Health Care Systems in Europe under Austerity

Institutional Reforms and Performance

E. Pavolini,A. Guillén

• Publisher: Palgrave Macmillan
• Year: 2013
• ISBN:
  9780230369627
• Topic: Politique et relations internationales
• Subtopic: Politique sociale

This book analyses recent reform trends of European health care systems. Using eight European countries case studies it connects policy reforms with a healthcare quadrilemma, and compares how well these systems perform in terms of economic efficiency, medical achievements, social inequalities, and responsiveness to patients and workers.

Part I
Country Case Studies

1

Sweden: Continued Marketization within a Universalist System

Paula Blomqvist and Ulrika Winblad

Introduction

In this chapter we describe the regulatory changes that have taken place in the Swedish health care system during the 2000s. Three main reform trends are identified: privatization in the primary care sector, the strengthening of patient rights and re-centralization of regulatory power within the system. All these reforms have roots that go back to the 1990s, when patient choice and private alternatives were first introduced in the system and the central state began to try to find ways to take back some of the regulatory powers lost during its far-reaching decentralization in previous decades. All three reform trends were, however, reinforced during the 2000s. After 2006, when a centre-right government coalition took office, they were also given a more coherent and ideologically articulated frame, foremost in that values like private provision and patient rights were stressed.

Even if there are some transforming effects of the reforms introduced in the 2000s, we argue that these reforms have not fundamentally altered the system, but rather re-oriented and strengthened certain aspects of it. In this period, the Swedish health care system became more pluralistic in its provision of services and more accessible to patients, particularly in the primary care sector. The transparency of the system and the potential for quality monitoring on the part of the central government increased. At the same time, the hallmark of the system, its solidaristic, tax-based, financing structure, remains intact, as does the delivery structure of predominantly public provision of care services.¹ Moreover, even if some attempts have been made in the last decade to strengthen national supervision over the system, foremost with respect to performance and medical quality, it is still governed by the locally elected and largely autonomous county councils. Taking this into consideration, we believe that the reforms in the 2000s can be described mainly as second order in Peter Hall’s terminology (Hall, 1993); in other words, that they concern means, rather than ends, and that their transformative effect is limited. Furthermore, the political goals which have underpinned recent reforms, such as improved access to care for patients, more innovation and private initiative on the provision side, and enhanced transparency in terms of its quality and performance are not new to the system. They have all been part of health policy discussions in Sweden for several decades. Given the incremental and partly disjointed character of the regulatory reforms undertaken in Swedish health care in the 2000s, we also argue that these policies should be understood as representing a gradual institutional change rather than disruption.

Regulatory reforms in the Swedish system in the 2000s

The Swedish health care system is financed by taxes and based on the logic of public planning. It is strongly decentralized, as both financing and provision of care rest with local bodies, the county councils. These are currently twenty-one in number² and governed by locally elected political assemblies. The county councils finance the provision of health services primarily through local income taxes, which make up about 80 per cent of the system’s financing. The rest is state grants (17 per cent) and, to a smaller extent, user fees (3 per cent). The provision of health services has been a predominantly public responsibility in Sweden since the first state hospitals were founded by King Gustav Vasa in the 16th century. Since 1862, the main responsibility for operating hospitals has rested with the county councils. As a result of the still overwhelming domination of public providers in Swedish health care, medical staff are usually employed directly by the county councils. Until the 1960s, the provision of health services was subject to fairly detailed regulation by national health authorities such as the Ministry of Social Affairs and the National Board of Health and Social Services (Socialstyrelsen). After 1970, the system was gradually deregulated and decentralized, giving local policy makers substantial autonomy in organizing the provision of health services. In 1983, following the new Health and Medical Service Act, the county councils finally became fully responsible for both financing and production of health services, a change which led to the role of the central government being further reduced. At this time, the share of private providers in the system was very low, estimated at around 1–2 per cent.

