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Health Services System of Sweden Health Services System of Sweden ARNT MEYER-LIE, M.D. T HE SWEDISH health services system has trative body directing the National Health been cited by authiorities in the United Service. The board supervises general health States and in other countries as providing solu- and pharmaceutical services, controls treatment tions to some contemporary problems in health of the ill in general and private hospitals, and care. It is of interest, then, to examine the ad- supervises the work of medical personnel and ministration of this system, which serves a pop- the hospitals, pharmacies, and other institu- ulationi of 7.77 million persons, 4.17 million of tions. It also has many administrative whom live in cities. responsibilities. National Authority Regional Authorities Numerous agencies cooperate to run the The basic regions in Sweden are the 24 Prov- Swedish National Health Service. All health inces, with an average population of 250,000 to services available to the public are subject to 300,000 each. The regional authorities respon- control by the National Government. Many ac- sible for planning, organizing, operating, and tivities of the health service are run by local financing general hospitals are the county coun- authorities, and in fields such as outpatient serv- cils. The councils have handled these activities ices and pharmacy some functions are per- since 1864 and have acquired responsibility for formed by private persons. additional health service tasks to such an extent In Sweden, unlike other Scandinavian coun- that 85 percent of their total gross expenditure tries, government activity takes place on two is related to health (fig. 1). levels-in the ministries and in the national ad- The area of a county usually corresponds to ministrative boards. The boards, which super- that of the Province. The county has local self- vise and direct government activity and State government under the county council regarding institutions according to directives of the leg- public health and vocational education and re- islature and the cabinet, are responsible to the habilitation, while the Province, which is the Crown. Thus, the Minister of Social Affairs has national administrative area, is controlled by no authority over the Director General of the the Provincial Governor-the representative Natiolnal Board of Health and Social Affairs. of the Crown. The Governor has no legal The national boards are, therefore, largely authority over the council. autonomous. The high standards of the Swedish The Board health National of Health and Social service can be attributed in part to the councils' Affairs is the most important central adminis- autonomy and their unrestricted right to im- pose taxes. Average county taxes take about 6 Dr. Meyer-Lie is senior county medical health of- percent of a taxpayer's income. The total county ficer, County of Virmland, Sweden. This paper is income is about 10 percent from State funds, based on a speech given at a medical conference in 14 percent from charges and fees, and the re- Bolzano, Italy, December 8, 1967. mainder from county taxes. Vol. 84, No. 1, January 1969 81 Figure 1. Organization of health services in a county National Board of Health and Social Affairs The county council (partly autonomous body) super- The county governor in the Pro- vises vincial Government Hospitals County administers with associated District medical officers, nurses, experts and midwives Public health committees care Outpatient Environmental hygiene Maternity and child welfare Housing hygiene Nursing homes Water hygiene Homes for mentally deficient Traffic medicine (drivers license) Tuberc.ulosis centers School health and hygiene Publi4 dental service V,ocational education Vocational rehabilitation Public health .~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Family planning advice bureaus and abortions I~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ Fields of work Pharmacy Social welfare committees Homes for aged Child welfare committees Homes for children Public health Environmental hygiene Social medicine Supervisory medical personnel Inspection of establishments (medical and social) Certain medical attendance Coordinate health, care of sick, and rehabilitation Military health and sick care 82 Public Health Reports Medical Health Officer The populations served by the regional hos- The county or Provincial medical health offi- pitals vary because of factors such as the sparse cer and his staff represent the National Board population in the northern districts. Theoreti- of Health in the county and perform supervi- cally, each regional hospital should serve about sory and inspectional functions for the board. 1 million persons. However, three regions have The health officer is not attached to the Provin- smaller populations-the northernmost has a cial government or to the county council, but population of 700,000. he is responsible to and paid by the State. Health Insurance System He is seated by law as an adviser in the The expenses of illness to private citizens are of administrative and executive bodies the a extent the health insurance county council and is also medical adviser to covered to great by the Provincial Governor. Involved with each service, compulsory in Sweden since 1955. Each of the county's power structures, he can help coordinate preventive, curative, and rehabilita- Figure 2. Regions for specialized care, Sweden tive services in the region. The medical officer also functions as a super- visor and consultant in the field of environmen- tal hygiene. He is assisted in this role by a deputy health officer and a senior sanitary consultant. Preventive health, school health, field epi- demiology, and environmental hygiene are the responsibilities of the towns and rural dis- tricts-the local communes. Communal councils appoint local public health committees to over- see observance of general health laws and to work for improved public health. These coun- cils are responsible to the State through the Provincial Governor. Regional Hospitals The population of each county is not large enough to support specialized services such as neurosurgery, neurology, thoracic surgery, car- diology, plastic surgery, pediatric surgery, urol- ogy, radiotherapy, dermatology, and specialized laboratory work. Therefore, in 1960 Parliament VAR MLAND divided the country into seven regions for spe- cialized care, and the counties cooperate to maintain a regional hospital in each (fig. 2). At the end of 1964, 40 such regional clinics and two laboratories had been opened within the G3teborg regional hospitals. The regional hospitals retain their status as central general hospitals for a county and have been expanded to include specialized facilities. Lund-Mail In five regions, university hospitals have be- Kitlo meters come the regional hospitals. It is expected that 0 200 400 the two remaining regional hospitals will also be used for medical education. 0 Miles 250 Vol. 84, No. 1, January 1969 83 STATISTICS ON HEALTH SERVICES OUTSIDE HOSPITALS, SWEDEN, 1965 743 rural medical officers' posts, 75 vacant 50,000 epileptics treated, 95 percent in ambulatory 1,818 public health nurses posts, 100 vacant care 376 midwifery districts, 39 vacant 29 central policlinics and 770 district policlinics in 1,433 maternity and child welfare units public dental service. 1,736 dental surgeons employed 57 central and 610 district tuberculosis units. 670,462 in service. 1,559 dental surgeons attached to the X-ray examinations made in the central units district policlinics worked 2,558,000 hours. 63 percent 198,000 visits to 27 policlinics for venereal disease; of time in district clinics devoted to children 134,040 medical personnel in service, including ad- 127,000 visits made when the disease was in its con- ministrative and hospital domestic staffs tagious phase 8,520 physicians, including 270 foreign physicians on 6,095 ruled cases in 20 consultation bureaus for sexual limited license, one per 890 population hygiene and abortion 6,080 dental surgeons 400,000 persons vaccinated against poliomyelitis, 23,190 nurses bringing total vaccinated to 5.2 million persons 1,040 nurse midwives 42 child guidance clinics 720 midwives Province has a Provincial Social Insurance the cost of constructing new buildings, will be Fund with local branches to administer the SKVr 139 million (U.S. $27 million). social insurances, including health insurance. Nonhospital services. The county council em- Swedish citizens living in the country are auto- ploys rural medical officers to provide care out- matically registered as members of such funds side the hospitals. Each of the 43 rural medical at age 16, and children under age 16 are covered officers in Viirmland has his practice and makes by their parents' insurance. The insurance serv- home calls in his own district. The council also ice refunds payments for medical treatment, employs 99 district nurses who give information certain dental and hospital treatment, and and advice on child care, home hygiene, health traveling expenses connected with such treat- care, and preventive health, and who provide ment. home nursing services. Patients are repaid three-fourths of the cost The county council is legally obliged to em- for treatment, but no more than three-fourths ploy district midwives in defined geographic of the fees stated in a special scale of charges. areas to give prenatal care, assist in deliveries, Swedish citizens pay nothing for inpatient hos- and give home postnatal care. The services of pital care. Costs are shared by the county
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