History of Health Technology Assessment in Sweden
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International Journal of Technology Assessment in Health Care, 25:Supplement 1 (2009), 42–52. Copyright c 2009 Cambridge University Press. Printed in the U.S.A. doi:10.1017/S0266462309090412 History of health technology assessment in Sweden Egon Jonsson University of Alberta and University of Calgary and Institute of Health Economics HISTORY OF HTA IN SWEDEN continued demands to the Parliament for increased local au- thority and decision making, the government created locally Environment for Healthcare Assessments elected governing bodies in each of the twenty-five regions in Sweden and cities. The main responsibility for the operation of health Sweden has a long history of using data as a basis to form care was handed over to these newly formed County Councils policies in many sectors of society. The very first docu- in 1864. The Councils were later allowed to levy taxes locally mented efforts to collect data and use some kind of evi- to pay for health care in their region (1). dence to judge health care began 350 years ago in Sweden. Nevertheless, the Government maintained substantial In 1663, the Swedish Collegium Medicorum (re-named Col- supervisory and monitoring control of health care by merg- legium Medicum in 1688) was established; initially to dis- ing the Collegium and a few other departments into a full- tinguish quackery from medicine, to develop a pharma- scale agency in 1878, named the National Board of Health copoeia, to control the trade of poisonous drugs, and banish (Medicinalstyrelsen). It was given strong authority, including all swindlers who “grease people with their fake, fraudulent, all mandates of the former Collegium, (e.g., examinations and harmful medicaments”(12;20;25;26). and the supervision of all healthcare workers in medicine, Eventually, the Collegium came to act on disciplinary pharmacy, dentistry, nursing, and midwifery). It also mon- issues, monitor the work of doctors, midwifes, and pharma- itored vaccination programs, forensic medicine, veterinary cists, influence the education and examination of doctors, and medicine, hospitals, and other institutions for somatic and represent state interests in the health of the population. The mental health care, and all health care for personnel in the Collegium required yearly reports from district physicians, army and navy. This agency also became the supervising “who described the disease profiles of local areas, the level body for the medical schools and the county councils. It kept of medical treatment and drug therapy available, as well as numerous types of records containing data of importance for the lifestyles of the population; nutrition, housing conditions, analyzing how the health services might be improved. levels of alcoholism and literacy...”, including information In 1912, the parliament passed legislation on another on treatments provided, along with crude outcome measures agency, the National Board of Social Affairs, to coordinate such as “improved” or “deceased” (20). new and existing social issues that several different ministries In 1813, the Collegium became a department of the civil dealt with previously, for example, labor market regulations, service named The Royal Health Board (Sundhetsstyrelsen) inspections, health prevention for workers, social insurance, and had greater authority over the provision of health care. and care of the poor and vulnerable children. This agency However, from 1797 to 1876, the monitoring of hospitals was also mandated to initiate an effective temperance move- remained with an aristocratic institution named Serafimeror- ment in the country. During the 1930s and 1940s, many densgillet. emerging social issues were to become important areas for Important bodies in the state administration in Sweden the new agency: care centers, playschools, charity homes, were the County Administrative Boards (Lansstyrelser), es- and summer camps for children. A specific problem that the tablished in 1634, in twenty-five regions and some major agency had to address was housing for the great number of cities across the country. Initially, their most important tasks refugees that entered the country during the Second World were to maintain law and order and to see to it that taxes War. Later, it had to take on many more responsibilities, such were raised appropriately. There were, however, no locally as the administration of government subsidies for students based institutions that could balance these state bureaucra- in higher education, mandatory pension funds, care of the cies’ influence on issues regarded as domestic. As a result of elderly, long-term care, and social services at home. 42 Downloaded from https://www.cambridge.org/core. IP address: 170.106.33.19, on 29 Sep 2021 at 15:18:44, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0266462309090412 HTA in Sweden In 1958, the supervision of medical and social welfare scientific knowledge and good experience.” Teams of se- services were unified by merging the medical and social lected experts were consulted on technology-related matters boards into a single agency, the National Board of Health and of particular relevance to regional hospitals in the country. Welfare (NBHW), currently the major agency for healthcare The assessments were based on findings from clinical re- services in Sweden. A few years earlier (1955), the national search. Using these findings and other data, for example, health insurance program that the parliament had legislated demographics and current disease panoramas, the NBHW in 1945 was put into effect. An important reform to control calculated and projected healthcare needs. In a relatively the diffusion of expensive and sophisticated technology was transparent manner, the teams presented their reasoning be- put in place in 1958 when highly specialized services were hind what they believed would be the appropriate level of use regionalized into seven regions. Each region would have a of these technological innovations. As a rule, these assess- regional hospital with the capacity to address rare and com- ments did not focus on any individual technology, but usually plicated cases of disease and trauma. These regional hos- covered a whole spectrum of technologies necessary to deal pitals would, in principle, be the first to be equipped with effectively with the need, for instance in radiation therapy, modern, capital-intensive medical technology, for example, thoracic surgery, neurosurgery, and specialized cardiac care. transplantation services and burn care. In 1968, the government and the county councils estab- Sweden’s long history of agencies and institutions in lished an independent agency named the Swedish Planning health care naturally included some forms of assessment and Rationalization Institute for the Health Services, (Spri). of health practices, procedures, programs, and technologies. Spri was mandated to address the effectiveness of health ser- Those were certainly not as rigorous, systematic, widespread, vices in the broadest possible sense. Spri’s program initially and common as the ones in place today. The basic tools of included issues of architectural design of hospitals, ventila- health technology assessment (HTA) were simply not avail- tion and other engineering issues concerning hospital build- able until much later. Databases of scientific studies first ings, ambulance equipment, classifications, staffing analyses, became available in the late 1960s, and personal computers and organization of services. However, as the agency quickly and the Internet were not available until the 1980s and 1990s. expanded, it soon entered many other fields of health care, A brief overview of the current Swedish healthcare sys- for example, health planning, assessment of medical technol- tem is available at http://www.sweden.se/eng/Home/Work- ogy, development of guidelines, cost-effectiveness analyses, live/Society-welfare/Health-care/Facts/Swedish-health-care/ and analyses of variation in health practices. The institute (26). often worked in close collaboration with the NBHW, the Federation of Swedish County Councils, the Swedish Med- ical Association, and eventually with the Medical Research Development of HTA in Sweden During the Council of Sweden. In 1974, researchers at Spri performed 1970s to Mid-1980s one of the first assessments of the computed tomography Although the history of HTA in Sweden is strongly linked to (CT) scanner (14) and later collaborated on that subject with the establishment of a national agency in 1987, the Swedish Barbara McNiel, a radiologist at Harvard University, who Council on Technology Assessment in Health Care (com- was a very strong proponent for HTA in the United States. monly known by its Swedish acronym SBU), other initia- In 1975, the NBHW, in collaboration with the Swedish tives, organizations, and institutions historically played an Society of Medicine, began to establish national quality regis- important role in the development of HTA in Sweden. ters for certain procedures. A cancer registry had been estab- Several actions were taken toward assessing health prac- lished already in 1958. These registries, now approximately tices and procedures long before formal systematic reviews, fifty in total, have become important tools for measuring evidence-based medicine (EBM), and HTA became estab- both technical capabilities and patient outcomes, including lished concepts in the country. Most agencies and institu- health-related quality of life,