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SWEDEN
9
SWEDEN In a lengthy country with a small population distri bution of medical care is not easy, and in the followin, report Dr S. AKE LiNDGREN, assistant director genera and head of the planning department of the Nationa Board of Health and Welfare, sets out Sweden’s pro posals for coping with the problem. In principle the State has delegated local admini stration to the communes, which are held responsibl for such things as housing, urban development recreational facilities, education, social-welfare services and environmental hygiene. To enable it to fulfil thes, duties the commune is entitled to levy tax at proper tional rates with no upper limit. In addition it qualifie for State subsidies. The "county council" (or landsting) has rights o taxation and State subsidies similar to the commune It is the planning authority for both therapeutic ane prophylactic services which provides a basis for ! coordinated system of medical care. It is responsible for services both inside and outside medical institu tions, for general medical care, for specialised care tha requires more elaborate resources, and for highly specialised care concentrated in a few units throughou the country. The country’s medical-care areas are divided int( districts with one or more medical officers. The trenc is towards larger districts with two or more doctor: working together. The medical officer is concernec mainly with medical care and in the rural areas witr mother and child services. General practice has lately been recognised as a specialty. Medical officers numbe] about 1100, and private general practitioners about 1000.
Usually a district general hospital has at least three basic departments: internal medicine, general surgery and X-ray. Each county has at least one central hospital with perhaps as many as 15 specialised departments The county council arranges highly specialised service: in cooperation with seven health and medical-care regions. Each region has at least one well-equipped hospital which is not only a central general hospital but also a regional hospital. In all there are aboul 14,000 hospital beds staffed by some 9000 doctors and 25,000
nurses.
In 1970-71 687 medical students medical faculties are closely linked
graduated. The to the regional hospitals. Postgraduate training starts with a generalservice period in a subordinate status but with full professional responsibility. Doctors who wish to specialise go on to a residency lasting 4-52 years. County councils run schools of nursing, and occupational service schools for other hospital and medicalcare personnel. Medical care is financed mainly through county income-tax. The patient pays only a token fee at the time of illness. Allowances for expenses under the National Insurance Act cover not only payments made to a doctor or hospital, but also reimbursement for travel expenses and for pharmaceutical preparations. All Swedish citizens are insured under the National Insurance Act. A uniform tariff applies to the public ambulatory services, including X-rays and laboratory work. Social Insurance also pays the county council a
fee for each visit. At present, reimbursement of dent costs is limited, but next year a national dental in surance scheme will cover all citizens from the age c 17 for 50% of the fees for dental care. For youngster dental care will be free. Sickness benefit reimburse about 80% of income loss in the most common incom brackets. The total cost of social security in 1973 is estimates at 42,000 million Sw. kr., covering the national budge and the budgets of the communes and the count: councils. About 50%of the total amount of the welfari budget is covered by the national Government, and th remainder by the communes and county councils. Old age pensions, pension supplements, and support t disabled people will be increased in 1976, together witl resources for vocational and rehabilitational training and semi-protected employment. Decentralised am bulatory care will be extended to psychiatry and long. term care. The National Board of Health and Welfarc will receive more resources for health education or
food, physical exercise, drug-abuse, cigarette-smoking and contraception. National control of drugs will be
strengthened. Medical research in Sweden is organised mainly within the universities and receives funds through th< Board of Education. It may also apply for funds to the Medical Research Council. Inside the universitie; research is concentrated in independent units staffec by full-time workers who can follow their careers tc professorial level. (Perhaps as a result, Sweden of al Western countries "suffers" least from the brair drain.) These units are largely financed by the Medical Research Council, although they work within the context of the formal university structure. Th Medical Research Council also supports health-service research. Financial support of medical research in the universities amounts to about 150 million Sw. kr. a year. There is
an increasing awareness of the need tc medical care with social work. This policy integrate led to the transfer of functions in 1962 from the Ministry of the Interior to the Ministry of Social Affairs. The decisive principle for the Swedish medicalcare delivery system is to provide individual patients with optimal care at the right place and at the right time. Translating this principle into practice has meant concentrating acute medical care in the most appropriate hospitals and closing some small hospitals. The rapid development of the hospital services over the past decade has brought about an imbalance, and future development will concentrate on health centres linked to hospitals or independent and outside the hospital hierarchy. The hospital-linked centres will make it unnecessary to admit people as inpatients before they can be seen by specialists. X-ray and laboratory equipment will be used by both the hospitals and the health centres. The independent health centres will vary in accordance with the different needs of geographical areas. The minimum medical staff will probably be 3-5 physicians. The staff of the health centres will also include social workers, and it is hoped that the doctors working in these centres will have had training in social work and public health. People realise that, because of the progress of medicine, medical care can do more for them all the time,
10 But we are continuously asking for help. be aware of the effects of the increasing costs of medical care-there is after all a limit to taxation, particularly in such a highly taxed country as Sweden. Those who are responsible for organising medical care have therefore a duty to ensure that all possible means of rationalisation are implemented and savings made on scarce resources and on expenditure.
