Sweden's plan for 2000 / by Marten Lagergren

Sweden's plan for 2000 A policy of 11 good health and health care on equal terms for the entire population 11 underlies HS 90-a special project which foresees the shape of the health services in the 1990s by Marten Lagergren weden is one of the few coun- tries in the world so far to have drawn up a detailed health strategy right up to the year 2000. Precisely with WHO's goal of Health for all in mind, the government brought into force a new Health and Medical Services Act on 1 January 1983, based on a policy of "good health and health care on equal terms for the entire population. " And the vehicle to bring about the aim of the Act is a special project called "HS 90-the Swedish Health Services in the 1990s." HS 90 has already produced a large number of reports on different aspects of health development. The points of departure and the guidelines pre- sented in these reports coincide with the strategic health policy drawn up by the Europeans Region of WHO. And the inain HS 90 survey-which dealt with health policies (preventive ef- forts), structure of the health care system, and staffing and education planning-formed the basis of a bill which was passed by the Parliament in Stockholm on 7 June last year. Within the context of HS 90, Swe- den's National Board of Health and Welfare has made quantitative esti- mates of the cost and manpower requirements which the proposed structural changes will call for. This cannot exactly be regarded as a na- tional plan, since one key factor of the health care system is its decentralisa- tion to regional authorities, which will Today's newborn child will be a teenager in the year 2000. Sweden's detailed health strategy is already looking ahead to that time. Photo WHO/E. Mandelmann WoRLD HEALTH, May 1986 have considerable autonomy in finan- cial matters. But the estimates at least give an indication of the new direction to be chosen and the likely demand for resources. Swedish health care is predomin- antly organized and financed by the public sector. Only five to six per cent is contributed by the private sector, and present planning rests on the assumption that this proportion will be retained. The new policy will devote a larger proportion of resources to preventing disease and injury; and it will em- phasis development and expansion of primary health care and encourage the active participation of all sectors of society in tracking down health hazards. The planners recognise that the shape of the future health care system must reflect the corresponding fea- tures of contemporary society, other- wise it will be out of tune and not capable of achieving its goals. It must therefore take note of the growing number of the elderly, especially the very old ; this is bound to increase the load on the health care system and reinforce the need for efficient coop- eration between the medical and the social sector. It must take into account the limited economic growth rate, as compared to the decades before the oil crisis, and changes in the employment situation. There will be fewer pos- sibilities for "informal" care in the social network due to the increasing participation of women in working life, greater numbers of people living alone, and more broken homes. Urbanisation and higher education- al levels, especially among the elderly, will lead to changing expectations and behaviour among patients, which in Health care in Sweden is already preparing to meet the special needs of the elderly, who will form an increasingly large proportion of society. Photo W HO/E. Mandelmann turn will call for altered roles on the part of professional care-takers. Tech- nological developments may create new opportunities but may also give rise to difficult ethical problems and an altered scale of priorities and changing attitudes and values-for in- stance, personal responsibility and freedom of choice with regard to medical treatment, the quality of life and even death-may easily come into conflict with professional values and interests. Consequently the HS 90 study en- visages a profound change in the struc- ture of the health system. This change 8 can be summarised as a general move- ment from specialised care in large central institutions to primary care and to health care in small local institu- tions, or the home . The total number of beds will only be reduced by 11 per cent, but this conceals a much more dramatic change in structure, since the number of psychiatric beds is sup- posed to decrease by 50 per cent and the number of beds in country hospi- tals (secondary and tertiary care) by 28 per cent. The number of visits to doctors in out-patient care, on the other hand, is planned to increase by 14 per cent. Even then, the average number of visits per inhabitant (3 . 7 by the year 2000) will be low compared to most European countries. Despite these reductions, the costs of the health care system will continue to rise, though at a far more modest rate than in the previous decades. This is, firstly, because the reduced number of beds will inevitably have the effect that the remaining patients will re- quire more intensive care during shor- ter lengths of stay; so the number of staff per bed must increase to cope with the more demanding pressure of work. Secondly, a dominant part of the costs consists of staff wages, and wages are bound to follow the general development of wages in society-that is, approximately the rate of economic growth. Health care represented 7.8 per cent of Sweden's gross national pro- duct in 1983, and will reach 8.0 per cent in the year 2000. Secondary and tertiary care (other than psychiatric), as a share of the total health budget, will drop from the 1983 figure of 60 per cent to 48 per cent in the year 2000; psychiatric care will fall from 17 per cent to 13 per cent; and prim- ary health care will rise from 23 per cent to 39 per cent. There will be a significant change in the composition of staff to meet the new demands-especially in out-pa- tient care. The number of doctors and fully-trained nurses will increase more rapidly than the rest of the staff. In 1983, doctors represented 4.9 per cent and nurses 21 per cent of the health personnel; in 2000, the figures will be 6.0 per cent and 24 per cent respec- tively. Auxiliary nurses will drop from 49 to 47 per cent, and technical and clerical staff from 25 to 23 per cent. The HS 90 plan represents a very serious effort to change the structure of the Swedish health care system into a shape that is more consistent with the new goals as indicated by WHO, and as expressed in the Swedish Health and Medical Services Act. De- centralisation means that the actual development of care will be to a large extent controlled by the regional au- thorities-the county councils. But these bodies have already shown a firm determination to pursue the agreed national policy. These changes are already getting under way, and their effect will be to ensure that health care in Sweden will indeed result in "good health and health care on equal terms for the entire popula- tion" in 14 years' time. • W oRLD HEALTH, May 1986