Great expectations: What can we learn from Sweden?

1. Great expectations: What can we learn from Sweden? Anders Anell, PhD, director The Swedish Institute for Health Economics (IHE), Lund

2. Swedish Health Care • Cornerstone of the Swedish welfare state • Quality health care for all, distributive justice • Decentralised decision-making • 21 county councils responsible for hospitals and primary care services • 289 municipalities responsible for care of the elderly and mentally handicapped (home care, nursing homes) • Public ownership and political control • With local exceptions • Weak primary care services

3. New policies introduced at different government levels • National government • Responsibility of local governments • Specific issues (focus on access, quality and equity) • Legislation or agreements + budget infusion • Local government • Experimentation with choice of providers, purchaser-provider split, contracting, privatisation, hospitals mergers and closure, new primary care models, integrated care and more

4. Impact of new policies • Impact of local-government reforms and national agreements limited compared to new legislation • The formation of reforms can often be explained by a political logic (i.e. maintaining legitimacy) • Politicians produce rhetoric, plans and actual changes • Coherence not necessary for survival • Changes in welfare and advances in medical technology more important than both local and national government reform

5. Development of GDP and total expenditure on health in Sweden, 1970-2004(Index 1970=100, 2000 GDP price level) Source: OECD Health Data 2005

6. Acute care bed days per capita and age group in Sweden, 1993 and 2004 Source: Sjukvårdsdata i Fokus, SKL, 2006

7. Expenditures for county council health care and municipal care of the elderly and the handicapped. Constant 1999 prices. 140 120 100 Billion SEK 80 60 40 20 0 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 Year County council exp. County council exp. (rev.) Municipality exp. Pharmaceuticals Source: Nationell handlingsplan för äldrepolitiken. Lägesrapport 2001. Statistisk Årsbok för Landsting. Apoteket AB.

8. Development of total health care expenditure in Sweden 1993-2004 (constant 2004 prices)

9. Health care expenditure and GDP per capita in the EU (15) + US and Norway, 1975 Source: OECD Health Data 2005

10. Health care expenditure and GDP per capita in the EU (15) + US and Norway, 2003 Source: OECD Health Data 2005

11. ”How would you assess health care services today compared to 10 years ago?” Source: Rosén P. Population survey in county council of Östergötland (Sample = 4 000 with 58% response rate, n = 2284, ages 18+).

12. Why? • Cost-containment policies in mid 90s and increased pressure for explicit priority setting • Political rhetoric • Election every fourth year; shift of local government common. Opposition (and media) has an interest to highlight problems. • Increased transparency related to access and quality (absolute level and differences) • Demand for patient influence and less reliance on experts

13. Waiting times and government policies • Important problem for politicians since late 1980s • Used as an argument for overall reform (privatisation) • Waiting time ’guarantees’, budget infusion from national level • Several explanations behind existing waiting times • Wider indications for treatment most important • Waiting list for cataract surgery doubled 1990-2000; the volume produced increased by 140%

14. Number of hip replacements in Sweden per 100 000 population and age group 1994, 1999 and 2004 Source: Sjukvårdsdata i Fokus, SKL, 2006

15. Number of coronary bypass and PCI in Sweden per 100 000 population and age1994, 1999 and 2004 Coronary bypass PCI Source: Sjukvårdsdata i Fokus, SKL, 2006

16. Regional expenditure per capita in Sweden for five new oncology drugs1, 2005-01 – 2005-06 Source: Dagens Medicin, 21 September 2005, p. 4-7. 1 Herceptin/trastuzumab, Erbitux/cetuximab, Avastin/bevacizumab, Mabthera/rituximab and Glivec/imatinib.

17. Variation in access to cancer therapy • Local priorities not transparent and limited by budget criteria • Less acceptance by national government (and the population) of variation in access to treatment (’post-code rationing’) • Towards a national cancer-plan (= agreement + budget infusion)? • increased use of national guidelines, less discretion for decision-making at local level and additional funding?

18. Expenditures for cancer drugs per capita in selected countries in 2002/2003 Sweden identified as ’average’ in terms of uptake of new cancer drugs in pan-European study. (Austria, Spain and Switzerland = top three countries; Czech Republic, Hungary, Norway,Poland and UK below-average.) Source: Wilking, Jönsson (2005)A pan-European comparison regarding patient access to cancer drugs. Karolinska Institutet, Stockholm.

19. Some challenges for the future • Balance between national and local decision-making • Ongoing parliamentary committee expected to suggest larger regions to replace county councils • Long-run financing of services (from 2015) • Alternatives to tax funding? • Recruitment of human resources • Both municipalities and county councils • Development of primary care and integration of services

20. Inequity in distribution of physician visits in Sweden due to weak primary care services Fig. 5: Horizontal inequity (HI) indices for the annual mean number of visits to a doctor in 19 OECD countries van Doorslaer, E. et al. CMAJ 2006;174:177-183