Sweden: Health System Review.

The Health Systems in Transition ( HiT) country reports provide an analytical description of each health system and of reform initiatives in progress or under development. They aim to provide relevant comparative information to support policy-makers and analysts in the development of health systems and reforms in the countries of the WHO European Region and beyond. The HiTs are building blocks that can be used: to learn in detail about different approaches to the financing, organization and delivery of health services; to describe accurately the process, content and implementation of health reform programmes; to highlight common challenges and areas that require more in-depth analysis; and to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in countries of the WHO European Region. This analysis of the Swedish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. This series is an ongoing initiative and material is updated at regular intervals.

A comparison of 2020 health policy responses to the COVID-19 pandemic in Canada, Ireland, the United Kingdom and the United States of America.

This paper compares health policy responses to COVID-19 in Canada, Ireland, the United Kingdom and United States of America (US) from January to November 2020, with the aim of facilitating cross-country learning. Evidence is taken from the COVID-19 Health System Response Monitor, a joint initiative of the European Observatory on Health Systems and Policies, the WHO Regional Office for Europe, and the European Commission, which has documented country responses to COVID-19 using a structured template completed by country experts. We show all countries faced common challenges during the pandemic, including difficulties in scaling-up testing capacity, implementing timely and appropriate containment measures amid much uncertainty and overcoming shortages of health and social care workers, personal protective equipment and other medical technologies. Country responses to address these issues were similar in many ways, but dissimilar in others, reflecting differences in health system organization and financing, political leadership and governance structures. In the US, lack of universal health coverage have created barriers to accessing care, while political pushback against scientific leadership has likely undermined the crisis response. Our findings highlight the importance of consistent messaging and alignment between health experts and political leadership to increase the level of compliance with public health measures, alongside the need to invest in health infrastructure and training and retaining an adequate domestic health workforce. Building on innovations in care delivery seen during the pandemic, including increased use of digital technology, can also help inform development of more resilient health systems longer-term.

Nordic responses to Covid-19: Governance and policy measures in the early phases of the pandemic.

This paper explores and compares health system responses to the COVID-19 pandemic in Denmark, Finland, Iceland, Norway and Sweden, in the context of existing governance features. Content compiled in the Covid-19 Health System Response Monitor combined with other publicly available country information serve as the foundation for this analysis. The analysis mainly covers early response until August 2020, but includes some key policy and epidemiological developments up until December 2020. Our findings suggest that despite the many similarities in adopted policy measures, the five countries display differences in implementation as well as outcomes. Declaration of state of emergency has differed in the Nordic region, whereas the emphasis on specialist advisory agencies in the decision-making process is a common feature. There may be differences in how respective populations complied with the recommended measures, and we suggest that other structural and circumstantial factors may have an important role in variations in outcomes across the Nordic countries. The high incidence rates among migrant populations and temporary migrant workers, as well as differences in working conditions are important factors to explore further. An important question for future research is how the COVID-19 epidemic will influence legislation and key principles of governance in the Nordic countries.

Tackling the COVID-19 pandemic: Initial responses in 2020 in selected social health insurance countries in Europe☆.

Countries with social health insurance (SHI) systems display some common defining characteristics - pluralism of actors and strong medical associations - that, in dealing with crisis times, may allow for common learnings. This paper analyses health system responses during the COVID-19 pandemic in eight countries representative of SHI systems in Europe (Austria, Belgium, France, Germany, Luxembourg, the Netherlands, Slovenia and Switzerland). Data collection and analysis builds on the methodology and content in the COVID-19 Health System Response Monitor (HSRM) up to November 2020. We find that SHI funds were, in general, neither foreseen as major stakeholders in crisis management, nor were they represented in crisis management teams. Further, responsibilities in some countries shifted from SHI funds to federal governments. The overall organisation and governance of SHI systems shaped how countries responded to the challenges of the pandemic. For instance, coordinated ambulatory care often helped avoid overburdening hospitals. Decentralisation among local authorities may however represent challenges with the coordination of policies, i.e. coordination costs. At the same time, bottom-up self-organisation of ambulatory care providers is supported by decentralised structures. Providers also increasingly used teleconsultations, which may remain part of standard practice. It is recommended to involve SHI funds actively in crisis management and in preparing for future crisis to increase health system resilience.

