- Email: [email protected]
How can our health systems be re-engineered to meet the future challenges? The Swedish experience
Social Science & Medicine 74 (2012) 677e679
Contents lists available at SciVerse ScienceDirect
Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed
Commentary
How can our health systems be re-engineered to meet the future challenges? The Swedish experience Johan Calltorp The Jönköping Academy for Improvement of Health and Welfare, The Nordic School of Public Health, Swedish Forum for Health Policy, Sweden
a r t i c l e i n f o Article history: Available online 4 January 2012 Keywords: Health determinants Health services Sweden USA UK
All health systems confront challenges according to their respective level of development linked to social, demographic and economic factors as well as the pattern of disease and its burden on society. Among well developed, mature and highly industrialized countries, it is of great interest to exchange knowledge between countries on their respective economic and health status. In fact, international comparison is one of the main ways to learn how key health system components interact with basic social, economic and epidemiological components. However comparative research on health systems still needs development to improve our understanding of basic issues. The health systems of the US, UK and Sweden have traditionally been used to illustrate different mechanisms of funding, organizational patterns and partly built in driving forces. In the US for example free market principles with a stronger belief in financial incentives and competition applied to health care have been more pronounced for a long period, although we observe, in the new globalized world, a rapid spread of these ideas to other countries. Through this three country comparison, in particular, it is possible to illuminate the interplay between the basic determinants of health and equity, the structure of the health system and its function. The specific focus on how the international economic crisis is impacting on welfare production, health equity and health system function is a theme of great significance. There are possibilities for important learning especially about factors and circumstances
E-mail address: [email protected]. 0277-9536/$ e see front matter Ó 2012 Published by Elsevier Ltd. doi:10.1016/j.socscimed.2011.12.003
working in the globalized world, but also “generic” health system issues (Anderson, 1972). Sweden provides an example of a highly integrated health system, developed over a long period of time (Calltorp, 1999). It is predominantly public in nature, regarding both financing, ownership of health facilities and delivery of services. In all 21 independent county councils are responsible for all aspects of delivery of a full range of curative and preventive services. The county councils (dating back in origin to 1862) are public bodies governed by elected politicians. The Swedish system is thus much closer to the UK model of health services than to the US. The main differences are that the UK National Health Service is a relatively comprehensive, single public organization with much more central control, while the US system is much more diversified and fragmented, with multiple actors and organizational arrangements within broad national and state frameworks. Swedish physicians are salaried on a defined number of weekly working hours with negotiated on call compensation, while the situation in both UK and the US is much more variable. Major ‘milestones’ in health policy development in Sweden have been the introduction of mandatory national health insurance (in the 1950s), the early regionalization of highly specialized services (in the 1960s). More recent policy changes have involved waves of macro structural changes and micro reorganization of services. A long-established intersectorial cooperation around health issues in Swedish society, with an active implementation of public health measures is another dimension that may help to explain the good outcome for population health and overall achievements of the system. The early introduction of policies for a general “welfare
678
J. Calltorp / Social Science & Medicine 74 (2012) 677e679
society” may be another important factor for good health results. Commentators have also emphasised the relatively strong consensus around social values in Sweden and also cooperation between public bodies at different levels of society and with other sectors of society (well developed social cohesion) (e.g. Brännstrom et al., 1994; McKee & Figueras, 1996). How, then, does this quite homogenous, well developed and “mature” welfare state respond to external pressures such as the global recession? How can social policies be built and developed to maintain the strongly stated goals of equity and solidarity in Sweden? How can innovation and development of health services be maintained when economic resources fluctuate or decline? The macro economic data show that Sweden has succeeded in maintaining a relatively stable fraction of GDP to health services e approximately 9.5%, since 1987 (Glenngard, Hjalte, Svensson, Anell, & Bankauskaite, 2005). This is a paradox given the decentralized nature of the system, where the 21 county councils take decisions on the level of tax funding of the system, which presently makes up around 75% of the total health care financing. The national government contributes the rest e mostly in block allocations to the county councils. This successful cost containment has been possible because the national government has concentrated its efforts on cost