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Great expectations: What can we learn from Sweden? Anders Anell, PhD, director The Swedish Institute for Health Economics (IHE), Lund.

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Presentation on theme: "Great expectations: What can we learn from Sweden? Anders Anell, PhD, director The Swedish Institute for Health Economics (IHE), Lund."— Presentation transcript:

1 Great expectations: What can we learn from Sweden? Anders Anell, PhD, director The Swedish Institute for Health Economics (IHE), Lund

2 Swedish Health Care Cornerstone of the Swedish welfare state –Quality health care for all, distributive justice Decentralised decision-making –21 county councils responsible for hospitals and primary care services –289 municipalities responsible for care of the elderly and mentally handicapped (home care, nursing homes) Public ownership and political control –With local exceptions Weak primary care services

3 New policies introduced at different government levels National government –Responsibility of local governments –Specific issues (focus on access, quality and equity) –Legislation or agreements + budget infusion Local government –Experimentation with choice of providers, purchaser- provider split, contracting, privatisation, hospitals mergers and closure, new primary care models, integrated care and more

4 Impact of new policies Impact of local-government reforms and national agreements limited compared to new legislation The formation of reforms can often be explained by a political logic (i.e. maintaining legitimacy) –Politicians produce rhetoric, plans and actual changes –Coherence not necessary for survival Changes in welfare and advances in medical technology more important than both local and national government reform

5 Development of GDP and total expenditure on health in Sweden, 1970-2004 (Index 1970=100, 2000 GDP price level) Source: OECD Health Data 2005

6 Acute care bed days per capita and age group in Sweden, 1993 and 2004 Source: Sjukvårdsdata i Fokus, SKL, 2006

7 0 20 40 60 80 100 120 140 19901991199219931994199519961997199819992000 Year Billion SEK County council exp.County council exp. (rev.) Municipality exp.Pharmaceuticals Source: Nationell handlingsplan för äldrepolitiken. Lägesrapport 2001. Statistisk Årsbok för Landsting. Apoteket AB. Expenditures for county council health care and municipal care of the elderly and the handicapped. Constant 1999 prices.

8 Development of total health care expenditure in Sweden 1993-2004 (constant 2004 prices)

9 Health care expenditure and GDP per capita in the EU (15) + US and Norway, 1975 Source: OECD Health Data 2005

10 Health care expenditure and GDP per capita in the EU (15) + US and Norway, 2003 Source: OECD Health Data 2005

11 How would you assess health care services today compared to 10 years ago? Better than 10 years ago15,6% About the same as 10 years ago17,6% Worse than 10 years ago42,3% Don´t know/uncertain24,5% Total100% Source: Rosén P. Population survey in county council of Östergötland (Sample = 4 000 with 58% response rate, n = 2284, ages 18+).

12 Why? Cost-containment policies in mid 90s and increased pressure for explicit priority setting Political rhetoric –Election every fourth year; shift of local government common. Opposition (and media) has an interest to highlight problems. Increased transparency related to access and quality (absolute level and differences) Demand for patient influence and less reliance on experts

13 Waiting times and government policies Important problem for politicians since late 1980s –Used as an argument for overall reform (privatisation) –Waiting time guarantees, budget infusion from national level Several explanations behind existing waiting times –Wider indications for treatment most important –Waiting list for cataract surgery doubled 1990-2000; the volume produced increased by 140%

14 Number of hip replacements in Sweden per 100 000 population and age group 1994, 1999 and 2004 Source: Sjukvårdsdata i Fokus, SKL, 2006

15 Number of coronary bypass and PCI in Sweden per 100 000 population and age 1994, 1999 and 2004 Coronary bypassPCI Source: Sjukvårdsdata i Fokus, SKL, 2006

16 Regional expenditure per capita in Sweden for five new oncology drugs 1, 2005-01 – 2005-06 Stockholm region21.44 SEK Uppsala/Örebro20.16 SEK Northern region19.31 SEK Southern region16.99 SEK Southeastern region16.34 SEK Western region16.08 SEK Source: Dagens Medicin, 21 September 2005, p. 4-7. 1 Herceptin/trastuzumab, Erbitux/cetuximab, Avastin/bevacizumab, Mabthera/rituximab and Glivec/imatinib.

17 Variation in access to cancer therapy Local priorities not transparent and limited by budget criteria Less acceptance by national government (and the population) of variation in access to treatment (post-code rationing) Towards a national cancer-plan (= agreement + budget infusion)? –increased use of national guidelines, less discretion for decision-making at local level and additional funding?

18 Expenditures for cancer drugs per capita in selected countries in 2002/2003 France16 Euro Italy13 Euro Sweden12 Euro Germany12 Euro Switzerland11 Euro Spain11 Euro Austria10 Euro UK10 Euro Norway9 Euro Netherlands9 Euro Finland9 Euro Denmark7 Euro Source: Wilking, Jönsson (2005)A pan-European comparison regarding patient access to cancer drugs. Karolinska Institutet, Stockholm. Sweden identified as average in terms of uptake of new cancer drugs in pan-European study. (Austria, Spain and Switzerland = top three countries; Czech Republic, Hungary, Norway,Poland and UK below-average.)

19 Some challenges for the future Balance between national and local decision- making –Ongoing parliamentary committee expected to suggest larger regions to replace county councils Long-run financing of services (from 2015) –Alternatives to tax funding? Recruitment of human resources –Both municipalities and county councils Development of primary care and integration of services

20 Fig. 5: Horizontal inequity (HI) indices for the annual mean number of visits to a doctor in 19 OECD countries van Doorslaer, E. et al. CMAJ 2006;174:177-183 Inequity in distribution of physician visits in Sweden due to weak primary care services


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