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The Swedish Health Care System

by Anna H. Glenngård, Lund University School of Economics and Management

What is the role of government?

All three levels of Swedish government are involved in the health care system. At the national level, the Ministry of Health and Social Affairs is responsible for overall health and health care policy, working in concert with eight national government agencies. At the regional level, 12 county councils and nine regional bodies (regions) are responsible for financing and delivering health services to their citizens. At the local level, 290 municipalities are responsible care of the elderly and the disabled. The local and regional authorities are represented by the Swedish Association of Local Authorities and Regions (SALAR).

Three basic principles apply to all health care in Sweden:

  1. Human dignity: All human beings have an equal entitlement to dignity and have the same rights regardless of their status in the community.
  2. Need and solidarity: Those in greatest need take precedence in being treated.
  3. Cost-effectiveness: When a choice has to be made, there should be a reasonable balance between the costs and the benefits of health care, measuring cost in relationship to improved health and quality of life.

Who is covered and how is insurance financed?

Publicly financed health care: Health expenditures represented 11 percent of GDP in 2013. About 84 percent of this spending was publicly financed, with county councils’ expenditures amounting to 57 percent, municipalities’ to 25 percent, and the central government’s to almost 2 percent (Statistics Sweden, 2015a). The county councils and the municipalities levy proportional income taxes on their populations to help cover health care services. In 2013, 68 percent of county councils’ total revenues came from local taxes and 18 percent from subsidies and national government grants financed by national income taxes and indirect taxes (SALAR, 2014). General government grants are designed to reallocate some resources among municipalities and county councils. Targeted government grants finance specific initiatives, such as reducing waiting times. In 2013, about 90 percent of county councils’ total spending was on health care (SALAR, 2014).

Coverage is universal and automatic. The 1982 Health and Medical Services Act states that the health system must cover all legal residents. Emergency coverage is provided to all patients from European Union / European Economic Area countries and to patients from nine other countries with which Sweden has bilateral agreements. Asylum-seeking and undocumented children have the right to health care services, as do children who are permanent residents. Adult asylum seekers have the right to receive care that cannot be deferred (e.g., maternity care). Undocumented adults have the right to receive nonsubsidized immediate care.

Private health insurance: Private health insurance, in the form of supplementary coverage, accounts for less than 1 percent of expenditures. Associated mainly with occupational health services, it is purchased primarily to ensure quick access to an ambulatory care specialist and to avoid waiting lists for elective treatment. Insurers are for-profit. In 2015, 614,000 individuals had private insurance, accounting for roughly 10 percent of all employed individuals aged 15 to 74 years (Swedish Insurance Federation, 2015).

What is covered?

Services: There is no defined benefits package. The publicly financed health system covers public health and preventive services; primary care; inpatient and outpatient specialized care; emergency care; inpatient and outpatient prescription drugs; mental health care; rehabilitation services; disability support services; patient transport support services; home care and long-term care, including nursing home care and hospice care; dental care and optometry for children and young people; and, with limited subsidies, adult dental care. As the responsibility for organizing and financing health care rests with the county councils and municipalities, services vary throughout the country.

Cost-sharing and out-of-pocket spending: In 2013, about 16 percent of all expenditures on health were private, and of these 93 percent were out-of-pocket (Statistics Sweden, 2015a). The majority of out-of-pocket spending is for drugs.

The county councils set copayment rates per health care visit and per bed-day, leading to variation across the country. Providers cannot charge above the scheduled fee. The table below shows fee ranges for 2014.  

ServiceFee Range (2014)
Swedish KronerU.S. Dollars
Primary care physician visit100–30011–34
Hospital physician consultation200–35022–39
Hospitalization per day80–1009–11
Source: SALAR, 2015.

(Please note that, throughout this profile, all figures in USD were converted from SEK at a rate of about SEK8.95 per USD, the purchasing power parity conversion rate for GDP in 2014 reported by OECD, 2015 for Sweden.)

Nationally, annual out-of-pocket payments for health care visits are capped at SEK1,100 (USD123) per individual. In all county councils, people under age 18—and in most county councils, people under 20—are exempt from user charges for visits.

Dental care: Dental and pharmaceutical benefits are determined at the national level. People under 20 have free access to all dental care. People 20 or older receive a fixed annual subsidy of SEK150–SEK300 (USD17–USD34), depending on age, for preventive dental care. For other dental services, within a 12-month period patients 20 or older pay the full cost of services up to SEK3,000 (USD335), 50 percent of the cost for services between SEK3,000 and SEK15,000 (USD1,676), and 15 percent of costs above SEK15,000. There is no cap on user charges for dental care.