containment as a main health care policy, and as an important part of the overall national program to balance public budgets. These policy goals have been executed and refined by successive governments e both earlier social democratic and present liberal coalition governments. The cost crisis regarding the public economy that Sweden went through in the years around 1990, with a severe reduction/containment programme throughout the 1990’s, has been important for forming policy (also discussed in other commentaries in this set; see Burström, 2012; Kristenson, 2012). The objective of achieving a “balanced public budget” has emerged as a strong policy consensus. At different times this has, of course, been controversial, but today in 2011 it is regarded as a successful policy. Compared with most other European countries, Sweden, for the moment, has one of the strongest public economies in Europe. The argument e from both the political left and the right e focuses on the “freedom to act for the future” that this policy has made possible. The important questions relate, of course, to whether the steps taken to accommodate the quite strong economic restraints on public budgets have been performed in the best possible way, how health outcomes may or may not have been affected negatively, and what lessons there are for the future. Other important issues concern indicators of health outcomes on the one hand and self perceptions of the situation on the other hand. Hard and more subtle data have to be combined in the analysis. Also issues of trust and belief in the system are crucial. Belief in the system is especially important for the predominately public Swedish health care system where collective solidarity underpins political support both for the tax financing “inputs” and the population health “outputs” from the system. The main more detailed policy responses within the Swedish health system following on the macro policies are described below. A first wave of policy response, when tighter cost constraints were developed in the latter part of the 1980’s and early 1990’s did focus on “easy savings” in a system that had lived through continuous growth for three decades. This targeted reduction of unnecessary duplication of services, as well as quite strong restraint of wage increases for the predominantly salaried work forces in the health service. A second wave of adaptations involved a strong drive for structural changes in the way services were organised and delivered, beginning from middle of the 1990’s (Harrison, 2004). There were insufficient financial resources to maintain the existing hospital structure e and quite strong arguments were made
regarding the scope to improve quality of outcomes by concentrating specialized treatments into a limited number of more specialized centres at regional, and at more local levels in the health system. These triggered restructuring both at the meso level (hospital mergers) and the micro level (mergers of clinics and reconfiguration of services). At the macro level at this time work also started on a reconfiguration of the county council structure, with mergers between some neighbouring county councils into bigger regions. It is interesting to see that the economic situation and arguments about quality of care became the main drivers for these various structural changes. Change was also driven to an increasing extent by international influences (such as the idea of the ‘purchaser e provider split’) and by change in other public service sectors where different management ideas were tried to achieve organizational change and innovation (Magnussen, Vrangbeck, & Saltman, 2009; Saltman & von Otter, 1992). The structural reform agenda has moved on since the year 2000, with an increased interest in process re-engineering, using ‘lean’ production models and other new organizational concepts (Baker, Macintosh-Murray, & Porcellato, 2008) and further reduction of hospital beds in favour of a policy to try to provide more care in outpatient settings. The national government has also tried e both by “forcing” but also by types of voluntary agreement with the county councils e to improve access and waiting times. The mechanisms proposed have included, for example, launching a “care guarantee” with access targets for different types of care (similar to the UK recent programs). These have placed growing demand on the county councils for increased organizational efficiency. National moves have been made towards a more rational service organization and more similar service patterns over the country regarding different highly specialized health services and important areas like oncology. An increased use of data regarding outcomes of services based on the high quality, detailed health data available in Sweden can also inform policy. Presenting these data in a way that is suitable for practical use in planning and linking them together to inform action both nationally and within each county council are current policy foci (Examples of this strategy are also reported by Kristenson (2012), in this collection of commentaries.). In October 2006 a new Swedish liberal coalition government took office after an earlier social democratic government and in September 2010 the same coalition won the election and continued governing, although without a majority. Much of the above mentioned health policies have been confirmed by this government with a continued focus on goals such as equity in outcome and access to health services (Examples of existing well-known and measurable disparities in health are drawn upon to support the political rhetoric