Belgium: Health System Review.

The Belgian health system covers almost the entire population for a large range of services. The main source of financing is social contributions, proportional to income. The provision of care is based on the principles of independent medical practice, free choice of physician and care facility, and predominantly fee-for-service payment. The Belgian population enjoys good health and long life expectancy. This is partly due to the population's good access to many high-quality health services. However, some challenges remain in terms of appropriateness of pharmaceutical care (overuse of antibiotics and psychotropic drugs), reduced accessibility for mental health and dental care due to higher user charges, socioeconomic inequalities in health status and the need for further strengthening of prevention policies. The system must also continue to evolve to cope with an ageing population, an increase of chronic diseases and the development of new technologies. This Belgian HiT profile (2020) presents the evolution of the health system since 2014, including detailed information on new policies. The most important reforms concern the transfer of additional health competences from the Federal State to the Federated entities and the plan to redesign the landscape of hospital care. Policy-makers have also pursued the goals of further improving access to high-quality services, while maintaining the financial sustainability and efficiency of the system, resulting in the implementation of several measures promoting multidisciplinary and integrated care, the concentration of medical expertise, patient care trajectories, patient empowerment, evidence-based medicine, outcome-based care and the so-called one health approach. Cooperation with neighbouring countries on pricing and reimbursement policies to improve access to (very high price) innovative medicines are also underway. Looking ahead, because additional challenges will be highlighted by the COVID-19 crisis, a focus on the resilience of the system is expected.

Canada: Health System Review.

This analysis of the Canadian health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. Life expectancy is high, but it plateaued between 2016 and 2017 due to the opioid crisis. Socioeconomic inequalities in health are significant, and the large and persistent gaps in health outcomes between Indigenous peoples and the rest of Canadians represent a major challenge facing the health system, and society more generally. Canada is a federation: the provinces and territories administer health coverage systems for their residents ( referred to as "medicare") , while the federal government sets national standards, such as through the Canada Health Act, and is responsible for health coverage for specific subpopulations. Health care is predominantly publicly financed, with approximately 70% of health expenditures financed through the general tax revenues. Yet there are major gaps in medicare, such as prescription drugs outside hospital, long-term care, mental health care, dental and vision care, which explains the significant role of employer-based private health insurance and out-of-pocket payments. The supply of physicians and nurses is uneven across the country with chronic shortages in rural and remote areas. Recent reforms include a move towards consolidating health regions into more centralized governance structures at the provincial/ territorial level, and gradually moving towards Indigenous self-governance in health care. There has also been some momentum towards introducing a national programme of prescription drug coverage ( Pharmacare) , though the COVID-19 pandemic of 2020 may shift priorities towards addressing other major health system challenges such as the poor quality and regulatory oversight of the long-term care sector. Health system performance has improved in recent years as measured by in-hospital mortality rates, cancer survival and avoidable hospitalizations. Yet major challenges such as access to non-medicare services, wait times for specialist and elective surgical care, and fragmented and poorly coordinated care will continue to preoccupy governments in pursuit of improved health system performance.

Physician revalidation in Europe.

Despite the increasing attention on patient mobility, there remains a lack of European-level interest in assuring the sustained competence of health professionals. Specifically, the existing European legal framework fails to recognise the introduction of periodic revalidation and requirements to participate in continuing professional development in some countries. This study shows that the definitions and mechanisms of revalidation vary significantly across member states. While some countries, eg Austria, Germany and Spain, look to continuing medical education as a means to promote recertification and quality of care, other countries, eg Belgium, France and the Netherlands, also incorporate peer review. In the UK the proposed revalidation scheme would include elements of relicensure through appraisal and feedback as well as physician recertification. Divergence between countries also exists in monitoring and enforcement. The European Commission should explore the implications for professional mobility of the diversity in the regulation of the medical profession.

A pricing policy towards the sourcing of cheaper drugs in Cyprus.