During the 1990s, the Swedish health care system was gradually opened up to more competition from private providers. Following a legal change in 1992, the county councils were allowed to contract out the provision of care to private actors, including for-profit firms. This led to a period of intense organizational experimenting in the system, where some county councils developed their own quasi-market models for increasing competitive pressures and the share of private providers (Saltman and von Otter, 1995; Anell, 1996). Another central part of local reforms during the 1990s was the introduction of the principle of the right of the patient to choose health care providers. The first attempt to introduce patient choice within the system was the 1989 patient choice recommendation initiated by the central organization for the county councils, the Swedish Association for Local Governments and Regions (SALAR). Later, this right was legally formalized, but remained a distant goal in many county councils due to poor local implementation (Winblad, 2008).The political concern with patient choice during the 1990s should be seen in light of the relatively weak role of patients within the Swedish health care system and its alleged bureaucratic nature at the time, which led to public discontent. As the provision of health services was subject to detailed local planning by the county councils and offered to citizens on the basis of residency, there had been no possibility in the system for choosing one’s care provider, even within the primary care sector. Typically, citizens were expected to seek care only at the public health centres and hospitals within their area of residence. During the 1980s, this led to a critical debate about the bureaucratic nature and lack of consumer friendliness of the system. An additional explanation for the emphasis on managerialist and market-orienting policies during the 1990s is the strong influence of new public management ideas in Sweden during this time, during both social democratic and right-wing governments (Blomqvist, 2002; 2004).

The managerialist reforms introduced during the 1990s, such as patient choice, purchaser–provider splits and the introduction of various forms of performance-related payments systems, led to the previous virtual public monopoly on care provision being abandoned in many county councils.³ Since these reforms were largely experimental in character and initiated in some county counties only, the share of private provision as part of the total expenditure in the system was still relatively modest at the end of the decade, at only about 10 per cent (Blomqvist, 2004). The managerialist reforms during the 1990s can be said to have opened up the system to private providers and introduced more organizational diversity at the local level, while at the same time creating a higher level of cost awareness among the staff and more recognition of the rights of patients.

During the 2000s, the reformation of the system continued along similar tracks, albeit with a slightly different emphasis. Access to care, and, in particular, waiting times became a political concern for the central government along with the desire to increase the transparency of the system. After 2006, when the previous Social Democratic government was replaced with a centre-right governing coalition, there was a more strongly stated ideological drive towards increasing the share of private providers and making the system more consumerist in orientation. Three main reform trends can be identified during this decade. The first is the continued strengthening of patient rights through regulatory measures like choice, the legal right to information and co-determination, and the introduction of a so-called waiting-time guarantee in 2005. The second is privatization of the primary care sector, manifested in the introduction of so-called primary care choice systems in the county councils in 2010 (Lagen of valfrihetssystem). The third is the re-centralization of regulatory powers within the system as the central state has introduced various new measures to increase its capacity to supervise and direct the system.

The first reform trend, the strengthening of patients’ rights, represents continuity in relation to the 1990s when patient empowerment was a political goal for both left- and right-wing governments. During the 2000s this goal was even more systematically pursued, with more emphasis on legal enforcement. In 2005, the then social-democratic government made an agreement with SALAR to introduce a so-called waiting time guarantee which stated that there should be a maximum waiting time of three months for treatment after a patient had been diagnosed. This was not the first attempt to shorten waiting times in the system in this manner, but this time the government provided substantive additional resources to the county councils. Even though compliance was formally voluntary, the reform was closely monitored by the government and new systems for collection of information regarding waiting times were set up. Also, SALAR helped the county councils to structure the implementation process, such as by arranging regular meetings where leading representatives from the county councils took part (Winblad et al., 2010). In 2010 the guarantee was legally enforced by the next (right-centre) government, which made it mandatory for the county councils to provide care for all patients within three months. If the clinics could not keep up with the guarantee, they were legally obliged to help patients seek care at another hospital at the expense of the home clinic. This created strong incentives for the clinics to shorten their waiting lists. Also, clinics that were able to honor the guarantee received an economic bonus (Winblad et al., 2010). Another reform carried out in the 2000s to strengthen the role of patients was the Patient Choice Recommendation, which was the result of an agreement between the central government and SALAR stating that patients should be provided with a free choice of care provider even across county council borders. The recommendation was met with strong resistance by some county councils, who feared the loss of budgetary control as patients would be allowed to seek care freely in other counties, but it was eventually endorsed by all (Fredriksson et al., 2012). Attempts to strengthen patient rights in the 2000s were also aided by amendments introduced in the Health and Medical Services Act in 1999 to legally enforce the rights of patients in the system. Examples of rights that were given legal status at this time include the right to full information regarding treatment alternatives, the right to co-determination in treatment decisions and – in cases of serious medical illness – the right to a second opinion by another care provider. These reforms, initiated to strengthen the role of patients within the system, can be seen as a continuing of the managerialist reforms of the 1990s, but with a stronger emphasis on the legal rights of patients.

