The Swedish healthcare system has traditionally been publicly financed and delivered. However, since 2006 there has been a political push for more privatization and innovation. As part of this, Sweden introduced mandatory patient choice of primary care providers in 2010. Both public and private organizations can now provide primary care. Observations show that access and satisfaction have increased, though medical quality data is lacking. Lower socioeconomic groups have increased use of services more. Around 30-40% of primary care is now privately delivered, including 15-20% by international for-profit companies. Opinions among GPs on the changes remain mixed.

1. A mixed model of public and private
involvement in development of
primary care – experiences from
Sweden
Nuffield Trust European Health Summit
January 28 – 29, 2013
Johan Calltorp MD PhD, Co-director The Swedish Forum on Health Policy
Karin Träff Nordström MD, Chair of the Swedish College of Primary Care
Practitioners, Manager Brahehälsan

2. Traditional features of the Swedish
health system
• Traditionally public regarding financing, delivery and control
• 21 county councils (directly elected political bodies) responsible for
totality of health care in the respective area
• Salaried physicians since 1970
• A focus on hospital care, since 1960´s – most of specialized outpatient
care delivered at hospitals
• Social services + ”non-medical” care for the elderly delivered by
municipalities (190 in Sweden)
• Traditional ”private care” = ca 1000 physicians on a tightly controlled fee-
schedule (primary care and the main out-patient specialities)
• One of the acute hospitals (St Görans in Stockholm County council) run by
a private company (Capio) since ca 10 years)
• The number of private health care insurances quite stable, ca 500.000
policies sold

4. Cost containment, restructuring of
inpatient services
• Overall costs of the system on a stable fraction
of GDP, ca 9,3 - 9,7 % for more than 20 years
• The early 1990´s economic crisis triggered a
program of hard cost containment and
structural rearrangements within the hospital
sector (closures, mergers, some care process
development)
• Increased ”pressure” has been developed
within the whole system

5. Primary care over time
• Until 1950´s a strong and traditional GP-led and
public health focused primary care system
(governmental run)
• 1972 this was integrated into the County Council
structure. GPs salaried. Organisation in primary care
centers often jointly with social services,
geographical area responsibility
• A number of reform efforts to strenghten primary
care over the years
• Still ca 10 % of resources, 15 % of medical workforce
• Function varies greatly over the country

6. A political agenda of ”privatization and
renewal” since 2006
• Since 2006 a liberal coalition government of 4 parties
– ”securing the welfare state” and innovate public
sector
• Abandoned the ”ban on for profit health delivery”.
County councils may contract with all types of private
providers
• 50 % of state owned pharmacies sold to private
owners, competition model
• Public private partnership in building the new
Karolinska Hospital in Stockholm

7. The new public/private primary care
system (Vårdval – choice of care)
• Mandatory system for County councils to arrange since 2010:
- A possibility for citizens to choose primary care provider
within a public announced and accepted number
- A possibility for organisations/companies to register as
primary care providers, given some basic criteria –
requirements on competencies, range of services, financial
conditions
- A capitation formula (basic + specific visit payments) – models
vary much between the county councils
- Some County Councils have more elaborate models that pick
up quality measures, linking to population goals, access and
low number of hospital ambulatory visits

8. Observations so far
• Access to primary care increased
• Satisfaction amongst the public has increased
• No data on improvement on medical quality
• Lower socio-economic groups have increased use more than higher
(Stockholm). The socio-economic divide much discussed
• A considerable number of new practices established
• 30 - 40 % of primary care (nationwide) is delivered by private companies
• Arrangements have favoured bigger companies to establish
• 15 – 20 % of primary care is now delivered by companies owned by
international for profit capital (3 major chains nationally)
• One national (physician owned) chain Praktikertjänst that in the 1960´s
pioneered out-patient services in new forms
• Very few volountary, not for profit organisations active – but some
• To some extent new care models has been developed, but not strikingly many
• There is a sense of ”released power” and an ”innovation climate”
• Opinions among GPs quite mixed

9. Observations so far
• Access to primary care increased
• Satisfaction among the public has increased
• No data on improvement of medical quality
• Lower socio-economic groups have increased use of services more than higher
(Stockholm). The socio-economic divide much discussed
• A considerable number of new practices established
• 50 % of primary care is delivered by private companies
• Arrangemets has favoured bigger companies to establish
• 15 – 20 % of primary care is now delivered by companies owned by
international for profit capital (3 major chains nationally)
• One national ( physician owned ) chain Praktikertjänst active that in the
1960´s pioneered out-patient services
• Very few volountary, not for profit organizations active – but some
• To some extent new care models developed, but not strikingly many new
• There is a sense of ”released power” and ”innovation climate”
• Opinions among GPs quite mixed