Prescription drugs: Individuals pay the full cost of prescribed medications up to SEK1,100 (USD123) annually, after which the subsidy gradually increases to 100 percent. The annual ceiling for out-of-pocket payments for prescriptions is SEK2,200 (USD246) for adults. A separate annual out-of-pocket maximum of SEK2,200 applies collectively to all children belonging to the same family. For certain prescription drugs not on the National Drug Benefits Scheme and not subject to reimbursement, patients must pay the full price.

Safety net: Because the Swedish health care system is designed to be socially responsible and equity-driven, all social groups are entitled to the same benefits. The ceilings on out-of-pocket spending apply to everyone, and the overall cap on user charges is not adjusted for income. Children, adolescents, pregnant women, and the elderly are generally targeted groups, exempted from user charges or granted subsidies for certain services such as maternity care or vaccination programs.

How is the delivery system organized and financed?

The health system is highly integrated. An important policy initiative driving structural changes since the 1990s has been the shifting of inpatient care to outpatient and primary care, and the concentration of highly specialized care in academic medical centers. All provider fees are set by county councils, leading to variation across the country. Public and private physicians (including hospital specialists), nurses, and other categories of health care staff at all levels of care are predominantly salaried employees. The average monthly salary for a physician with a specialist degree (including specialists in general medicine) was SEK73,000 (USD8,157) in 2014 (Statistics Sweden, 2015b). There is no regulation prohibiting physicians (including specialists) and other staff who work in public hospitals or primary care practices from also seeing private patients outside the public hospital or primary care practice. Employers of health care professionals, however, may establish such rules for their employees.

Primary care: Primary care accounts for about 20 percent of all expenditures on health, and about 16 percent of all physicians work in this setting (Swedish Medical Association, 2013, 2014). Primary care has no formal gatekeeping function. Team-based primary care, with general practitioners, nurses, midwives, physiotherapists, psychologists, and gynecologists, is the main form of practice. There are, on average, four general practitioners in a primary care practice. General practitioners or district nurses are usually the first point of contact for patients. District nurses employed by municipalities also participate in home care and regularly make home visits, especially to the elderly; they have limited prescribing authority.

People may register with any public or private provider accredited by the local county council, with most individuals registering with a practice instead of a physician. Registration is not required to visit a practice. There are more than 1,100 primary care practices, of which 40 percent are privately owned. Providers (public and private) are paid a combination of fixed payment for their registered individuals (about 80% of total capitated payment), fee-for-service (17%–18%), and performance-related payment (2%–3%) for achieving quality targets in such areas as patient satisfaction, enrollment in national registers, compliance with guidelines based on evidence-based medicine, and recommendations from county council drug formulary committees.

Outpatient specialist care: Outpatient specialist care is provided at university and county council hospitals and in private clinics. Patients have a choice of specialist. Public and private providers are paid through the same fixed, prospective, per-case payments (based on diagnosis-related groups), complemented by price or volume ceilings and quality components.

Administrative mechanisms for direct patient payments to providers: Patients normally pay the provider fee up front for primary care and other outpatient visits. In most cases, it is also possible for patients to pay later.

After-hours care: Primary care providers are required to provide after-hours care in accordance with the conditions for accreditation in each county council. Practices in proximity to each other (normally three to five practices) collaborate on after-hours arrangements. Through their websites and phone services, providers advise their registered patients where to go for care. Staff providing after-hours primary care services normally include general practitioners as well as nurses. There is no special arrangement for provider payment, and the same copayments apply as those during regular hours (see above, “Cost-sharing and out-of-pocket spending”). Information regarding after-hours patient visits is routinely sent to the practice where the patient is registered.

In addition, seven university hospitals and about 50 county council hospitals provide full emergency services 24 hours a day.

All county councils and regional bodies provide information on how and where to seek care through their websites and a national phone line, with medical staff available all day to give treatment advice. Moreover, all county councils and their regional counterparts collaborate to provide online information about pharmaceuticals, medical conditions, and pathways for seeking care. A similar private colloboration exists as well.