and they must
GHANA As a former director of Ghana’s medical service, Dr F. T. SAl surveys the medical scene in that country with an informed eye. His suggestions for the future reflect his sensible view that it is better to be content with achieving the possible rather than to regret failing in the impossible, and he reiterates his early and constant recognition of the unobtrusive merits of nutrition and health education for a developing country. Ghana has probably more expensive health services than most countries in Black Africa. At present a proportion-variously estimated as 30-40" o—is under
missions, private organisations, and agencies, but they have to follow governmental policies. The administration is completely centralised. There is a Minister of Health and below him the Director of Medical Services and a Principal Secretary; the Director of Medical Services has deputies for public health, for curative medicine, and for dental health. There is a unit for planning directly under the Director. The National Redemption Council has approved a new administrative arrangement whereby the Ministry of Health will have a Commissioner/Minister as overall political head and a Principal Secretary as administrative head; the health services are to be controlled from a separate Department of Health Services, headed by a Director-General of Health. Under the proposed administration the health services would be divided regionally, with each region headed by a regional health director who would be on a par with a deputy director of the health services and have direct access to the Director-General. The local authorities are at present unable to discharge even those elementary health activities which are in their care, such as environmental sanitation, registration of births and deaths, and supervision of local-authority clinics and midwifery units, and it seems necessary for the strongest possible regional authority to be set up and to supervise them. The hospitals include Government hospitals, hospitals under missions, mines, and industrial concerns, and a few private hospitals in the big towns. There are 112 general hospitals, and 3 central hospitals are supposed to have full specialist cover. The total number of hospital beds in 1970 was 9628, giving a bed/population ratio of 1/830. The distribution both of hospitals and of hospital beds favours the towns and the southern parts of the country. The 49 health centres have outpatient facilities, a
dispensary, and, usually,
a
maternity wing. They
are
intended to be referral points for the health posts. Each centre is supposed to care for 200,000 people, and each post for about 10,000-15,000. In fact, not more than 20 health posts were functioning by the end of 1971. Fortunately, local-authority dressing-stations and dispensaries and maternity clinics staffed by midwives take some of the load off the health posts. At the end of 1970 the country had about 667 doctors (and less than 50 dental surgeons); 339 of the doctors were non-Ghanaian and 369 were in Government service. 2768 midwives and nurses were in Government service and about 80 health-centre superintendents. These are senior nurses who act as auxiliaries to physicians. They have had one year’s training in elementary diagnosis and treatment of disease and the administration of a health centre. State-registered nurses are helped by enrolled nurses; and public-health nurses (only about 160 in all) by community-health nurses, and pharmacies by dispensing attendants. In 1964 the first medical school was established. Since 1969 it has turned out 30-40 doctors a year, and an annual capacity of 50 is expected. Training for State-registered nurses is centred in Accra and Kumasi, for pharmacists in Kumasi, and for auxiliary physicians in Kintampo; but there are training programmes for all levels of auxiliaries in many of the hospitals, both Government and missionary. As a general rule the major Government hospitals train the full professionals and other hospitals train the auxiliaries. In 1972-73 Ghana was supposed to be devoting the equivalent of about U.S. S18 million to health services, a per-caput expenditure of about$2. In actual buying power, this is probably less than the per-caput average over the previous three years. The money is derived from direct taxation. Mission hospitals have small Government grants and charge reasonable economic fees. The present Government has indicated that the scale of fees must be reduced, yet it cannot afford to increase its grants. All industries and commercial concerns employing over a hundred people are required by law to provide medical cover for their employees. A few have their own doctors and hospitals, but most use the Government resources. At present, Ghana has no single organisation for medical research, which is carried out in various hospitals and in the medical school. Most international support for research programmes vanished soon after independence; but some international assistance remains. The Danfa project, for instance, is supported through the United States Agency for International Development (A.I.D.) and is pursued in collaboration with the University of California in Los Angeles. Sicklecell work has been done in collaboration with Prof. Hermann Lehmann and his group in Cambridge. It is now hoped to form a Council for Scientific and Industrial Research. For over ten years medical leaders in Ghana have been advocating reorientation of the nation’s health services. The needs are: to control communicable diseases; to provide better antenatal, intranatal, and postnatal care; to provide care for the preschool child; and to provide better sanitation. A massive immunisation campaign should be mounted. All these services
SWEDEN In a lengthy country with a small population distri bution of medical care is not easy, and in the followin, report Dr S. AKE LiNDGREN, assistant director genera and head of the planning department of the Nationa Board of Health and Welfare, sets out Sweden’s pro posals for coping with the problem. In principle the State has delegated local admini stration to the communes, which are held responsibl for such things as housing, urban development recreational facilities, education, social-welfare services and environmental hygiene. To enable it to fulfil thes, duties the commune is entitled to levy tax at proper tional rates with no upper limit. In addition it qualifie for State subsidies. The "county council" (or landsting) has rights o taxation and State subsidies similar to the commune It is the planning authority for both therapeutic ane prophylactic services which provides a basis for ! coordinated system of medical care. It is responsible for services both inside and outside medical institu tions, for general medical care, for specialised care tha requires more elaborate resources, and for highly specialised care concentrated in a few units throughou the country. The country’s medical-care areas are divided int( districts with one or more medical officers. The trenc is towards larger districts with two or more doctor: working together. The medical officer is concernec mainly with medical care and in the rural areas witr mother and child services. General practice has lately been recognised as a specialty. Medical officers numbe] about 1100, and private general practitioners about 1000.