In contrast to other EU countries, Cyprus lacks comprehensive health care coverage for its population, thus a significant portion of the population lacks insurance for medicines. Due to the small size of the country and small indigenous pharmaceutical industry, pharmaceuticals are mainly imported. Prices in the private sector are determined based on the ex-factory price from the country of origin. Distribution margins are calculated as a percentage of the import price, which creates perverse incentives for wholesalers to import products from high price countries, or import very expensive products, to maximize their income. In this article, we compare pharmaceutical prices in Cyprus to other EU counties with higher or similar GDP per capita and found Cyprus to be a high price country. We then propose a new pricing system to change wholesaler incentives, which would encourage them to shop around for the best buy in Europe. Prices can be set based on average prices from a basket of European countries, and adjusted to reflect the GDP per capita level in Cyprus. This will establish the wholesale price that the government will accept, and wholesalers can procure products from any country at a lower rate. Thus, wholesalers would be encouraged to go for the lowest prices and the authorities would be indifferent to the actual price they obtain, so long as the necessary criteria (good manufacturing practice, safety, effectiveness and efficacy) are met. Our proposal has implications for low and middle income countries where this system of pharmaceutical pricing and wholesaler incentives can be used.

Malta: Health System Review.

Maltese life expectancy is high, and Maltese people spend on average close to 90% of their lifespan in good health, longer than in any other EU country. Malta has recently increased the proportion of GDP spent on health to above the EU average, though the private part of that remains higher than in many EU countries. The total number of doctors and GPs per capita is at the EU average, but the number of specialists remains relatively low; education and training are being further strengthened in order to retain more specialist skills in Malta. The health care system offers universal coverage to a comprehensive set of services that are free at the point of use for people entitled to statutory provision. The historical pattern of integrated financing and provision is shifting towards a more pluralist approach; people already often choose to visit private primary care providers, and in 2016 a new public-private partnership contract for three existing hospitals was agreed. Important priorities for the coming years include further strengthening of the primary and mental health sectors, as well as strengthening the health information system in order to support improved monitoring and evaluation. The priorities of Malta during its Presidency of the Council of the EU in 2017 include childhood obesity, and Structured Cooperation to enhance access to highly specialized and innovative services, medicines and technologies. Overall, the Maltese health system has made remarkable progress, with improvements in avoidable mortality and low levels of unmet need. The main outstanding challenges include: adapting the health system to an increasingly diverse population; increasing capacity to cope with a growing population; redistributing resources and activity from hospitals to primary care; ensuring access to expensive new medicines whilst still making efficiency improvements; and addressing medium-term financial sustainability challenges from demographic ageing.

Israel: Health System Review.

Israel is a small country, with just over 8 million citizens and a modern market-based economy with a comparable level of gross domestic product per capita to the average in the European Union. It has had universal health coverage since the introduction of a progressively financed statutory health insurance system in 1995. All citizens can choose from among four competing, non-profit-making health plans, which are charged with providing a broad package of benefits stipulated by the government. Overall, the Israeli health care system is quite efficient. Health status levels are comparable to those of other developed countries, even though Israel spends a relatively low proportion of its gross domestic product on health care (less than 8%) and nearly 40% of that is privately financed. Factors contributing to system efficiency include regulated competition among the health plans, tight regulatory controls on the supply of hospital beds, accessible and professional primary care and a well-developed system of electronic health records. Israeli health care has also demonstrated a remarkable capacity to innovate, improve, establish goals, be tenacious and prioritize. Israel is in the midst of numerous health reform efforts. The health insurance benefits package has been extended to include mental health care and dental care for children. A multipronged effort is underway to reduce health inequalities. National projects have been launched to measure and improve the quality of hospital care and reduce surgical waiting times, along with greater public dissemination of comparative performance data. Major steps are also being taken to address projected shortages of physicians and nurses. One of the major challenges currently facing Israeli health care is the growing reliance on private financing, with potentially deleterious effects for equity and efficiency. Efforts are currently underway to expand public financing, improve the efficiency of the public system and constrain the growth of the private sector.

United Kingdom (Northern Ireland): Health system review.

