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Learning from Sweden's Health Care System

The Commonwealth Fund has consistently ranked Sweden’s universal health care system above Canada’s. 

In fact, their last two international health care studies found that Sweden spends about the same on health care as Canada (as a % of GDP), but yet they deliver better results. (For their 2017 study, click here and click here for the 2021 study).

Like Canada, the Swedish system covers all citizens. We wondered – how are they able to provide better care?

With that in mind, SecondStreet.org travelled to Sweden in May of 2023 to learn more.

After speaking with several experts in Stockholm, we learned about some key differences between their system and the Canadian model.

Collaborative Approach With The Private Sector

As noted in our short documentary, Fixing Canada’s Health Care: Lessons from Sweden (see above to watch), Sweden takes a more collaborative approach with the private sector. 

The Swedes seem to put patients, not ideology, at the centre of their health care system. The Swedish government will deliver services through private facilities or government-run hospitals. It also doesn’t matter if a health care facility uses unionized or non-unionized staff. Again, the care provided to patients is what matters most.

Consider what the Economist magazine noted in 2013:

“Sweden has gone further than any other European country in embracing the purchaser-provider split—that is, in using government money to buy public services from whichever providers, public or private, offer the best combination of price and quality.” 

This differs from Canada where many activists and politicians will criticize the very mention of exploring whether or not a private provider might be able to deliver high-quality surgery and diagnostic scans to patients.

Across Canada, family doctors’ offices are private businesses. Many provinces also hire, at least on a limited basis, private clinics to provide elective surgery to patients in the public system. In Saskatchewan, surgeries performed in private facilities are estimated to cost between 26-45% less than government-run hospitals. In Ontario, the province’s Auditor General found that private clinics provided surgeries anywhere from 20-40% less than in government-run hospitals. Many other provinces have also proven that these relationships can work quite well – same quality of services, lower cost. 

Despite these examples of success, hiring private clinics to provide more services regularly turns into an ideological debate instead of questioning whether or not it could help patients. 

For instance, during the last Alberta election, the very idea of private hospitals became a divisive issue. Similarly, the “Ontario Health Coalition” has been vocal in opposition to the government partnering with more private clinics to provide surgeries to patients in the public system. There were no proposals with actual analysis presented, the activists were just opposed to the government even considering the idea.

In Sweden, their system goes farther than Canada when it comes to partnering with the private sector.

Perhaps the best example of Sweden’s willingness to partner with private companies is the St. Göran hospital – a government-owned hospital that is funded by the government but managed by the private firm Capio. This relationship has been praised by several observers and organizations, including the Montreal Economic Institute, the Economist magazine and the British government to name a few. 

The hospital’s CEO indicated that services provided by the hospital cost the government approximately 30% less than what the same services cost at nearby government-run hospitals. Gustaf Drougge, a health care expert who founded the Swedish think tank Synaps, estimated the savings were a bit lower, telling SecondStreet.org they were in the 15-20% range. Either way, it’s a positive story if quality health care is being delivered for a significantly lower cost – the savings ultimately mean there are more dollars available to help patients.

The Commonwealth Fund describes Sweden’s overall hospitals situation:

“There are seven university hospitals, all public, and about 70 public community hospitals owned by the regions. There are also six private hospitals, of which three are not-for-profit. Private hospitals include emergency, orthopedic, and surgery centers. All hospital staff are salaried employees.”

But it’s not just surgery and hospitals where Sweden collaborates with the private sector.

SecondStreet.org spoke with Kalle Conneryd Lundgren, the Chief Operating Officer of Kry, a Sweden-based digital health care provider. Their digital tool allows patients to connect with nurses, doctors, psychologists and other health care staff through videoconferencing. Alternatively, patients can visit one of their health care centres for an in-person appointment.

The company’s rates are quite reasonable. For example, in the Stockholm area, those 19 and under, and patients over 85, do not have to pay to meet with health care staff online. Those in the 20-84 age range pay nothing to speak with a nurse, but pay about 100 SEK ($12.38 CAD) to speak with a doctor or psychologist. At the same time, Kry bills the government for each patient visit. This is similar to how your family doctor’s office bills the government after your visit. 

Canada also has digital health tools such as Telus Health, Maple and MyCare, but the relationship with the government is quite different. Ottawa has actually cut back funding to provincial governments because it takes exception to these companies charging patients for appointments. 

It was interesting to hear Lundgren explain how his tool is saving the Swedish health care system a significant amount of money. The reason is that by treating patients virtually, Kry is preventing some of these patients from visiting an emergency room – a service that costs the government “hundreds” of dollars per visit. Conversely, his firm will bill the government “$30 or so.”

Accountability

Sweden provides its citizens with a “healthcare guarantee”.

In short, health regions must provide patients with timely health care or pay for the patient to receive the care in another region.

Consider the guarantee by service:
Assessment by a physician: 3 days
Appointment with a specialist: 90 days
Treatment: 90 days

In total, if you need, say, a hip operation, the Swedish system makes it very hard for health regions to string patients along for a year, two years or longer (like we see in Canada). The guarantee aims for a maximum of six months.

Private Choice

Finally, Swedish patients have the right to choose outside of the public system. If they don’t want to wait upwards of, say, six months for the public system to provide treatment, they can always pay for private insurance.

According to the Commonwealth Fund, approximately 13% of employed people in Sweden have private insurance. What this does is help take pressure off of the public system, while giving Swedes more choice and helping to drive innovation at the same time.