Hospitals: There are seven university hospitals, and about 70 hospitals at the county council level. Six of them are private, and three of those are not-for-profit. The rest are public. Counties are grouped into six health care regions to facilitate cooperation and to maintain a high level of advanced medical care. Highly specialized care, often requiring the most advanced technical equipment, is concentrated in university hospitals to achieve higher quality and greater efficiency and to create opportunities for development and research. Acute care hospitals (seven university hospitals and two-thirds of the 70 county council hospitals) provide full emergency services. Global budgets or a mix of global budgets, diagnosis-related groups, and performance-based methods are used to reimburse hospitals. Two-thirds or more of total payment is usually in the form of budgets, and about 30 percent is based on DRGs. Performance-based payment related to attainment of quality targets constitutes less than 5 percent of total payment. The payments are traditionally based on historical (full) costs.

Mental health care: Mental health care is an integrated part of the health care system and is subject to the same legislation and user fees as other health care services. People with minor mental health problems are usually attended to in primary care settings, either by a general practitioner or by a psychologist or psychotherapist; patients with severe mental health problems are referred to specialized psychiatric care in hospitals. Specialized inpatient and outpatient psychiatric care, include that related to substance use disorders, is available to adults, children, and adolescents.

Long-term care and social supports: Responsibility for the financing and organization of long-term care for the elderly and for the support of people with disabilities lies with the municipalities, but the county councils are responsible for those patients’ routine health care. Older adults and disabled people incur a separate maximum copayment for services commissioned by the municipalities (SEK1,780 [USD199] per month in 2015). The Social Services Act specifies that older adults have the right to receive public services and assistance at all later stages of life, e.g., home care aids, home help, and meal deliveries. Also included is end-of-life care, either in the individual’s home or in a nursing home or hospice. The Health and Medical Services Act and the Social Services Act regulate how the county councils and the municipalities manage palliative care. The organization and quality of palliative care vary widely both between and within county councils. Palliative care units are located in hospitals and hospices. An alternative to palliative care in a hospital or hospice is advanced palliative home care.

There are both public and private nursing homes and home care providers. About 14 percent of all nursing home and home care was privately provided in 2012 (Statistics Sweden, 2015a), although the percentage varies significantly among municipalities. Payment to private providers is usually contract-based, following a public tendering process. Eligibility for nursing home care is based on need, which is determined collaboratively by the client and staff from the municipality; often a relative participates as well. There is a national policy to promote home assistance and home care over institutionalized care, and that policy entitles older people to live in their homes for as long as possible. Municipalities can also reimburse informal caregivers either directly (“relative-care benefits”) or by employing the informal caregiver (“relative-care employment”).

What are the key entities for health system governance?

The Health and Medical Services Act specifies that responsibility for ensuring that everyone living in Sweden has access to quality health care lies with the county councils and municipalities. The county councils are responsible for the funding and provision of health services, while the municipalities are responsible for meeting the care and housing needs of older adults and people with disabilities. In primary care, there is competition among providers (public and private) to register patients, although they cannot compete through pricing, since the county councils set fees.

County councils control the establishment of new private practices by regulating conditions for accreditation and payment. Those conditions pertain primarily to opening hours and to the minimum number of clinical competencies at the practice. The right to establish a practice and be publicly reimbursed applies to all public and private providers fulfilling the conditions for accreditation.

The central government, through the Ministry of Health and Social Affairs, is responsible for overall health care policies. There are eight government agencies directly involved in the areas of medical care and public health.

The National Board of Health and Welfare supervises all health care personnel, disseminates information, develops norms and standards for medical care, and, through data collection and analysis, ensures that those norms and standards are met. The agency is the licensing authority for health care staff. (Health care personnel are not required to reapply for their license.) The National Board of Health and Welfare also maintains health data registries and official statistics.

The Swedish eHealth Agency, established in 2014, focuses on promoting public involvement and providing support for professionals and decision-makers. The agency stores and transfers electronic prescriptions issued in Sweden and is responsible for transferring electronic prescriptions abroad. The agency is also responsible for Sweden’s national drug statistics and for statistics on pharmaceutical sales.

The Health and Social Care Inspectorate is responsible for supervising health care, social services, and activities concerning support and services for persons with certain functional impairments. It is also responsible for issuing permits in those areas.

The Swedish Agency for Health and Care Services Analysis analyzes and evaluates health policy, as well as the availability of health care information to citizens and patients. The results of such analyses are published.