Usually a district general hospital has at least three basic departments: internal medicine, general surgery and X-ray. Each county has at least one central hospital with perhaps as many as 15 specialised departments The county council arranges highly specialised service: in cooperation with seven health and medical-care regions. Each region has at least one well-equipped hospital which is not only a central general hospital but also a regional hospital. In all there are aboul 14,000 hospital beds staffed by some 9000 doctors and 25,000
nurses.
In 1970-71 687 medical students medical faculties are closely linked
graduated. The to the regional hospitals. Postgraduate training starts with a generalservice period in a subordinate status but with full professional responsibility. Doctors who wish to specialise go on to a residency lasting 4-52 years. County councils run schools of nursing, and occupational service schools for other hospital and medicalcare personnel. Medical care is financed mainly through county income-tax. The patient pays only a token fee at the time of illness. Allowances for expenses under the National Insurance Act cover not only payments made to a doctor or hospital, but also reimbursement for travel expenses and for pharmaceutical preparations. All Swedish citizens are insured under the National Insurance Act. A uniform tariff applies to the public ambulatory services, including X-rays and laboratory work. Social Insurance also pays the county council a
fee for each visit. At present, reimbursement of dent costs is limited, but next year a national dental in surance scheme will cover all citizens from the age c 17 for 50% of the fees for dental care. For youngster dental care will be free. Sickness benefit reimburse about 80% of income loss in the most common incom brackets. The total cost of social security in 1973 is estimates at 42,000 million Sw. kr., covering the national budge and the budgets of the communes and the count: councils. About 50%of the total amount of the welfari budget is covered by the national Government, and th remainder by the communes and county councils. Old age pensions, pension supplements, and support t disabled people will be increased in 1976, together witl resources for vocational and rehabilitational training and semi-protected employment. Decentralised am bulatory care will be extended to psychiatry and long. term care. The National Board of Health and Welfarc will receive more resources for health education or
food, physical exercise, drug-abuse, cigarette-smoking and contraception. National control of drugs will be
strengthened. Medical research in Sweden is organised mainly within the universities and receives funds through th< Board of Education. It may also apply for funds to the Medical Research Council. Inside the universitie; research is concentrated in independent units staffec by full-time workers who can follow their careers tc professorial level. (Perhaps as a result, Sweden of al Western countries "suffers" least from the brair drain.) These units are largely financed by the Medical Research Council, although they work within the context of the formal university structure. Th Medical Research Council also supports health-service research. Financial support of medical research in the universities amounts to about 150 million Sw. kr. a year. There is
an increasing awareness of the need tc medical care with social work. This policy integrate led to the transfer of functions in 1962 from the Ministry of the Interior to the Ministry of Social Affairs. The decisive principle for the Swedish medicalcare delivery system is to provide individual patients with optimal care at the right place and at the right time. Translating this principle into practice has meant concentrating acute medical care in the most appropriate hospitals and closing some small hospitals. The rapid development of the hospital services over the past decade has brought about an imbalance, and future development will concentrate on health centres linked to hospitals or independent and outside the hospital hierarchy. The hospital-linked centres will make it unnecessary to admit people as inpatients before they can be seen by specialists. X-ray and laboratory equipment will be used by both the hospitals and the health centres. The independent health centres will vary in accordance with the different needs of geographical areas. The minimum medical staff will probably be 3-5 physicians. The staff of the health centres will also include social workers, and it is hoped that the doctors working in these centres will have had training in social work and public health. People realise that, because of the progress of medicine, medical care can do more for them all the time,
10 But we are continuously asking for help. be aware of the effects of the increasing costs of medical care-there is after all a limit to taxation, particularly in such a highly taxed country as Sweden. Those who are responsible for organising medical care have therefore a duty to ensure that all possible means of rationalisation are implemented and savings made on scarce resources and on expenditure.
