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to medical personnel and patients at all levels, from the general practitioner, who is the District Medical Officer, to specialists at the huge Sahlgrenska Hospital. What follows is an account of what I found, based on visits, observations, conversations and on material written by Swedes most involved in health care.

HISTORICAL BACKGROUND

To gain some perspective about Swedish medical care a brief look at Sweden and Swedish social and medical development will be helpful. Sweden stretches almost 1000 miles from the flat farmland near Malmo at its southern tip to the rugged mountains and lakes of Lappland to the north, above the Arctic Circle. It is slightly larger than California in area, and provides land for over eight million Swedes. The largest city is Stockholm the capital. Goteborg, Sweden's second city has a population of 647,000. Swedish institutions are old: its Parliament goes back to 1435 and its first university, Uppsala, was founded in 1477. Its first hospital, the Seraphimer in Stockholm, was founded in 1752.

After four hundred years of warfare, peace came to Scandanavia in 1815 and has persisted since then.

In the second half of the nineteenth century the Industrial Revolution gradually changed Sweden from a predominantly agricultural to an industrial nation. Swedes left their farms and flocked to the city factories. Resources of iron ore, forests and water power combined with technological skill have created a prosperous economy in the mid-twentieth century, and helped to erase the poverty of the early parts of this century. The labor

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setbacks, labor strength grew at the polls; the labor backed SocialDemocrat Party has been in power in Sweden continuously since 1932 and received a plurality again in the 1970 elections, when Prime Minister Olok Palme was re-elected.

The Swedish economy is mixed. There is government ownership of railroads, iron mines and TV stations, but private ownership of most factories and retail stores. Medicine, as we shall see, is mostly under government control and financing.

Thus, these characteristics of Sweden--a homogenous people, a long tradition of culture and government, over 150 years of peace, a prosperous mixed industrial economy and forty years of socialist political dominance. form the important background for understanding Sweden's unique developments in social welfare and medical care.

DEVELOPMENT OF MEDICAL CARE: SOCIAL INSURANCE

As Sweden emerged from a poor agricultural economy to a more prosperous industrial economy in the earlier parts of the twentieth century, many workers retained memories of their personal experiences of poverty, unemplovment and insecurity of their youth. These workers formed the main support for the Social-Democratic Party, whose main goal in its forty years of nower has been enacting public measures to protect all Swedes against threats of insecurity and illness.3 Sweden's National Social Insurance, financed by taxes and compulsory insurance fees, covers every aspect of Swedish life from maternity benefits and child health care to sickness,

unemployment

The emphasis

and disability insurance to old age pensions at age 67.4,5 in social welfare has changed from the turn of the century concept of "helping people to help themselves" to the gradual assumption by the rublic

sector of the responsibility for organizing and to a large extent financing the system offering insurance against sickness, disability and old age.

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Before 1955 voluntary health insurance existed in Sweden but this was felt to be insufficient, because the people who needed care the most were "poor risks" and were not covered at all and the cash benefits the insured received for sickness were felt to be inadequate. In 1955 the Swedish National Health Insurance created national compulsory tax health insurance and in 1963 health insurance was combined with various pensions into a National Social Insurance Act.

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financed

Now the Health Insurance part of the National Social Insurance provides for all Swedes:

1. Hospital care: total coverage for care at government hospitals for unlimited periods, including room charges, the attendance of staff doctors, surgery, lab and x-ray charges and all drugs. Hospitals are financed and run by the County Councils.

2. Sickness benefits: for wage earners, proportional to their salary levels. (See Fig. 1) For example, a man who earns 30,000 S Kr. (Swedish crowns), about $6,000 yearly, would pay a yearly supplemental tax for Sickness Insurance fee of about $100 and would receive 43 S Kr. (about $8.60) a day in sickness benefits for a period up to two years, after which time he would be given a disability pension. Most companies, however, subtract the amount of government sickness benefits from whatever salary the sick employee continues to receive.

3. Ambulatory Care: partial reimbursement of doctors' fees, drugs, and the patient's traveling expenses. In January, 1970 the "Seven Crown

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County Councils was introduced. In essence, the patient now pays the first seven crowns (about $1.40) himself for each out-patient visit. The County Council will be reimbursed 31 crowns (about $6.20) from the Social Insurance. The Seven Crown Reform also directly affected patients choice of doctors and doctors salary levels, the implications of which will be discussed in more detail later.

4. Maternity and child benefits: include complete coverage for prenatal care, delivery by midwives in a hospital, infant care at Child Welfare Centers, cash grants of $180 a year for each child and school medical care for children.

The outstanding feature of the Swedish Social Insurance scheme is that all Swedes have equal coverage and, hence, equal access to all types of medical care, independent of their salary level, social status or health condition. On the other side of the coin, complete insurance coverage which is compulsory is accompanied by high taxes and loss of individual choice in selecting health coverage plans.

COST

Sweden's expenditures for social welfare and health care comprise a large percentage of the total government expenses. In 1968-1969 social welfare expenses, including health care, were 28% of the total government expenses, versus 16% for education and only 14% for military expenses. Health costs were 1.4 billion dollars, which represented 5.5% of the Gross National Product. Health costs in Sweden increase at a rate of about

7% a year.

The Swedish system for health and social welfare is entirely tax

financed, and, because benefits are so comprehensive, tax rates are high.

For example, a married Swede earning $4,000 a year pays 41% in taxes, while

a $10,000 a year man pays 60% in taxes.

LEVELS OF MEDICAL CARE

The first priority of Swedish medical care planners usually starts with Sweden's excellent system of regional hospitals, and eventually encompasses out-patient facilities. However, from a patient's viewpoint medical care starts when he is first sick or injured and he seeks out primary (or first contact) medical care. If his illness is severe or he needs evaluation by a specialist, he is referred to an intermediate care facility, in Sweden either the Central Polyclinics or the Hospital "Open Wards," the out-patient clinics. If he needs more extensive diagnostic evaluation, medical treatment or surgery, he is admitted to the district hospital, which Swedes refer to as a "country hospital", even though it might be in a sizable city. If he requires more specialized diagnosis or treatment than the district hospital can provide, he is transferred to one of Sweden's seven regional hospitals.

I. PRIMARY MEDICAL CARE

The reason that the emphasis in Swedish medical planning has been on hospital care of patients is that Swedish planners have viewed hospital care as the most efficient way to utilize Sweden's small supply of doctors.8 However, there has been a dramatic increase in demand for primary medical care, so that now more importance in being placed on the care of out-patients 9

to relieve the pressures for hospitalization.` There was an increase in