The Public Health Agency provides the national government, government agencies, municipalities, and county councils with new knowledge, based on scientific evidence, in the area of infectious disease control and public health, including health technology assessment. The Swedish Council on Technology Assessment in Health Care, which promotes use of cost-effective health care technologies, has a mandate to review and evaluate new treatments from medical, economic, ethical, and social points of view. Information from the council’s reviews is disseminated to central and local government officials and medical staff to provide basic data for decision-making purposes.

The principal agency for assessing pharmaceuticals is the Dental and Pharmaceutical Benefits Agency. Since 2002, it has had a mandate to decide whether particular drugs should be included in the National Drug Benefit Scheme; prescription drugs are priced in part on the basis of their value. The agency’s mandate also includes dental care. The Medical Products Agency, meanwhile, is the Swedish national authority responsible for the regulation and surveillance of the development, manufacture, and sale of drugs and other medicinal products.

What are the major strategies to ensure quality of care?

County councils are responsible for accrediting health care providers and following up on conditions for accreditation. These activities include assessing whether quality targets—those associated with a pay-for-performance scheme or tied to requirements for continued accreditation—have been achieved. Providers are evaluated based on information from patient registries and national quality registries, surveys related to patient satisfaction, and clinical audits.

Concern for patient safety has increased during the past decade, and patient safety indicators are compared regionally (see below). Eight priority target areas for preventing adverse events have been specified: health care–associated urinary tract infections; central line infections; surgical site infections; falls and fall injuries; pressure ulcers; malnutrition; medication errors in health care transitions; and drug-related problems (SALAR, 2011).

The National Board of Health and Social Welfare, together with the National Institute for Public Health and the Dental and Pharmaceutical Benefits Agency, conducts systematic reviews of evidence and develops guidance for establishing priorities in support of disease management programs developed at the county council level. International guidelines and specialists are also central to the development of these local programs. There is a tendency to develop regional guidelines to inform the setting of priorities in order to avoid unnecessary variation in clinical practice. For example, the National Cancer Strategy was established in 2009, and six Regional Cancer Centers (RCCs) were formed in 2011. The RCCs’ role is to contribute to more equitable, safe, and effective cancer care through regional and national collaboration.

The 90 or so national quality registries are used for monitoring and evaluating quality among providers and for assessing treatment options and clinical practice. Registries contain individualized data on diagnosis, treatment, and treatment outcomes. They are monitored annually by an executive committee, funded by the central government and by county councils, and managed by specialist organizations.

Since 2006, the government has published annual performance comparisons and rankings of the county councils’ health care services, using data from the national quality registers, the National Health Care Barometer Survey, the National Waiting Time Survey, and the National Patient Surveys. The 2012 publication included 169 indicators, organized into various categories such as prevention, patient satisfaction, waiting times, trust, access, surgical treatment, and drug treatment. Some 50 indicators are shown also for hospitals, but without rankings. Statistics on patient experiences and waiting times in primary care are also made available through the Internet (www.skl.se) to help guide people in their choice of provider.

What is being done to reduce disparities?

The 1982 Health and Medical Services Act emphasizes equal access to services on the basis of need, and a vision of equal health for all. International comparisons indicate that health disparities are relatively low in Sweden. The National Board of Health and Welfare and the Public Health Agency compile and disseminate comparative information about indicators on public health. Approaches to reducing disparities include programs to support behavioral changes, and the targeting of outpatient services to vulnerable groups in order to prevent diseases at an early stage. To prevent providers from avoiding patients with extensive needs, most county councils allocate funds to primary care providers based on a formula that takes into account both overall illness (based on diagnoses) and registered individuals’ socioeconomic conditions.

What is being done to promote delivery system integration and care coordination?

The division of responsibilities between county councils (for medical treatment) and municipalities (for nursing and rehabilitation) requires coordination. Efforts to improve collaboration and develop more integrated services include the development of national action plans supported by targeted government grants. In 2005, Sweden introduced a “guarantee” to improve access to care and to ensure the equality of that access across the country. The guarantee is based on the “0–7–90–90 rule”: instant contact (zero delay) with the health system for advice; seeing a general practitioner within seven days; seeing a specialist within 90 days; and waiting no more than 90 days to receive treatment after being diagnosed. For county councils to be eligible for the grant targeted at accessibility, 70 percent of all patients must receive care within the stipulated time frames. At the county council level, providers are eligible for grants linked partly to the fulfillment of goals related to coordination and collaboration in care provided to the elderly with multiple diagnoses.

What is the status of electronic health records?