The political context within which Northern Irelands integrated health and social care system operates has changed since the establishment of a devolved administration (the Northern Ireland Assembly, set up in 1998 but suspended between 2002 and 2007). A locally elected Health Minister now leads the publicly financed system and has considerable power to set policy and, in principle, to determine the operation of other health and social care bodies. The system underwent major reform following the passing of the Health and Social Care (Reform) Act (Northern Ireland) in 2009. The reform maintained the quasi purchaser provider split already in place but reduced the number and increased the size of many of the bodies involved in purchasing (known locally as commissioning) and delivering services. Government policy has generally placed greater emphasis on consultation and cooperation among health and social care bodies (including the department, commissioners and care providers) than on competition. The small size of the population (1.8 million) and Northern Irelands geographical isolation from the rest of the United Kingdom provide a rationale for eschewing a more competitive model. Without competition, effective control over the system requires information and transparency to ensure provider challenge, and a body outside the system to hold it to account. The restoration of the locally elected Assembly in 2007 has created such a body, but it remains to be seen how effectively it will exercise accountability.

Sweden health system review.

Life expectancy in Sweden is high and the country performs well in comparisons related to disease-oriented indicators of health service outcomes and quality of care. The Swedish health system is committed to ensuring the health of all citizens and abides by the principles of human dignity, need and solidarity, and cost-effectiveness. The state is responsible for overall health policy, while the funding and provision of services lies largely with the county councils and regions. The municipalities are responsible for the care of older and disabled people. The majority of primary care centres and almost all hospitals are owned by the county councils. Health care expenditure is mainly tax funded (80%) and is equivalent to 9.9% of gross domestic product (GDP) (2009). Only about 4% of the population has voluntary health insurance (VHI). User charges fund about 17% of health expenditure and are levied on visits to professionals, hospitalization and medicines. The number of acute care hospital beds is below the European Union (EU) average and Sweden allocates more human resources to the health sector than most OECD countries. In the past, the Achilles heel of Swedish health care included long waiting times for diagnosis and treatment and, more recently, divergence in quality of care between regions and socioeconomic groups. Addressing long waiting times remains a key policy objective along with improving access to providers. Recent principal health reforms over the past decade relate to: concentrating hospital services; regionalizing health care services, including mergers; improving coordinated care; increasing choice, competition and privatization in primary care; privatization and competition in the pharmacy sector; changing co-payments; and increasing attention to public comparison of quality and efficiency indicators, the value of investments in health care and responsiveness to patients needs. Reforms are often introduced on the local level, thus the pattern of reform varies across local government, although mimicking behaviour usually occurs.

Malta: health system review

Maltese life expectancy is high and people spend on average close to 90% of their lifespan in good health. Malta has recently increased the proportion of GDP spent on health to above the EU average, though the private part of that remains higher than in many EU countries. The total number of doctors and GPs per capita is at the EU average, but the number of specialists remains relatively low. The health system offers universal coverage to a comprehensive set of services, free at the point of use for people entitled to statutory provision. The historical pattern of integrated financing and provision is shifting towards a more pluralist approach; people often choose to visit private primary care providers and in 2016 a new public–private partnership contract for three existing hospitals was agreed. Important priorities for the coming years include further strengthening of primary and mental health sectors, and strengthening the health information system to support improved monitoring and evaluation. The priorities during the Presidency of the Council of the EU in 2017 include childhood obesity, and Structured Cooperation to enhance access to highly specialized and innovative services, medicines and technologies. Overall, the Maltese health system has made remarkable progress. The main challenges include: adapting the health system to an increasingly diverse population; increasing capacity to cope with a growing population; redistributing resources and activity from hospitals to primary care; ensuring access to expensive new medicines whilst making efficiency improvements; and addressing medium-term financial sustainability challenges from demographic ageing.

Belgium: Health system review.

The Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. The Belgian population continues to enjoy good health and long life expectancy. This is partly due to good access to health services of high quality. Financing is based mostly on proportional social security contributions and progressive direct taxation. The compulsory health insurance is combined with a mostly private system of health care delivery, based on independent medical practice, free choice of physician and predominantly fee-for-service payment. This Belgian HiT profile (2010) presents the evolution of the health system since 2007, including detailed information on new policies. While no drastic reforms were undertaken during this period, policy-makers have pursued the goals of improving access to good quality of care while making the system sustainable. Reforms to increase the accessibility of the health system include measures to reduce the out-of-pocket payments of more vulnerable populations (low-income families and individuals as well as the chronically ill). Quality of care related reforms have included incentives to better integrate different levels of care and the establishment of information systems, among others. Additionally, several measures on pharmaceutical products have aimed to reduce costs for both the National Institute for Health and Disability Insurance (NIHDI) and patients, while maintaining the quality of care.

