​​The Swedish national health system (NHS) is funded by taxes and run by public authorities. But contrary to England, the delivery and regulation of healthcare is deeply decentralized. The 1982 Health and Medical Services Act requires self-governing county councils (Landsting) and regions (Regioner) to provide high quality universal medical care and preventive services to their residents, while municipalities are in charge of elderly and long-term care. Local authorities enjoy significant freedom in the allocation of resources within their geographical area. They levy proportional income taxes in order to finance those services. An overwhelming share of county councils’ budget is devoted to health care (approximately 90%) and the overall share of health expenditure financed by local taxes is about 75%. The remainder is covered by State grants (15-20%) and out-of-pocket fees (5-10%).

Elected county councils and regions employ most doctors and health professionals working in the in- and outpatient facilities they operate. Since the early 1990s, a growing number of private health centres are operating under negotiated contracts with county council boards. There are now around 1100 public and private primary care facilities across the country. Primary care centres are multidisciplinary and generally consist of 4-10 GPs, nurses and specialists. In addition to basic medical care, the centres provide public health and preventive services. The national government retains the authority to set minimum qualifications and to exercise oversight over local institutions. Local authorities are represented at national level by an overarching organization (Sveriges Kommuner och Landsting – SKL) which engages in national health care policies and publishes expert reports. SKL also takes part in national collective wage bargaining with health professionals’ organisations. The central government and agencies set up regulations, produce information and statistics and provide incentives for local authorities to improve the responsiveness, equality and quality of care.

Blatant territorial imbalances (Northern Sweden covers 2/3 of the country and is inhabited by merely 12% of the total population) have made private medicine and solo practice unsustainable in remote areas, prompting the government to subsidize medical officers in the early stage of the State building process and paving the way for an irresistible expansion of the public sector in the post-war era. Access to health care in disadvantaged areas was framed by the social-democratic government as a social rights issue which could only be tackled through State takeover of private medicine and enhanced public planning of medical supply. By the late 1970s, publicly owned primary health care centres had become the cornerstone of the system. County councils were instructed to determine the number and location of primary care facilities based on streamlined population-density criteria – regardless of the level of income in various areas. Sweden was a frontrunner in the development of primary care, but ambulatory care remained vastly underfunded and understaffed in comparison to an oversized and overspecialized hospital sector. Shortage of primary care medical workforce has been a major concern since the 1950s. But as the economic crisis hit Sweden in the mid-1980s, and county councils engaged in drastic cost-containment reforms, perceived decline in the quality of service, lack of patient-centeredness and above all increased waiting time emerged as the most pressing issues on the national agenda. In the broader context of ideological decline of the social-democratic model, primary care reforms have been heavily influenced by a paradigm shift from the strive to foster access equity towards competition and consumer choice reforms. Predominantly right-right local governments in urbanized areas such as Stockholm experimented with new public management and market reforms in primary care in the early 1990s (through internal markets and privatization of supply). These changes were resisted by social-democratic strongholds in Northern Sweden, where county council officials feared that performance-oriented schemes and the establishment of new private providers would favour choice in wealthy suburban areas and hurt access to care in poor or remote regions. In 2010, the centre-right government implemented a nation-wide reform that made choice of primary care provider and freedom of establishment for private care mandatory. The government furthermore redirected the traditional equity-oriented fund in order to favour county councils that actively implemented national waiting-time targets (kömiljarden).

A new phase seems to have started in the aftermath of these reforms. After decades of focus on choice and competition, the uneven implementation of primary care reform shed a light on their negative effects on geographical equity. Recent studies show that while more than 200 private primary care providers have been established across the country, very few of them settled in disadvantaged areas. The national audit office (Riksrevisionen) indeed pointed out that access to primary care mainly benefited socio-economically privileged areas (RiR 2014:22). Starting in 2016, the “waiting time” State grant has been re-directed back to promoting equity in access (tillgänglighetsmiljard) as opposed to consumer-oriented performance. Once again, national primary care reforms seem to mirror broader political shifts (a new centre-left government was elected in 2014), but it also stems from decades of local initiatives and experiments. County councils are confronted with looming shortage of primary care workforce and in some cases have to shorten the opening hours or to reduce the variety of services provided by first line health centres. Since the 2000s, many county councils have implemented various measures aiming at attracting doctors to underserviced areas, by promoting rural medicine specialization with expertise in emergency surgery on site, building local health centres (sjukstugor) in remote places. Northern counties have for instance joined forces with neighbouring regions in Finland and Norway to set up a “recruit & retain” program. Counties such as Västerbotten have explored telemedicine and videoconference alternatives to GP visits. They also resorted to less innovative and more costly solutions such as paying private recruitment companies offering so-called “physicians for hire” (hyrläkare).

DFG-ANR Project RegMedProv