The Scandinavian health care systems, despite a much higher de gree of organization and rationalization than is found in the United States, still have significant problems. The large public investment in social welfare has led to a tax structure characterized by high rates and a very progressive formula. This, in turn, has lessened incentives for earning higher incomes on the part of professionals, including physicians, to the point where demands for fringe benefits have almost entirely replaced demands for higher incomes as the prime goal of negotiations between physicians and the government. Shorter work weeks and longer vacations have been one of the most sought-after i benefits. This is particularly true in Sweden. Consequently, serious shortages of physicians exist, particularly in the major cities, during holiday periods, at night and on weekends. Year-round manpower shortages are still acute, particularly in rural areas. Sweden has proposed to double its output of physicians during the next ten (10) years, in order to cope with its manpower shortages. All of the Scandinavian countries continue to be net importers of medical personnel, sending students to other European countries for training. Inadequacies in the provision of health services in the public sector exist. In Finland, for example, the public sector is extensively sup plemented by the private, notably in urban areas. In Helsinki, 30 to 40 percent of all outpatient visits are in the private sector, even though only about 6 percent of all physicians in Helsinki are in private practice exclusively. Almost all hospital based physicians practice privately in order to supplement their salaried positions. An active market for private medical services continues to exist and expand. particularly for outpatient diagnostic services. The Scandinavian countries consider health care to be a right of the individual and an obligation of society to the individual. An article describing the Finnish health care system by Dr. A. S. Haro, of the Finnish Board of Medicine, is included and accurately reflects the prevalent attitude toward government involvement in the provision of health services in Scandinavia. Arrangements for the provision of medical care, rooted at a local or regional level and supervised and subsidized by the state govern ment, exist in all of the Scandinavian countries. This basic element has clearly shaped the approaches to health care in all of the coun tries the Subcommittee visited. No disagreement exists on the basic premise that health care is an obligation of society to the individual. Debate centers around the mechanisms for delivering services, rather than on whether or not services should be provided at all, as is the case in the United States. Disagreement exists concerning the channels through which state funds should flow. One example is in payment to physicians. There are advocates of full time salaried physicians, thos of direct reimbursement of physicians on a fee for service system by the government, and those of reimbursement of patients for the cost of outpatient physician services. In general, the range of debate in Scandinavia is much narrower than is that in the United States. Where we in this country have only recently squarely faced the issue of health care as a right of all people (an issue which has by no means been resolved) the Scandinavians settled this issue concerning health care and other social benefits long ago. While the Scandinavians are in the process of tuning up their health care machine, Americans are still attempting to decide which type of machine to select. The report section dealing with Scandinavia is organized into two parts. The first section highlights characteristics of the health care systems in each of the four countries visited which were thought to be particularly noteworthy in comparison with analagous characteristics in the United States. The second part (the six Appendices) contains a brief Subcommittee. itinerary, as well as more extensive descriptions of the health services systems in each of the countries which were visited. A special acknowledgement is owed the chief health officers in each country: Dr. Esther Amundsen of Denmark. Dr. Karl Evang of Norway. Dr. Bror Rexed of Sweden. Particular thanks should go to Dr. S. Ake Lindgren of Sweden and Dr. Inge Jespersen of Denmark for valuable assistance to the Subcommittee staff in arranging the itinerary, and to Dr. A. S. Haroof Finland for contributing an excellent description of some aspects of the Finnish health care system to the body of the report. HEALTH CARE IN SWEDEN HOSPITAL SERVICES Equity in the delivery of health services has for many years been a basic principle, deeply ingrained in Scandinavian culture. In Sweden, as in the other Scandinavian countries, attempts to achieve equity in health as well as other social services have taken the form of emphasis on public responsibility for the provision of specified services. Since the middle of the last century, the Swedish county councils have had responsibility for providing hospital beds and other medical services for the residents of that county. In order to do that, the county councils, bodies which are democratically elected, have been given the right to raise taxes. In addition, they have the responsibility for planning and organizing health services within the county, subject to the approval of the national planning body. In 1928, the New Hospital Act was passed by the Swedish parliament. Legislation which explicitly spelled out the obligations of the county councils in the provision of institutional care was enacted for the first time. There is an extensive and highly developed regionalized hospital system in Sweden. For many years, Swedish hospitals have been the responsibility of the Swedish Counties. Hospital care is financed largely through taxes, and almost entirely in the public sector. Each county is responsible for the provision of a minimum number of hospital beds, and the services which accompany those beds. The provision of medical services is by far the overriding function of the counties. They have the responsibility for planning, organizing, financing and operating hospital and other medical services. The counties are able to raise money to finance services in a number of ways. The great bulk of their income, however, comes from taxation. Of their total income, 71 percent comes from taxes, 14 percent from state contributions, 11 percent from fees, 1 percent from interest and the remaining 3 percent from various sources. There are twenty-three counties in Sweden. In addition, the cities of Gothenburg and Malmo are responsible for providing medical care. The Karolinska hospital is a state operated hospital, also deriving some of its income from the county and municipality of Stockholm. Since 1967, the counties have been responsible for the operation of mental hospitals. The great bulk of the hospitals in Sweden, therefore, are owned and operated by the counties. The counties have an average population of about 255,000. The largest county has a population of 650,000. Each county has at least one central general hospital, with 500-800 beds. The central hospital serves as a local hospital for the area in which it is located, but also as a referral hospital for the entire county. There may, in addition, be several smaller, local hospitals in the county. In some rural areas, 71-413 O 73 - 29 cottage hospitals also exist. Each hospital has an outpatient depart ment, which provides some of the outpatient services for that area. Each county, therefore, has a highly coordinated and integrated system of hospitals of various types. In addition, several counties may cooperate in supporting a major referral center, called a regional hos pital. Seven such regional hospitals exist in Sweden, six of them university hospitals. Each region has a population of approximately 1,000,000. In addition to the services provided at district and central hospitals, regional hospitals may provide additional services in spe cialty areas such as neurology, neurosurgery, thoracic surgery, and plastic surgery. For historical reasons, having to do with the role of the counties in providing hospital beds, Sweden's medical care system is strongly hospital oriented. Sweden has a large number of hospital beds for its population and a long average length of stay by American stand ards. The Swedes recognize this situation as a defect in their medical care system, and are making attempts to remedy the situation. One area of control is in the construction of new hospital facilities. Any new hospital construction which takes place in Sweden is subject to the review of the national organization for research in health services (SPRI) and to the approval of a special national board. This has proven to be an effective device for rationalizing the distribution of hospitals and other expensive medical facilities geographically. In this way, resources can be directed to the areas of greatest need as determined by the national board. MEDICAL CARE OUTSIDE THE HOSPITAL District Medical Officers Approximately 1,000 district medical officers are employed by the counties in Sweden. In addition to duties in the area of public health, these medical officers function as private practitioners. Many rural areas, which don't have other general practitioners have a district medical officer. They practice either in a hospital polyclinic (outpatient department) or in free standing health centers owned by the county. Even the practitioners practicing in the health stations work closely with the specialists on the staff of the district or central hospitals. Private Practice Although there are estimated to be a fairly large number of private practitioners in Sweden, only two are located in Norbotten, tx northernmost county occupying the northern quarter of Sweden. Most are found in urban areas. Eighty-five percent of Swedish doctors are employed by the government, and a definite movement to diminish private practice is underway. Whereas the hospitals and district health officers receive their salaries from funds derived primarily from general revenues or other tax-based income, the large majority outpatient services are finnaced through the Swedish national health insurance. Twenty-five percent of all outpatient services are rendered by private practitioners. Essentially no inpatient services are delivers by private practitioners. |