Israel: health system review

Israel is a small country, with just over 8 million citizens and a modernmarket-based economy with a comparable level of gross domestic productper capita to the average in the European Union. It has had universal healthcoverage since the introduction of a progressively financed statutory healthinsurance system in 1995. All citizens can choose from among four competing,non-profit-making health plans, which are charged with providing a broadpackage of benefits stipulated by the government.Overall, the Israeli health care system is quite efficient. Health status levelsare comparable to those of other developed countries, even though Israelspends a relatively low proportion of its gross domestic product on health care(less than 8%) and nearly 40% of that is privately financed. Factors contributingto system efficiency include regulated competition among the health plans, tightregulatory controls on the supply of hospital beds, accessible and professionalprimary care and a well-developed system of electronic health records. Israelihealth care has also demonstrated a remarkable capacity to innovate, improve,establish goals, be tenacious and prioritize.Israel is in the midst of numerous health reform efforts. The healthinsurance benefits package has been extended to include mental health careand dental care for children. A multipronged effort is underway to reduce healthinequalities. National projects have been launched to measure and improve thequality of hospital care and reduce surgical waiting times, along with greaterpublic dissemination of comparative performance data. Major steps are alsobeing taken to address projected shortages of physicians and nurses.One of the major challenges currently facing Israeli health care is thegrowing reliance on private financing, with potentially deleterious effectsfor equity and efficiency. Efforts are currently underway to expand publicfinancing, improve the efficiency of the public system and constrain the growthof the private sector.

Sweden: health system review

Life expectancy in Sweden is high and the country performs well with respect to disease-oriented indicators of health service outcomes and quality of care. The Swedish health system is committed to ensuring the health of all citizens and abides by the principles of human dignity, need and solidarity, and cost–effectiveness. The state is responsible for overall health policy, while the funding and provision of services lie largely with the county councils and regions. The municipalities are responsible for the care of older and disabled people. The majority of primary care centres and almost all hospitals are owned by the county councils. Health care expenditure is mainly tax funded (80%) and is equivalent to 9.9% of gross domestic product (2009). Only about 4% of the population has voluntary health insurance. User charges fund about 17% of health expenditure and are levied on visits to professionals, hospitalization and medicines. The number of acute care hospital beds is below the European Union average and Sweden allocates more human resources to the health sector than most OECD countries. In the past, the Achilles heel of Swedish health care included long waiting times for diagnosis and treatment, and divergence in quality of care between regions and socioeconomic groups. Recent principal health reforms relate to: concentrating hospital services; regionalizing health care services, including mergers; improving coordinated care; increasing choice, competition and privatization in primary care; privatization and competition in the pharmacy sector; changing co-payments; and increasing attention to public comparison of quality and efficiency indicators, the value of investments in health care and responsiveness to patients’ needs.

United Kingdom (Northern Ireland): health system review

The political context within which Northern Ireland’s integrated health and social care system operates has changed since the establishment of a devolved administration (the Northern Ireland Assembly, set up in 1998 but suspended between 2002 and 2007). A locally elected Health Minister now leads the publicly financed system and has considerable power to set policy and, in principle, to determine the operation of other health and social care bodies. The system underwent major reform following the passing of the Health and Social Care (Reform) Act (Northern Ireland) in 2009. The reform maintained the quasi purchaser–provider split already in place but reduced the number and increased the size of many of the bodies involved in purchasing (known locally as commissioning) and delivering services. Government policy has generally placed greater emphasis on consultation and cooperation among health and social care bodies (including the department, commissioners and care providers) than on competition. The small size of the population (1.8 million) and Northern Ireland’s geographical isolation from the rest of the United Kingdom provide a rationale for eschewing a more competitive model. Without competition, effective control over the system requires information and transparency to ensure provider challenge, and a body outside the system to hold it to account. The restoration of the locally elected Assembly in 2007 has created such a body, but it remains to be seen how effectively it will exercise accountability.