Swedish models of health care reform: a review and assessment

Resource constraints and the necessity to improve efficiency and effectiveness have provided challenges for the Swedish health care system during the 1990s. Whereas there are no comprehensive reforms of funding and organization, measures have been taken at both national and regional level to meet these challenges. Decentralization has been a core issue in long-term reforms and current changes can be seen as continuing this pattern. As a consequence different solutions are sought in the various county councils (locally elected self-government bodies financing and procuring health services). In about one third of these county councils some sort of purchaser-provider models have been introduced. Emerging evaluation reports claim that the models have succeeded in improving efficiency; making the system more patient-oriented; and enhancing cost-consciousness. The roles of politicians, managers and professionals are also more clear, according to the proponents. However, there are also problems with more difficulties in controlling costs, and with inadequate remuneration systems. Over time the purchaser-provider schemes have matured, developing from emphasizing short-term tendering, negotiations and detailed contracts to more comprehensive agreements based on mutual commitments to improve health services. Rhetoric has changed; competition has been replaced by co-operation. The lure of the market concept has diminished. Similarities can be seen between county councils with and without purchaser-provider models.