arguing for this focus.). New policy foci also include “innovation and renewal” of health services with an emphasis on new delivery mechanisms. Important changes in regulations and laws are to allow and encourage new actors as providers of health services within the public financing. A new primary care system has been set in place where patients are entitled to choose among providers and those are allowed to establish given certain certification requirements. At present the combination of these policies have resulted in private companies delivering up to 50% of primary care in some regions. The pharmaceutical monopoly has been abandoned in favour of a mixed either private or public ownership of different pharmacies. Also private/public partnerships have been introduced for the financing of new hospitals, such as the new Karolinska Hospital in Stockholm (Anell, 2010; Swedish Parliament, 2008). So far the Swedish health system changes can be judged as relatively moderate and cautious. There is a gap between political rhetoric and actual changes. The most recent political focus is as much on access and choice for citizens as a response to long waiting
J. Calltorp / Social Science & Medicine 74 (2012) 677e679
times. There is concern that the health care system may be less responsive to the more ‘human’ dimensions of care and wellbeing than the biomedical-technological aspects that are generally taken well taken care of. This may be understood as a reaction against a “too rational health system”, shaped by professions and bureaucratic perspectives (such as rationalization of specialist care and a focus on managerial techniques). This shows parallels with the health policy development in the UK, US and generally in most industrialized countries. Given the strong economic constraint that Swedish health services have worked under for more than 20 years the present system is a system under some “stress”. On the surface, adaptations such as restructuring of services at both macro and micro levels of the system can be judged as relatively successful, in spite of initial failures in care provision that arose from sweeping hospital reconfigurations through rapid mergers. The real challenge e still not very successfully addressed e seems to be to make continuous structural changes in line with, and supporting, development of the care needs of the population (due to more older people, a growing chronic diseases burden and co-morbidity from different chronic diseases becoming more common). The organizational reconfiguration needs not only to be carried out in line with a changing needs pattern but also combined with changing technological options. It should lead to a pattern of constant and meaningful change e and preferably not in disruptive leaps. This is of course a very challenging task for all health professionals and is putting high demands on health managers. Many tools to support change have been developed during recent years within areas such as quality improvement and organizational redesign to help with this. Another strongly challenging area is what is sometimes called “value based health care” which aims to combine measurement of outcome and results for individual patients and groups of patients, also linked to individual care giving organizations. The approach is truly multidisciplinary and combines what earlier was often called technology assessment and quality improvement (in the US also called ‘comparative effectiveness research). More precise measurement is one dimension, but also implementation through more effective guidelines for clinical practice. This area is undergoing rapid development and expansion and will play a role in providing tools for the future health practice and management (Calltorp and Maathz, 2009) Of key importance is how to link this defined and prescribed evidence base to traditional professional values such as independent and individual decision making. The financing of health services will be of outmost importance for the future. At present in Sweden there is a clear “avoidance” of this issue in political debate, which is quite natural in a publicly governed and mainly tax-financed health system e similar to other Nordic systems and to the UK. The policy option of increasing taxation does not seem to be the most likely way forward given the present period of economic recession in many countries, which makes tax rises for those in employment difficult to justify for many societies. It has been argued that the political debate should concentrate on how to achieve increased private contributions by the users of health services. Even if there are clear political value
679
issues in this debate, there is also an international knowledge base that can be applied and called on (Saltman et al., 2011). It is of great importance to distinguish how different payment arrangements effect equity and socio-economic gradients. The health services system is perhaps the most complex knowledge system in modern societies. The model of biomedical innovation from laboratory to clinical application is wellestablished. Public health, epidemiology and other socio-medical sciences have a well-established position in helping to inform strategies for average health improvement and reduction of inequalities in health for populations and groups and also a clear tradition of guiding practice and decision making. It seems urgent now that scientific knowledge is also mobilized to take action on issues relating to health service organization, management and institutional change in health services. These need to be developed, in a way that is knowledge