Sweden: Trust is the key word

Reflections on system resilience and the need to stimulate innovation, including the use of AI, are emerging in Sweden. TrendSanità spoke about this with Birger Forsberg, Associate Professor in International Health at the Karolinska Institutet

Sweden ranks high in terms of its healthcare system, with a model based on universal coverage and a relatively low proportion of healthcare expenditure borne by households, 13.1% (2021). The health expenditure/GDP ratio of 11.2% indicates a significant commitment to health, which is indicative of a priority in ensuring fair and high-quality access to health services for all citizens. Responsibility for health care in Sweden lies with the twenty-one regions, each of which is led by its own political council, which is elected every four years in popular elections.

To get a more complete view of the current state of Swedish healthcare TrendSanità interviewed Birger Forsberg, Associate Professor in International Health at the Karolinska Institutet, has been a consultant and member of some well-known International Organisations such as WHO, the World Bank and UNICEF.

«The regional council is responsible to its own constituency, not to the central government. The regions collect a personal income tax. This covers about 70 to 80% of the regional costs, the remainder comes from state subsidies, between 12-15%, and from patient expenses. – Birgen explains and continues – about 85% of regional costs are allocated to healthcare. Regional health care financing accounts for about 90 % of the total health care expenditure in Sweden, excluding patient expenses that are counted as out-of-pocket payments».

Between the public and private sectors

Exploring the Swedish healthcare system is like opening a window on the Baltic Sea where equity and accessibility define the horizon of the country’s medical care.

In Sweden, 88% of regional healthcare expenditure goes to public providers, and the key word is trust: trust in institutions that take care of citizens and put public health as a priority.

«The regions act as both purchasers and service providers, the rest goes to private providers who then provide services under contracts with the individual regions. In Sweden there is a small private health insurance sector, its turnover is about 1 % of the total health expenditure – Forsberg elaborates -. It is largely a publicly funded system through the regional councils, most of the providers are public, so there are good opportunities to guide them through regional, but also national, guidelines and directives».

Beyond this robust care structure, between public and private, lie profound challenges and reflections on efficiency, innovation and equality. Exploring both the strengths and weaknesses of this system allows us to grasp not only its complexity, but also its resilience to the challenges of our time and changing demands.

Birger Forsberg

«The Swedish healthcare system faces challenges common to large public bodies, such as slow decision-making and a lack of incentives to rapidly expand services in response to citizens’ needs. Innovation mainly comes from private providers, although limited by their dependence on public funding. Political decisions can sometimes be irrational and short-term, while annual budget cycles hinder long-term planning of services. – admits Forsberg and adds – some see the presence of private providers as a source of fragmentation in the system, concentrated mainly in cities and major metropolitan areas. In 2015, the introduction of digital services for doctor visits by private companies prompted regions to develop similar services. Today, digital healthcare is an integral part of public services, with private companies expanding their offerings to a range of services, including specialist and general medical services».

Despite the recognition of the Swedish healthcare system as a jewel in the crown of European healthcare, there are still challenges that raise questions about universal access to care. In a context where equity is a priority objective, there are signals of bureaucratic processes and waiting times that could jeopardise the readiness and effectiveness of health services.

The challenges are slow bureaucratic processes and waiting times

«Our health service is supposed to be one of those with the highest access to care in Europe and in the world, some political parties and researchers are focusing on health inequalities, analysing the differences in access to health services and health outcomes between different groups of people. There is some research suggesting that people from more advantaged social groups have higher health care costs when they are admitted to hospitals. However, the reasons for this, if true, would not be determined. In general, access to health services in Sweden is remarkable. Everyone can access services on equal terms, the main problems identified are that waiting times are sometimes too long and that coordination between healthcare providers could be improved» says Forsberg proudly pointing out: «The level of access to healthcare in the country is high. In some less populated areas of the country, hospitals can be distant, however, this is mitigated thanks to public funding that allows residents to be transported to hospitals when needed once services have identified the patient’s need. Regarding financial access, surveys show that approximately 3-5% of respondents have refrained from seeking assistance for financial reasons at some point in the past year, it is not known whether or not this behaviour is related to the severity of the illness. Finally, people with financial difficulties have the possibility of obtaining financial support from social services, but there are no tax exemptions for people other than children in most regions, and in some regions for people aged 85 and over».

Planning for the future: between personnel shortages and the use of AI

Sweden is at a crossroads and the need for creative strategies to address the growing deficit in the regions and ensure continuity and a high standard of care arises.

As in most European countries, one of the main challenges is the shortage of employees, which affects multiple professional groups, not just physicians.

«There is a lack of health professionals, psychologists, physicians, nurses…From the national training forecasts there is no indication that the need will be met in the coming decades. Therefore, we need task shifting and to give more tasks to nurses, we also need to allow more people with training in the above categories to immigrate to Sweden. We need to speed up the process by which doctors and nurses with foreign qualifications become licensed to practice in the Swedish health services. There is already a pool of such professionals in Sweden who have great difficulty obtaining a licence», Forsberg states firmly.

Although the shortage of qualified personnel is a problem for the country, due to the regional deficit this year, Birgen Forsberg emphasises « the response has been to increase the regional tax, as was the case in the Stockholm region, and to cut spending, as a result, some regions have announced the dismissal of staff», Birgen Forsberg emphasises.

The resilience of the Swedish healthcare system is undeniable, especially in providing high quality standards despite financial constraints. «I believe that we will continue to produce the same results in the coming years, some tax increases will be necessary and efficiency can be improved through various measures. The most important would be to allow more competition and thus more innovation in the health sector. – Says Forsberg and continues – it would be advantageous to incentivise private sector investment in the healthcare system, for example by promoting the establishment of private clinics and the provision of services that support the expansion of support functions. These could include implementing digital solutions based on artificial intelligence and facilitating public access to health information. Although efforts are underway within the regional administration to pursue these objectives, the process is proceeding at a slow pace and needs to be accelerated».

In a concluding note, Forsberg emphasises the European priorities, which require a coordinated approach based on the collaboration of the member states: «promote greater availability of healthcare personnel and emphasise healthcare and prevention within the national economy, in line with documented preferences in the population. Finally, explore advanced technological solutions, including those based on AI».

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Carmine Iorio
Laureato in Farmacia. Dottorando in Etica della Comunicazione, della ricerca scientifica e dell’innovazione tecnologica, Università degli Studi di Perugia