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.

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.

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.

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.

Canada: examen du système de santé

La présente analyse du système de santé du Canada examine les évolutions récentes dans l’organisation et la gouvernance, le financement de la santé, la prestation de soins de santé, les réformes de santé et le rendement du système de santé. L’espérance de vie est élevée, mais a atteint un plateau entre 2016 et 2017 en raison de la crise des opioïdes. Les inégalités socioéconomiques en matière de santé sont importantes, et les écarts marqués et persistants dans les résultats en matière de santé entre les Autochtones et les autres Canadiens représentent un grand défi pour le système de santé, et la société de façon plus générale. Le Canada est une fédération : les provinces et territoires font l’administration de systèmes de couverture de santé pour leurs résidents (appelés « régimes d’assurance-maladie »), alors que le gouvernement fédéral fixe des normes nationales, notamment par la Loi canadienne sur la santé, et est responsable de la couverture de santé de sous-groupes précis. Les soins de la santé sont principalement financés par l’État, avec environ 70 % des dépenses de santé financées par des recettes fiscales générales. Pourtant, les régimes d’assurance-maladie ont des lacunes importantes, comme les médicaments d’ordonnance en dehors de l’hôpital, les soins de longue durée, les soins de santé mentale, et les soins dentaires et de la vue, ce qui explique le rôle important des régimes d’assurance-maladie privés liés à l’emploi et des paiements déboursés par les patients. Le bassin de médecins et d’infirmières est inégal à l’échelle du pays, avec des pénuries chroniques dans les régions rurales et éloignées. Les réformes récentes comprennent une tendance vers le regroupement des régions sanitaires en structures de gouvernance plus centralisées à l’échelle provinciale ou territoriale, et un passage graduel vers l’autonomie des soins de santé par les Autochtones. Il y a également eu une lancée vers l’introduction d’un programme national de couverture des médicaments d’ordonnance (régime d’assurance-médicaments), mais la pandémie de COVID-19 de 2020 pourrait occasionner un virage dans les priorités, vers d’autres problèmes importants du système de santé, comme la mauvaise qualité et la surveillance réglementaire du secteur de soins de longue durée. Le rendement du système de santé s’est amélioré au cours des dernières années, selon les taux de mortalité à l’hôpital, la survie au cancer et les hospitalisations évitables. Des défis majeurs – comme l’accès à des services non couverts par l’assurance-maladie, les délais d’attente pour une consultation avec un spécialiste et les interventions chirurgicales non urgentes, ainsi que la fragmentation et la mauvaise coordination des soins – continueront toutefois de préoccuper les gouvernements dans leur quête d’amélioration du rendement du système de santé.

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.

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.

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.

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.

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.

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.

What do we know about the strengths and weakness of different policy mechanisms to influence health behaviour in the population?

With health care systems under increasing pressure the development of a well defined and effective public health strategy has never been more important. Many health problems are potentially avoidable and governments have long had tools at their disposal to influence population health and change individual behaviours, directed both ‘upstream’ at some of the underlying causes of poor health, as well as at ‘downstream’ challenges when poor health behaviours are already manifest. But how effective are these different actions? This policy summary briefly maps out what is known about some of these mechanisms, including approaches that have come to recent prominence from behavioural economics and psychology. Combinations of taxation, legislation and health information remain the core components of any strategy to influence behavioural change. There remain many unanswered questions on how best to design new innovative interventions that can complement, and in some instances augment, these well established mechanisms.

Promoting health, preventing disease: is there an economic case?

A core question for policy-makers will be the extent to which investments in preventive actions that address some of the social determinants of health represent an efficient option to help promote and protect population health. Can they reduce the level of ill health in the population? How strong is the evidence base on their effectiveness and, from an economic perspective,how do they stack up against investment in the treatment of health problems? Are there potential gains to be made by reducing or delaying the need for the consumption of future health care resources? Will they limit some of the wider costs of poor health to society, such as absenteeism from work, poorer levels of educational attainment, higher rates of violence and crime, and early retirement from the labour force due to sickness and disability? This policy summary provides an overview of what is known about the economic case for investing in a number of different areas of health promotion and noncommunicable disease prevention. It focuses predominantly on addressing some of the risk factors for health: tobacco and alcohol consumption, impacts of dietary behaviour and patterns of physical activity, exposure to environmental harm, risks to mental health and well-being, as well as risks of injury on our roads.

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.

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 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.