based, to inform and support policy, decision making and operation of the health service. The analysis of the Swedish case study as well as the UK and US and international trends linked to the current strong global pressures of different kinds show very clearly the need for this kind of knowledge mobilization. References Anderson, O. W. (1972). Health care e Can there be equity? The US, UK and Sweden. New York: Wiley & Sons. Anell, A. (2010). Choice and privatization in Swedish primary care. Health Economics, Policy and Law. doi:10.1017/S1744133110000216. Baker, R., Macintosh-Murray, A., & Porcellato, C. (2008). High performing healthcare systems. Delivering quality by design. Toronto: Longwoods Publishing Company. Brännstrom, I., Emmelin, I., Dahlgren, L., Johansson, M., & Wall, S. (1994). Cooperation, participation and conflicts faced in public-health e lessons learned from a long-term prevention program in Sweden. Health Education Research, 9(3), 317e329. Burström, B. (2012). Sweden e socioeconomic factors and health, Commentary. Social Science & Medicine, 74(5), 654e655. Calltorp, J. (1999). Priority setting in health policy in Sweden and a comparison with Norway. Health Policy, 50(1e2), 1e22. Calltorp, J., & Maathz, G. (2009). Strategies and steering tools for successful health service (Strategier och ledningsredskap för framgångsrik hälso- och sjukvård, Swedish). Stockholm: LIF. Glenngard, A. H., Hjalte, F., Svensson, M., Anell, A., & Bankauskaite, V. (2005). Sweden. Health systems in transition series. Brussels: European Observatory on Health Policies and Systems. Harrison, M. (2004). Implementing change in health systems. Market reforms in the United Kingdom, Sweden and The Netherlands. London: Sage. Kristenson, M. (2012). Impact of socioeconomic determinants on psychosocial factors and lifestyle e implications for health service: the Swedish experience: Commentary. Social Science & Medicine, 74(5), 661e664. McKee, M., & Figueras, J. (1996). For debate e setting priorities: can Britain learn from Sweden? British Medical Journal, 312(7032), 691e694. Magnussen, J., Vrangbeck, K., & Saltman, R. B. (2009). Nordic health care systems. Recent reforms and current policy challenges. The European Observatory on Health Policies and Systems. London: Open University Press. Saltman, R. B., Calltorp J., and de Roo A. (2011). Health sector innovation and partnership: public responses to the new economic context. Paper presented at OECD 50th Anniversary Conference on Health Reform: Meeting the challenge of ageing and multiple morbidities. OECD, Paris June 22, 2011. Saltman, R. B., & von Otter, C. (1992). Planned markets and public competition: Strategic reform in northern European health systems. Buckingham: Open University Press. Swedish Parliament. (2008). Governmental proposal to Swedish Parliament 2008/ 2009:74. Choice in primary care (Swe) “Vårdval I primärvården”.
Contents lists available at SciVerse ScienceDirect
Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed
Commentary
How can our health systems be re-engineered to meet the future challenges? The Swedish experience Johan Calltorp The Jönköping Academy for Improvement of Health and Welfare, The Nordic School of Public Health, Swedish Forum for Health Policy, Sweden
a r t i c l e i n f o Article history: Available online 4 January 2012 Keywords: Health determinants Health services Sweden USA UK
All health systems confront challenges according to their respective level of development linked to social, demographic and economic factors as well as the pattern of disease and its burden on society. Among well developed, mature and highly industrialized countries, it is of great interest to exchange knowledge between countries on their respective economic and health status. In fact, international comparison is one of the main ways to learn how key health system components interact with basic social, economic and epidemiological components. However comparative research on health systems still needs development to improve our understanding of basic issues. The health systems of the US, UK and Sweden have traditionally been used to illustrate different mechanisms of funding, organizational patterns and partly built in driving forces. In the US for example free market principles with a stronger belief in financial incentives and competition applied to health care have been more pronounced for a long period, although we observe, in the new globalized world, a rapid spread of these ideas to other countries. Through this three country comparison, in particular, it is possible to illuminate the interplay between the basic determinants of health and equity, the structure of the health system and its function. The specific focus on how the international economic crisis is impacting on welfare production, health equity and health system function is a theme of great significance. There are possibilities for important learning especially about factors and circumstances
E-mail address: [email protected]. 0277-9536/$ e see front matter Ó 2012 Published by Elsevier Ltd. doi:10.1016/j.socscimed.2011.12.003
