COMPARATIVE HEALTH-CARE SYSTEMSon average than American men, and Swedish wom-
en live two years longer than their American coun-
terparts. These favorable statistical indicators com-
pel a closer look into how the Swedish health-care
system is organized.
The Swedish welfare state, including health-
care and social services, is one of the most compre-
hensive and universal in the world. Health-care in
Sweden is the responsibility of the state, which
delegates it, in turn, to each of Sweden’s twenty-
one county councils (Swedish Institute 1999). Elect-
ed officials in each county are charged with provid-
ing comprehensive health services for residents,
and with levying the taxes to finance them. The
system is decentralized; each county by law must
provide the same generous common core of serv-
ices to all residents, although just how they decide
to do it can vary. In the 1990s, Sweden embarked
on a series of reforms in order to increase health-
care quality and efficiency. As a result, Swedish
citizens now have greater freedom in choosing
their own primary care physicians. The vast ma-
jority of these doctors are employed by the county
councils to practice in small group clinics and
health centers distributed geographically through-
out the country. Specialist physicians practice in
hospitals where they also see outpatients on both a
referral and self-referral basis. The medical divi-
sion of labor also includes district nurses, physical
therapists, and midwives, all of whom are used
extensively to deliver care through local health
centers (maternity clinics in the case of midwives).
Midwives also work in hospitals where they have
responsibility for normal cases of labor and deliv-
ery. Sweden’s elderly constitute an increasing pro-
portion of the population, creating significant chal-
lenges for both current and future health and
social services. Sweden’s social policy emphasizes
that citizens should be able to live in their own
homes for as long as possible, meaning that nurs-
ing home placement occurs only when absolutely
necessary. Services for the elderly may involve as
many as five or six home nursing visits per day in
order for the disabled and elderly to remain at
home in the community.
Swedish citizens are taxed heavily to maintain
the quality and level of services they expect; at the
same time, they have shown high levels of political
support for maintaining their expensive system. In
the 1980s, many services were entirely free; howev-
er, today there typically is a modest copayment.
The copayment for a primary care physician visit,
for example, currently ranges from $12 to $17
depending on the county council. For specialist
physician visits the copayment ranges from $15 to
$31, and for hospital stays it is fixed at $10/day.
The Swedish system includes a high-cost ceiling so
that, after a person spends approximately $113
out-of-pocket each year, health-care services are
free. Medications must be purchased by the indi-
vidual until they have reached a threshold of a little
more than $100. Prescriptions are then discount-
ed until the patient has spent $225, at which point
medications become free (Swedish Institute 1999).
These amounts have increased somewhat during
the 1990s, but due to Swedens already high taxa-
tion rate, county councils were hesitant to ask
patients to pay more. Reforms during the same
period included establishing internal performance
incentives or ‘‘public competition’’ (Saltman and
Von Otter 1992), a structural arrangement that
arguably enabled Sweden to maintain the basic
features of its health-care system without large tax
or out-of-pocket increases. Some have expressed
concern that the system is stretched to its limits.
Regardless of which view is correct, the Swedish
system requires a healthy economy in order to
continue, given continuing cost pressures and an
increasingly aged population.
The Swedish model of a publicly owned and
financed health-care system shares common fea-
tures with systems in several other countries, in-
cluding the United Kingdom, Finland, and Cana-
da. The British National Health Service (NHS),
like its Swedish counterpart, provides publicly fund-
ed, comprehensive health-care to the population,
and enjoys a solid base of citizen support, albeit
under ongoing criticism. What distinguishes the
NHS from health-care systems in other Western
countries is its frugality. Characterized by long
waiting lists and what Klein (1998) refers to as
‘‘rationing by professionally defined need,’’ Brit-
ain runs the cheapest health-care system in Eu-
rope, outside of Spain and Portugal. In the early
1990s, the NHS went through a series of dramatic
changes, creating ‘‘internal markets,’’ a system of
inside competition intended to increase produc-
tivity and further decentralize its historically large
and unwieldy bureaucracy. These reforms—sever-
al of which were adopted by Sweden—reorgan-
ized primary care practices and shifted physician
payment from fixed salary to capitation. NHS