and they must
GHANA As a former director of Ghana’s medical service, Dr F. T. SAl surveys the medical scene in that country with an informed eye. His suggestions for the future reflect his sensible view that it is better to be content with achieving the possible rather than to regret failing in the impossible, and he reiterates his early and constant recognition of the unobtrusive merits of nutrition and health education for a developing country. Ghana has probably more expensive health services than most countries in Black Africa. At present a proportion-variously estimated as 30-40" o—is under
missions, private organisations, and agencies, but they have to follow governmental policies. The administration is completely centralised. There is a Minister of Health and below him the Director of Medical Services and a Principal Secretary; the Director of Medical Services has deputies for public health, for curative medicine, and for dental health. There is a unit for planning directly under the Director. The National Redemption Council has approved a new administrative arrangement whereby the Ministry of Health will have a Commissioner/Minister as overall political head and a Principal Secretary as administrative head; the health services are to be controlled from a separate Department of Health Services, headed by a Director-General of Health. Under the proposed administration the health services would be divided regionally, with each region headed by a regional health director who would be on a par with a deputy director of the health services and have direct access to the Director-General. The local authorities are at present unable to discharge even those elementary health activities which are in their care, such as environmental sanitation, registration of births and deaths, and supervision of local-authority clinics and midwifery units, and it seems necessary for the strongest possible regional authority to be set up and to supervise them. The hospitals include Government hospitals, hospitals under missions, mines, and industrial concerns, and a few private hospitals in the big towns. There are 112 general hospitals, and 3 central hospitals are supposed to have full specialist cover. The total number of hospital beds in 1970 was 9628, giving a bed/population ratio of 1/830. The distribution both of hospitals and of hospital beds favours the towns and the southern parts of the country. The 49 health centres have outpatient facilities, a
dispensary, and, usually,
a
maternity wing. They
are
intended to be referral points for the health posts. Each centre is supposed to care for 200,000 people, and each post for about 10,000-15,000. In fact, not more than 20 health posts were functioning by the end of 1971. Fortunately, local-authority dressing-stations and dispensaries and maternity clinics staffed by midwives take some of the load off the health posts. At the end of 1970 the country had about 667 doctors (and less than 50 dental surgeons); 339 of the doctors were non-Ghanaian and 369 were in Government service. 2768 midwives and nurses were in Government service and about 80 health-centre superintendents. These are senior nurses who act as auxiliaries to physicians. They have had one year’s training in elementary diagnosis and treatment of disease and the administration of a health centre. State-registered nurses are helped by enrolled nurses; and public-health nurses (only about 160 in all) by community-health nurses, and pharmacies by dispensing attendants. In 1964 the first medical school was established. Since 1969 it has turned out 30-40 doctors a year, and an annual capacity of 50 is expected. Training for State-registered nurses is centred in Accra and Kumasi, for pharmacists in Kumasi, and for auxiliary physicians in Kintampo; but there are training programmes for all levels of auxiliaries in many of the hospitals, both Government and missionary. As a general rule the major Government hospitals train the full professionals and other hospitals train the auxiliaries. In 1972-73 Ghana was supposed to be devoting the equivalent of about U.S. S18 million to health services, a per-caput expenditure of about$2. In actual buying power, this is probably less than the per-caput average over the previous three years. The money is derived from direct taxation. Mission hospitals have small Government grants and charge reasonable economic fees. The present Government has indicated that the scale of fees must be reduced, yet it cannot afford to increase its grants. All industries and commercial concerns employing over a hundred people are required by law to provide medical cover for their employees. A few have their own doctors and hospitals, but most use the Government resources. At present, Ghana has no single organisation for medical research, which is carried out in various hospitals and in the medical school. Most international support for research programmes vanished soon after independence; but some international assistance remains. The Danfa project, for instance, is supported through the United States Agency for International Development (A.I.D.) and is pursued in collaboration with the University of California in Los Angeles. Sicklecell work has been done in collaboration with Prof. Hermann Lehmann and his group in Cambridge. It is now hoped to form a Council for Scientific and Industrial Research. For over ten years medical leaders in Ghana have been advocating reorientation of the nation’s health services. The needs are: to control communicable diseases; to provide better antenatal, intranatal, and postnatal care; to provide care for the preschool child; and to provide better sanitation. A massive immunisation campaign should be mounted. All these services