particularly on children, young people and older people. Special emphasis is put on initiatives aimed at strengthening and supporting parents in their parenting role, increasing suicide prevention efforts, promoting healthy eating habits and physical activity, and reducing the use of tobacco (Swedish National Institute of Public Health, 2011).
Programmes designed to prevent accidents and ill health have been successful in Sweden. Deaths due to traffic accidents have been continuously reduced since the 1970s. In 1997, the Swedish government adopted a so-called “zero-vision”, aspiring to no deaths or serious injuries caused by road traffic. The number of traffic-related deaths decreased from 16.2 to 3.8 deaths per 100 000 inhabitants between 1970 and 2009.
The number of daily smokers has decreased substantially during the past 30 years. The proportion of daily smokers among men in Sweden is lower than in any other European country. The reduction in the number of daily smokers has been achieved partly by the adoption of non-smoking campaigns and tax increases on tobacco.
Also, programmes and treatments to prevent mortality due to breast cancer have been successful, resulting in a decrease from 32.8 to 25.9 deaths per 100 000 inhabitants between 1993 and 2009 (see section 1.4). Women over the age of 40 and those aged 25 years, respectively, are offered the chance to take part in screening programmes against breast and cervical cancer. Men over the age of 50 years are usually offered a PSA-test to detect cancer of the prostate. Moreover, screening against aortic aneurysm and colon cancer is being implemented in several county councils.
All women are offered regular health checks, screening, psychological support and education throughout their pregnancy and almost all women participate in the programme. In Sweden, maternal and child mortality is among the lowest in the world. Special attention is given to identifying and helping women who are socially vulnerable, for example, at risk of violence. All newborn babies are tested for phenylketonuria. Regarding child immunization, all parents are offered vaccination against 10 serious diseases for their children free of charge and the coverage rate is very high in Sweden (see section 1.4).
The Swedish Institute for Infectious Disease Control is responsible for surveillance of communicable diseases and analysis of the current epidemiological situation in Sweden (and internationally). The surveillance is carried out in close collaboration with the County Medical Officers of Communicable Disease Control. The basis for the surveillance is the registration of the notifiable diseases specified in the Communicable Disease Act of 1998. According to the Act, a physician is obliged to notify cases of 54 communicable diseases grouped into: diseases dangerous to society (e.g. diphtheria, hepatitis, cholera and rabies), sexually transmitted diseases (such as gonorrhoea and HIV), and other notifiable diseases (such as malaria and measles). These pathogens are notifiable, in parallel, to the Swedish Institute for Infectious Disease Control and the County Medical Officers, by both clinicians and laboratories (see section 2.7.1 Information systems).
In the budget bill for 2015, the Swedish government proposed an annual grant of SEK 200 million (about €19 million) to improve women’s health. The proposal focused on two key areas: improving women’s health in general and improving obstetric and maternal care in particular. In 2016, the grants were increased to SEK 400 million (€38 million), including a SEK 130 million (€12 million) intended for improving primary care in socioeconomically vulnerable areas.
Since then the grants have been increased and prolonged such that in 2018, the government proposed SEK 1 billion (€95 million) annually for 2020-2022, aimed at improving obstetric, maternal and neonatal care. The country councils are free to use the grant to meet local needs as long as they focus on the key areas.
1.59 billion for maternity care and women's health (2019). The Swedish Government web site (in Swedish): https://www.regeringen.se/pressmeddelanden/2019/05/159-miljarder-kronor-till-forlossningsvarden-och-kvinnors-halsa/