working in the globalized world, but also “generic” health system issues (Anderson, 1972). Sweden provides an example of a highly integrated health system, developed over a long period of time (Calltorp, 1999). It is predominantly public in nature, regarding both financing, ownership of health facilities and delivery of services. In all 21 independent county councils are responsible for all aspects of delivery of a full range of curative and preventive services. The county councils (dating back in origin to 1862) are public bodies governed by elected politicians. The Swedish system is thus much closer to the UK model of health services than to the US. The main differences are that the UK National Health Service is a relatively comprehensive, single public organization with much more central control, while the US system is much more diversified and fragmented, with multiple actors and organizational arrangements within broad national and state frameworks. Swedish physicians are salaried on a defined number of weekly working hours with negotiated on call compensation, while the situation in both UK and the US is much more variable. Major ‘milestones’ in health policy development in Sweden have been the introduction of mandatory national health insurance (in the 1950s), the early regionalization of highly specialized services (in the 1960s). More recent policy changes have involved waves of macro structural changes and micro reorganization of services. A long-established intersectorial cooperation around health issues in Swedish society, with an active implementation of public health measures is another dimension that may help to explain the good outcome for population health and overall achievements of the system. The early introduction of policies for a general “welfare
678
J. Calltorp / Social Science & Medicine 74 (2012) 677e679
society” may be another important factor for good health results. Commentators have also emphasised the relatively strong consensus around social values in Sweden and also cooperation between public bodies at different levels of society and with other sectors of society (well developed social cohesion) (e.g. Brännstrom et al., 1994; McKee & Figueras, 1996). How, then, does this quite homogenous, well developed and “mature” welfare state respond to external pressures such as the global recession? How can social policies be built and developed to maintain the strongly stated goals of equity and solidarity in Sweden? How can innovation and development of health services be maintained when economic resources fluctuate or decline? The macro economic data show that Sweden has succeeded in maintaining a relatively stable fraction of GDP to health services e approximately 9.5%, since 1987 (Glenngard, Hjalte, Svensson, Anell, & Bankauskaite, 2005). This is a paradox given the decentralized nature of the system, where the 21 county councils take decisions on the level of tax funding of the system, which presently makes up around 75% of the total health care financing. The national government contributes the rest e mostly in block allocations to the county councils. This successful cost containment has been possible because the national government has concentrated its efforts on cost containment as a main health care policy, and as an important part of the overall national program to balance public budgets. These policy goals have been executed and refined by successive governments e both earlier social democratic and present liberal coalition governments. The cost crisis regarding the public economy that Sweden went through in the years around 1990, with a severe reduction/containment programme throughout the 1990’s, has been important for forming policy (also discussed in other commentaries in this set; see Burström, 2012; Kristenson, 2012). The objective of achieving a “balanced public budget” has emerged as a strong policy consensus. At different times this has, of course, been controversial, but today in 2011 it is regarded as a successful policy. Compared with most other European countries, Sweden, for the moment, has one of the strongest public economies in Europe. The argument e from both the political left and the right e focuses on the “freedom to act for the future” that this policy has made possible. The important questions relate, of course, to whether the steps taken to accommodate the quite strong economic restraints on public budgets have been performed in the best possible way, how health outcomes may or may not have been affected negatively, and what lessons there are for the future. Other important issues concern indicators of health outcomes on the one hand and self perceptions of the situation on the other hand. Hard and more subtle data have to be combined in the analysis. Also issues of trust and belief in the system are crucial. Belief in the system is especially important for the predominately public Swedish health care system where collective solidarity underpins political support both for the tax financing “inputs” and the population health “outputs” from the system. The main more detailed policy responses within the Swedish health system following on the macro policies are described below. A first wave of policy response, when tighter cost constraints were developed in the latter part of the 1980’s and early 1990’s did focus on “easy savings” in a system that had lived through continuous growth for three decades. This targeted reduction of unnecessary duplication of services, as well as quite strong restraint of wage increases for the predominantly salaried work forces in the health service. A second wave of adaptations involved a strong drive for structural changes in the way services were organised and delivered, beginning from middle of the 1990’s (Harrison, 2004). There were insufficient financial resources to maintain the existing hospital structure e and quite strong arguments were made