Preventative Care

Each year in Canada, provincial governments spend billions of dollars treating patients with entirely preventable diseases and health problems – some cases of diabetes, cancer, heart disease and more.

Conversely, Sweden is seen as a leader in Europe when it comes to preventative health care and has some interesting policies in place.

In particular, they have an interesting approach to encourage healthy living known as physical activity on prescription – “PAP”.

In short, if a patient could benefit from exercise, Swedish health officials will offer assistance with developing an exercise plan based on the patient’s lifestyle and interests. This plan is then given to the patient in the form of a printed prescription. Follow-up appointments are then conducted to help encourage participants or make any adjustments.

We describe this policy further in our preventative health care policy brief. The same brief also examines a Swedish policy that encourages healthier living by allowing employees to receive tax free wellness benefits from their employers. 

To learn more about Sweden’s Physical Activity on Prescription policy, see the short clip below or view this interview with Dr. Mats Borjesson from Sweden.

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Prevention – reduce demand in the first place

If Canadians lived healthier lives, we could reduce demand for emergency services, orthopaedic surgeries, primary care and more. 

For instance, if you visit the Canadian Cancer Society’s website, you’ll read that “about four in ten” cancer cases are preventable. The Heart and Stroke Foundation notes that “almost 80 percent of premature heart disease and stroke can be prevented through healthy behaviours.” A similar number of Diabetes cases are also preventable. 

Many joint replacements and visits to ERs and walk-in clinics could also be avoided through healthy living. 

To be sure, not all health problems can be avoided through healthy living – everyday the system treats Canadians with genetic conditions, helps those injured in unavoidable accidents and more.  

But there is an opportunity to reduce pressure on the health care system through Canadians shifting to healthier lifestyles – better diets, more exercise, etc. 

To learn more, watch our Health Reform Now documentary (scroll up) or see this column. 

Partner with non-profits and for-profit clinics

European countries will partner with anyone who can help patients. 

It doesn’t matter if it’s a non-profit, a government entity or a private clinic. What matters is that patients receive quality treatment, in a timely manner and for a competitive price.  

In Canada, governments often delivery services using government-run hospitals instead of seeing if non-profit or private clinics could deliver the services more effectively. 

When governments have partnered with non-profit and private clinics, the results have often been quite good – Saskatchewan, Ontario and British Columbia are just a few examples of where partnerships have worked well. 

Canada should pursue more of these partnerships to reduce wait times and increase the volume of services provided to patients.  

To learn more, watch our Health Reform Now documentary (scroll up) or see the links above. 

Make cross border care more accessible

In Canada, citizens pay high taxes each year and we’re promised universal health care services in return. The problem is, wait times are often extremely long in our health system – sometimes patients have to wait years to see a specialist or receive surgery. 

If patients don’t want to wait long periods, they often have to reach into their own pocket and pay for treatment outside the province or country. 

Throughout the European Union, we also find universal health care systems. But a key difference is that EU patients have the right to go to other EU countries, pay for surgery and then be reimbursed by their home government. Reimbursements cover up to what the patient’s home government would have spent to provide the treatment locally. 

If Canada copied this approach, a patient waiting a year to get their hip operation could instead receive treatment next week in one of thousands of surgical clinics throughout the developed world. 

Governments benefit too as the patient is now back on their feet and avoiding complications that sometimes come with long wait times – meaning the government doesn’t have to treat those complications on top of the initial health problem. 

To learn more, watch our Health Reform Now documentary (scroll up) or this shorter video. 

Legalize access to non-government providers

Canada is the only country in the world that puts up barriers, or outright bans patients from paying for health services locally. 

For instance, a patient in Toronto cannot pay for a hip operation at a private clinic in Toronto. Their only option is to wait for the government to eventually provide treatment or leave the province and pay elsewhere. 

Countries with better-performing universal health care systems do not have such bans. They allow patients a choice – use the public system or pay privately for treatment. Sweden, France, Australia and more – they all allow choice. 

Why? One reason is that allowing choice means some patients will decide to pay privately. This takes pressure off the public system. For instance, in Sweden, 87% of patients use the public system, but 13% purchase private health insurance. 

Ultimately, more choice improves access for patients. 

To learn more, watch our Health Reform Now documentary (scroll up) or watch this short clip on this topic. 

Shift to funding services for patients, not bureaucracies

In Canada, most hospitals receive a cheque from the government each year and are then asked to do their best to help patients. This approach is known as “block funding”. 

Under this model, a patient walking in the door represents a drain on the hospital’s budget. Over the course of a year, hospital administrators have to make sure the budget stretches out so services are rationed. This is why you might have to wait until next year or the year after for a hip operation, knee operation, etc. 

In better-performing universal health systems, they take the opposite approach – hospitals receive money from the government each time they help a patient. If a hospital completes a knee operation, it might receive, say, $10,000. If it completes a knee operation on another patient, it receives another $10,000. 

This model incentivizes hospitals to help more patients – to help more patients with knee operations, cataract surgery, etc. This approach also incentivizes hospitals to spend money on expenses that help patients (e.g. more doctors, nurses, equipment, etc.) rather than using the money on expenses that don’t help patients (e.g. more admin staff). 

To learn more about this policy option, please watch our Health Reform Now documentary (scroll up) or see this post by MEI.