A short report on changes in the Swedish health care system

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, by SUNDVALL Maria

This article is based on one of the reports at the European healthworkers conference, held in the International Institute for Research and Education in May 2011. See (ESSF article 22173): Statement from the European Conference for the defence of a public health service and (article 22172): European conference for the defence of a public health service and other national reports.

 A brief overview

Organizing the main part of health care is the responsibility of the county councils on a regional basis. The municipalities have a responsibility for the care of old people and to some extent for the care of persons with long term psychiatric illness. The state regulates and supervises and contributes to the financing. The finances of the health sector come mainly from county and municipal taxes but also from state grants and user fees. The services are not free at the point of use – on the contrary, they are quite expensive. For example, to visit a specialist physician in public care in the Stockholm County costs 32 euro, which is a lot for many people even though there is a maximum fee of 95 euro a year. Medication, glasses and dental care are also paid for by the patient (with some reductions) .

Most of the health system has been public up till ten - fifteen years ago. There have been private specialists and GPs especially in the big cities (concentrated in the rich areas) and private insurances have been quite rare.

The sickness benefits are financed by a national insurance, partly paid by the employers and partly through transfers from the state.

 Neoliberal policies changing health care

There have been a number of cuts in health care since the early 80ies in terms of share of the GNP. It is said that 100 000 jobs were lost in the 90ies, mainly among staff active in the daily care of the patients in inpatient or outpatient settings.

Private funding increased in the last ten years through higher fees.

Privatization started – timidly – in the early 90ies at the initiative of national and local right-wing governments. It is significant that socialdemocrats coming back to power have not pursued the same privatization drive, but neither rolled back the privatizations. In the Stockholm County there has been a change of local government at every election for round 20 years, and the socialdemocrats have each term implemented (sometimes very impopular) cuts, only to be voted out and replaced by right wing governments that have privatized. (The line was broken in the elections of 2010 when the right wing alliance was voted back in local and national power with a “promise” to continue privatizations.)

Since the early 90ies the health care system has been characterized by New Public Management ie the idea that public services should imitate the functioning of the private. Purchaser/provider systems and buy and sell mechanisms have been introduced. Today we have quite an intricate system of “points” and “bonuses” and “quality registers”, designed to control and increase the efficacy of the staff. The effects of this are of course questioned by many scientists, trade unionists etc. All established parties favour this system, however.

In 2006 the most confident right-wing government in the history of Sweden was elected (and sadly reelected in 2010). It immediately launched an accelerated privatization drive. In 2007 a law was passed permitting the sale of publicly owned hospitals, all of them, as a whole or in parts. The law also permitted patients with private insurances into publicly financed hospitals, something that the opponents call a “rapid lane” – of course no one would pay for a private insurance unless it was beneficial. In reality no whole hospital has been sold, so far, but parts of them have been privatized.

There have been different types of privatization:

- Direct transfer to a group of staff, that sets up a small firm – this has however been stopped since it was deemed illegal under EU regulations to give competition advantages to a particular group.

- Services have been put out to tender with contracts normally lasting 3-5 years. This has disrupted continuity especially in the care of the elderly and it has also led to a rapid development of oligopolies in that sector.

- The favoured method for the moment is to let “the money follow the patient”, which is often advertised as the method of “free choice”. For example this system has been introduced in the primary care of many counties, meaning that any certified provider can open a health centre and get funding from the county according to the number of patients listed, or the number of visits or a mixture of both.

The worst “free choice” system has been introduced in Stockholm, where all earlier extra resources to compensate the primary care centres in low income areas have been abolished at the same time as the GPs are compensated almost only according to visits. This has led to a “more accessible” health care – increasing short visits for the healthy and reducing resources for old people with many diseases. It has also led to an increase of social inequality in the access of health care.

A year ago the free choice system in primary care was turned into a law forcing all counties to introduce some variant of it. This law is said to be unique in Western Europe – obviously there are many countries with a lot of private GPs but it is not so common that the authorities give public funding to private care givers without any control over where they choose to establish!

Since 2008 new “reforms” of sickness benefits have been introduced, reducing the number of days on sick leave according to fixed dates. At the same time the possibility of getting a disability pension has been drastically reduced, leading to many tragic cases, where for instance people with cancer have to stop treatment because the national insurance authorities demand that they start working part time. An especially vicious effect that has caused the concern of the trade unions is that jobs have become less secure. Normally (at least in theory) you cannot sack a person without cause and especially not for being ill, but with the new rules the employer basically has to wait 180 days – if the person cannot go back to his own employer he has to look for any work on the national labour market after that date.

Resistance

Resistance against the development has been too weak. The staffs in the health services are split on many trade unions. The unions of the doctors and nurses have traditionally been pro-privatization. The union of the auxiliary nurses, porters, mental health workers as well as of the workers employed in the care of the eldery – the biggest union in Sweden – has been ambivalent to privatization at best.

There have been local struggles against cuts, especially against the closure of one hospital, one maternity ward, one health centre at the time, but normally there has been no continuation. There have been only a few local campaigns against privatization.

The Network for Common Welfare was formed in 2005 with an idea of bringing people together from different campaigns (not only on health issues), to be a memory and continuity, to strenghten propaganda and opinion building. It brings together local welfare activists, ecologists, anti-globalization activists (Attac) and some trade unions and is mainly active in the bigger cities. The state-employed workers’ union has been active from the start. In the last few years contacts with the municipal workers’ and the nurses’ union have increased, as well as contacts with users’ organizations and progressive scientists. The Stockholm TUC as a whole has developed a more radical stance than the TUC nationally, formulating a welfare platform.

In the last few months we have seen a broader mobilization against the reforms of the sickness benefits, bringing together of a broad range of forces including all churches. The government has only promised minor changes to the system, and the protests will certainly continue.