regarding the scope to improve quality of outcomes by concentrating specialized treatments into a limited number of more specialized centres at regional, and at more local levels in the health system. These triggered restructuring both at the meso level (hospital mergers) and the micro level (mergers of clinics and reconfiguration of services). At the macro level at this time work also started on a reconfiguration of the county council structure, with mergers between some neighbouring county councils into bigger regions. It is interesting to see that the economic situation and arguments about quality of care became the main drivers for these various structural changes. Change was also driven to an increasing extent by international influences (such as the idea of the ‘purchaser e provider split’) and by change in other public service sectors where different management ideas were tried to achieve organizational change and innovation (Magnussen, Vrangbeck, & Saltman, 2009; Saltman & von Otter, 1992). The structural reform agenda has moved on since the year 2000, with an increased interest in process re-engineering, using ‘lean’ production models and other new organizational concepts (Baker, Macintosh-Murray, & Porcellato, 2008) and further reduction of hospital beds in favour of a policy to try to provide more care in outpatient settings. The national government has also tried e both by “forcing” but also by types of voluntary agreement with the county councils e to improve access and waiting times. The mechanisms proposed have included, for example, launching a “care guarantee” with access targets for different types of care (similar to the UK recent programs). These have placed growing demand on the county councils for increased organizational efficiency. National moves have been made towards a more rational service organization and more similar service patterns over the country regarding different highly specialized health services and important areas like oncology. An increased use of data regarding outcomes of services based on the high quality, detailed health data available in Sweden can also inform policy. Presenting these data in a way that is suitable for practical use in planning and linking them together to inform action both nationally and within each county council are current policy foci (Examples of this strategy are also reported by Kristenson (2012), in this collection of commentaries.). In October 2006 a new Swedish liberal coalition government took office after an earlier social democratic government and in September 2010 the same coalition won the election and continued governing, although without a majority. Much of the above mentioned health policies have been confirmed by this government with a continued focus on goals such as equity in outcome and access to health services (Examples of existing well-known and measurable disparities in health are drawn upon to support the political rhetoric arguing for this focus.). New policy foci also include “innovation and renewal” of health services with an emphasis on new delivery mechanisms. Important changes in regulations and laws are to allow and encourage new actors as providers of health services within the public financing. A new primary care system has been set in place where patients are entitled to choose among providers and those are allowed to establish given certain certification requirements. At present the combination of these policies have resulted in private companies delivering up to 50% of primary care in some regions. The pharmaceutical monopoly has been abandoned in favour of a mixed either private or public ownership of different pharmacies. Also private/public partnerships have been introduced for the financing of new hospitals, such as the new Karolinska Hospital in Stockholm (Anell, 2010; Swedish Parliament, 2008). So far the Swedish health system changes can be judged as relatively moderate and cautious. There is a gap between political rhetoric and actual changes. The most recent political focus is as much on access and choice for citizens as a response to long waiting
J. Calltorp / Social Science & Medicine 74 (2012) 677e679
times. There is concern that the health care system may be less responsive to the more ‘human’ dimensions of care and wellbeing than the biomedical-technological aspects that are generally taken well taken care of. This may be understood as a reaction against a “too rational health system”, shaped by professions and bureaucratic perspectives (such as rationalization of specialist care and a focus on managerial techniques). This shows parallels with the health policy development in the UK, US and generally in most industrialized countries. Given the strong economic constraint that Swedish health services have worked under for more than 20 years the present system is a system under some “stress”. On the surface, adaptations such as restructuring of services at both macro and micro levels of the system can be judged as relatively successful, in spite of initial failures in care provision that arose from sweeping hospital reconfigurations through rapid mergers. The real challenge e still not very successfully addressed e seems to be to make continuous structural changes in line with, and supporting, development of the care needs of the population (due to more older people, a growing chronic diseases burden and co-morbidity from different chronic diseases becoming more common). The organizational reconfiguration needs not only to be carried out in line with a changing needs pattern but also combined with changing technological options. It should lead to a pattern of constant and meaningful change e and preferably not in disruptive leaps. This is of course a very challenging task for all health professionals and is putting high demands on health managers. Many tools