1. A mixed model of public and private
involvement in development of
primary care – experiences from
Sweden
Nuffield Trust European Health Summit
January 28 – 29, 2013
Johan Calltorp MD PhD, Co-director The Swedish Forum on Health Policy
Karin Träff Nordström MD, Chair of the Swedish College of Primary Care
Practitioners, Manager Brahehälsan

2. Traditional features of the Swedish
health system
• Traditionally public regarding financing, delivery and control
• 21 county councils (directly elected political bodies) responsible for
totality of health care in the respective area
• Salaried physicians since 1970
• A focus on hospital care, since 1960´s – most of specialized outpatient
care delivered at hospitals
• Social services + ”non-medical” care for the elderly delivered by
municipalities (190 in Sweden)
• Traditional ”private care” = ca 1000 physicians on a tightly controlled fee-
schedule (primary care and the main out-patient specialities)
• One of the acute hospitals (St Görans in Stockholm County council) run by
a private company (Capio) since ca 10 years)
• The number of private health care insurances quite stable, ca 500.000
policies sold

4. Cost containment, restructuring of
inpatient services
• Overall costs of the system on a stable fraction
of GDP, ca 9,3 - 9,7 % for more than 20 years
• The early 1990´s economic crisis triggered a
program of hard cost containment and
structural rearrangements within the hospital
sector (closures, mergers, some care process
development)
• Increased ”pressure” has been developed
within the whole system

5. Primary care over time
• Until 1950´s a strong and traditional GP-led and
public health focused primary care system
(governmental run)
• 1972 this was integrated into the County Council
structure. GPs salaried. Organisation in primary care
centers often jointly with social services,
geographical area responsibility
• A number of reform efforts to strenghten primary
care over the years
• Still ca 10 % of resources, 15 % of medical workforce
• Function varies greatly over the country

6. A political agenda of ”privatization and
renewal” since 2006
• Since 2006 a liberal coalition government of 4 parties
– ”securing the welfare state” and innovate public
sector
• Abandoned the ”ban on for profit health delivery”.
County councils may contract with all types of private
providers
• 50 % of state owned pharmacies sold to private
owners, competition model
• Public private partnership in building the new
Karolinska Hospital in Stockholm

7. The new public/private primary care
system (Vårdval – choice of care)
• Mandatory system for County councils to arrange since 2010:
- A possibility for citizens to choose primary care provider
within a public announced and accepted number
- A possibility for organisations/companies to register as
primary care providers, given some basic criteria –
requirements on competencies, range of services, financial
conditions
- A capitation formula (basic + specific visit payments) – models
vary much between the county councils
- Some County Councils have more elaborate models that pick
up quality measures, linking to population goals, access and
low number of hospital ambulatory visits

8. Observations so far
• Access to primary care increased
• Satisfaction amongst the public has increased
• No data on improvement on medical quality
• Lower socio-economic groups have increased use more than higher
(Stockholm). The socio-economic divide much discussed
• A considerable number of new practices established
• 30 - 40 % of primary care (nationwide) is delivered by private companies
• Arrangements have favoured bigger companies to establish
• 15 – 20 % of primary care is now delivered by companies owned by
international for profit capital (3 major chains nationally)
• One national (physician owned) chain Praktikertjänst that in the 1960´s
pioneered out-patient services in new forms
• Very few volountary, not for profit organisations active – but some
• To some extent new care models has been developed, but not strikingly many
• There is a sense of ”released power” and an ”innovation climate”
• Opinions among GPs quite mixed

9. Observations so far
• Access to primary care increased
• Satisfaction among the public has increased
• No data on improvement of medical quality
• Lower socio-economic groups have increased use of services more than higher
(Stockholm). The socio-economic divide much discussed
• A considerable number of new practices established
• 50 % of primary care is delivered by private companies
• Arrangemets has favoured bigger companies to establish
• 15 – 20 % of primary care is now delivered by companies owned by
international for profit capital (3 major chains nationally)
• One national ( physician owned ) chain Praktikertjänst active that in the
1960´s pioneered out-patient services
• Very few volountary, not for profit organizations active – but some
• To some extent new care models developed, but not strikingly many new
• There is a sense of ”released power” and ”innovation climate”
• Opinions among GPs quite mixed