Generally, both the quality of IT systems and their level of use are high in hospitals and in primary care; more than 90 percent of primary care providers used electronic patient records for diagnostic data in 2009 (Health Consumer Powerhouse, 2009). Nearly all Swedish prescriptions are e-prescriptions. Patients increasingly have access to their electronic medical record for the purposes of scheduling appointments or viewing their personal health data, but there is variation in this regard between county councils. The Swedish eHealth Agency (eHälsomyndigheten) was formed in 2014 to strengthen the national e-health infrastructure. Its activities focus on promoting public involvement and providing support for professionals and decision makers (see governance section, above).

How are costs contained?

County councils and municipalities are required by law to set and balance annual budgets for their activities. For prescription drugs, the central government and the county councils form agreements, lasting a period of years, on the levels of subsidy paid by the government to the councils. The Dental and Pharmaceutical Benefits Agency also employs value-based pricing for prescription drugs, determining reimbursement based on an assessment of health needs and cost-effectiveness. In some county councils, there are also local models for value-based pricing for specialized care such as knee replacements.

Because county councils and municipalities own or finance most health care providers, they are able to undertake a variety of cost-control measures. For example, contracts between county councils and private specialists are usually based on a tendering process in which costs constitute one variable used to evaluate different providers. The financing of health services through global budgets, volume caps, capitation formulas, and contracts, as well as salary-based pay for staff, also contributes to cost control, as providers retain responsibility for meeting costs with funds received through those prospective payment mechanisms. In several counties, providers are also financially responsible for prescription costs.

What major innovations and reforms have been introduced?

Important policy areas that have been under scrutiny at both the local and the national level during the last two years include the quality and equity of care, coordination of care, and patients’ rights. Studies following Sweden’s 2010 market reform in primary care show that objectives related to accessibility have been achieved. Its effects on quality, equity, and efficiency, however, are unclear. Accurate reporting and monitoring to measure these criteria remain important challenges in Swedish primary care and are a concern for policymakers.

In the area of specialized care, there have been recent efforts to foster greater equity. The government has committed to providing SEK500 million (USD55.87 million) per year from 2015 to 2018 to reduce waiting times in cancer care and to reduce regional disparities. This effort is to be built on work previously undertaken within the framework of the National Cancer Strategy and the six Regional Cancer Centers (RCCs). In addition, a commission on equitable health, established in 2015, is to submit a report (due by the end of May 2017) containing proposals for reducing health inequalities in society.

To improve continuity and coordination of care, in 2014 the government launched a four-year national initiative for people with chronic diseases. Its three areas of focus are patient-centered care, evidence-based care, and prevention and early detection of disease.

In 2015, a new law addressing patients’ rights went into effect, with the purpose of strengthening the rights of patients and enhancing patient integrity, influence, and shared decision-making. The law clarifies and expands providers’ responsibility in conveying information to their patients, patients’ right to a second opinion, and patients’ choice of provider in outpatient specialist care throughout the country. The government has commissioned the Swedish Agency for Health and Care Services Analysis to monitor and follow up on implementation of the new law until 2017.

References

Anell, A., Glenngård, A.H., Merkur, S. (2012). “Sweden: Health System Review,” Health Systems in Transition 14(5):1–161.

Health Consumer Powerhouse (2009). Euro Health Consumer Index 2009 Report (Danderyd: Health Consumer Powerhouse). Organisation for Economic Co-operation and Development (OECD) (2015), OECD.Stat (database). DOI: 10.1787/data-00285-en, accessed Jul. 2, 2015.

Statistics Sweden (2015a). Systems of Health Accounts (SHA) 2001–2013.

Statistics Swecen (2015b). Lönestrukturstatistik, landstingskommunal sector 2014.

SALAR (2011). National Initiative for Improved Patient Safety (Stockholm: Swedish Association of Local Authorities and Regions).

SALAR (2014). Statistik inom hälso- och sjukvård samt regional utveckling. Verksamhet och ekonomi i landsting och regioner 2013 (Stockholm: Swedish Association of Local Authorities and Regions).

SALAR (2015). Patientavgifter i hälso- och sjukvården 2015 (Stockholm: Swedish Association of Local Authorities and Regions).

Swedish Insurance Federation (2015). www.svenskforsakring.se. Accessed June 18, 2015.

Swedish Medical Association (2013). Läkarförbundets undersökning av primärvårdens läkarbemanning (Stockholm: Sveriges läkarförbund).

Swedish Medical Association (2014). Kostnader och produktion i primärvårdens vårdval(Stockholm: Sveriges läkarförbund).