to support change have been developed during recent years within areas such as quality improvement and organizational redesign to help with this. Another strongly challenging area is what is sometimes called “value based health care” which aims to combine measurement of outcome and results for individual patients and groups of patients, also linked to individual care giving organizations. The approach is truly multidisciplinary and combines what earlier was often called technology assessment and quality improvement (in the US also called ‘comparative effectiveness research). More precise measurement is one dimension, but also implementation through more effective guidelines for clinical practice. This area is undergoing rapid development and expansion and will play a role in providing tools for the future health practice and management (Calltorp and Maathz, 2009) Of key importance is how to link this defined and prescribed evidence base to traditional professional values such as independent and individual decision making. The financing of health services will be of outmost importance for the future. At present in Sweden there is a clear “avoidance” of this issue in political debate, which is quite natural in a publicly governed and mainly tax-financed health system e similar to other Nordic systems and to the UK. The policy option of increasing taxation does not seem to be the most likely way forward given the present period of economic recession in many countries, which makes tax rises for those in employment difficult to justify for many societies. It has been argued that the political debate should concentrate on how to achieve increased private contributions by the users of health services. Even if there are clear political value
679
issues in this debate, there is also an international knowledge base that can be applied and called on (Saltman et al., 2011). It is of great importance to distinguish how different payment arrangements effect equity and socio-economic gradients. The health services system is perhaps the most complex knowledge system in modern societies. The model of biomedical innovation from laboratory to clinical application is wellestablished. Public health, epidemiology and other socio-medical sciences have a well-established position in helping to inform strategies for average health improvement and reduction of inequalities in health for populations and groups and also a clear tradition of guiding practice and decision making. It seems urgent now that scientific knowledge is also mobilized to take action on issues relating to health service organization, management and institutional change in health services. These need to be developed, in a way that is knowledge based, to inform and support policy, decision making and operation of the health service. The analysis of the Swedish case study as well as the UK and US and international trends linked to the current strong global pressures of different kinds show very clearly the need for this kind of knowledge mobilization. References Anderson, O. W. (1972). Health care e Can there be equity? The US, UK and Sweden. New York: Wiley & Sons. Anell, A. (2010). Choice and privatization in Swedish primary care. Health Economics, Policy and Law. doi:10.1017/S1744133110000216. Baker, R., Macintosh-Murray, A., & Porcellato, C. (2008). High performing healthcare systems. Delivering quality by design. Toronto: Longwoods Publishing Company. Brännstrom, I., Emmelin, I., Dahlgren, L., Johansson, M., & Wall, S. (1994). Cooperation, participation and conflicts faced in public-health e lessons learned from a long-term prevention program in Sweden. Health Education Research, 9(3), 317e329. Burström, B. (2012). Sweden e socioeconomic factors and health, Commentary. Social Science & Medicine, 74(5), 654e655. Calltorp, J. (1999). Priority setting in health policy in Sweden and a comparison with Norway. Health Policy, 50(1e2), 1e22. Calltorp, J., & Maathz, G. (2009). Strategies and steering tools for successful health service (Strategier och ledningsredskap för framgångsrik hälso- och sjukvård, Swedish). Stockholm: LIF. Glenngard, A. H., Hjalte, F., Svensson, M., Anell, A., & Bankauskaite, V. (2005). Sweden. Health systems in transition series. Brussels: European Observatory on Health Policies and Systems. Harrison, M. (2004). Implementing change in health systems. Market reforms in the United Kingdom, Sweden and The Netherlands. London: Sage. Kristenson, M. (2012). Impact of socioeconomic determinants on psychosocial factors and lifestyle e implications for health service: the Swedish experience: Commentary. Social Science & Medicine, 74(5), 661e664. McKee, M., & Figueras, J. (1996). For debate e setting priorities: can Britain learn from Sweden? British Medical Journal, 312(7032), 691e694. Magnussen, J., Vrangbeck, K., & Saltman, R. B. (2009). Nordic health care systems. Recent reforms and current policy challenges. The European Observatory on Health Policies and Systems. London: Open University Press. Saltman, R. B., Calltorp J., and de Roo A. (2011). Health sector innovation and partnership: public responses to the new economic context. Paper presented at OECD 50th Anniversary Conference on Health Reform: Meeting the challenge of ageing and multiple morbidities. OECD, Paris June 22, 2011. Saltman, R. B., & von Otter, C. (1992). Planned markets and public competition: Strategic reform in northern European health systems. Buckingham: Open University Press. Swedish Parliament. (2008). Governmental proposal to Swedish Parliament 2008/ 2009:74. Choice in primary care (Swe) “Vårdval I primärvården”.