Transcript Health Financing

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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
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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
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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
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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.
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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.”
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http://en.wikipedia.org/wiki/Healthcare_in_Sweden
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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.
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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
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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
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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”
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Almost negative population growth rate
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High burden of diseases of old age
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High burden of mental illnesses
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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
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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
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A central quality assurance board and
medical responsibility board
Tendency for institutions to be “arrogant” for
they have a virtual monopoly of services
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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
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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
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Reforms more focused on fiscal
management, cost effectiveness and
organizational changes
Government remains as the major provider
and consumer of health care
Limited competition
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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
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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
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