A second reform trend that can be observed in the 2000s in Swedish health care is (continued) privatization in the primary care sector through the so-called primary care choice law enacted in 2009. The law, which came into force in 2010, stipulates that all county councils introduce a so-called choice model, whereby private care providers are free to establish themselves if they fulfill certain basic criteria and thereafter get reimbursed financially on the basis of how many listed patients they manage to attract. For patients, the choice models mean that they can choose freely where to ‘enlist’ among competing public and private GPs and health care centers, and that funds within the system will be distributed according to their choice, at no additional cost to themselves. In this manner, the primary care choice law also adds to the strengthening of consumer power within the system. In line with the Swedish tradition of localized decision-making in the health care system, the primary care choice law left it open for the county councils to design the specific features of the choice systems themselves, including what criteria must be fulfilled for private providers to establish themselves and how reimbursement formulas are constructed. Evaluations of developments in the county councils after 2010 have shown that the choice models have led to a 20 per cent increase in the share of private primary care providers in the country as a whole, albeit with great local variations (Swedish Competition Agency, 2010).

The central government’s efforts to increase the share of private providers have so far been confined foremost to the primary care sector, even though the so-called stop law prohibiting sale of acute care hospitals introduced by the previous social democratic government in 2000 was overturned in 2007. Since then, there has been no further privatization within the hospital sector in Sweden (Anell, 2011), as there has been no apparent interest among the county councils to privatize hospitals. So far, only one acute care hospital in Sweden has been partially privatized as its operation was put out to tender (in Stockholm in 1999).

The third regulatory trend visible in the Swedish health system in the 2000s is recentralization. This trend is evident in a range of different political initiatives which have had the effect of centralizing regulatory control within the system, some of which were initiated in the late 1990s (Fredriksson, 2012 and Saltman, 2012). It should be noted that re-centralization here refers exclusively to regulatory powers, not the financial structure of the system or its institutions for providing care services, both of which remain locally governed. The post-war Swedish health care system has been characterized by a high degree of soft law or non-binding regulation. One part of this governance structure is the annual negotiations between the government and the county councils (represented by SALAR) on how to allocate the state grants, which are typically directed towards distinct areas which the government wants to prioritize. Such agreements about resource allocation and priority-setting are formally voluntary but have in practice usually been followed by the county councils. In recent years, however, the government has increasingly turned to binding legal regulation when governing the system. This inclination, evident foremost after 2006, reflects a desire to strengthen the role of the central state in relation to the county councils and has also been motivated by the documented geographical differences in health utilization and health outcomes across the country (Government Commission, 2012).

Another sign of the recentralization trend within the Swedish health care system is the increased focus on audit and quality monitoring within this sector. Since the middle of the 2000s, SALAR and the National Board of Health and Welfare produce yearly Open Comparisons (Öppna jämförelser), in which hundreds of quality indicators are presented for each county council. This provides a unique opportunity for the state to compare the quality within each part of the health care sector and puts pressure on the county councils to improve quality. In addition to this, the National Board of Health and Welfare produces national guidelines for several diagnosis groups (in collaboration with medical experts) in order to direct the distribution of resources at the local level and streamline the behaviour of the medical professionals (Fredriksson, 2012). A third sign of the increased recentralization within the system is reinforced regulatory control by national agencies. For instance, the National Board of Health and Welfare has begun focusing more explicitly on inspections of the health care units. Six regional inspection units have been set up during the 2000s. Having previously announced the inspections beforehand, surprise inspections are now more commonly used. Furthermore, two new national agencies have recently been created. In 2011, the Swedish Agency for Health Care Services Analysis (Myndigheten för Vårdanalys), and in 2013, the Health and Social Care Inspectorate (Inspektionen för vård och omsorg). The agencies were established by the government in order to monitor quality and strengthen the role of the patients within the system. Taken together, these re-centralizing reforms point to an enhanced regulatory role for the national government in the system in relation to the county councils.

How far-reaching are the changes in the Swedish health system in the last decade? Employing Peter Hall’s three-level model, we would assert that ...