Health Poky, 21 (1992) 129-141 129

01992 Elsevier Science Publishers B.V. AU rights reserved. 0168~8510/92/$05.00

HPE 00404

Reforming the Swedish health services:

The international context

Chris Ham
Khgs Fund College, London, U.K.

Accepted 25 November 1991

Summary

This article reviews the performance of Swedish health services in the

international context. It notes that Sweden stands out as a country which has
made a maJor commitment to the welfare state. Nowhere is this more evident than in
the health services. Expendltum on health care is high by intematlonal standards
and over 99% of expendlture derives from public sources. Despite Sweden’s
achievement in providing comptohenslve health care to its population, a number of
problems have emerged in recent years. In response to these problems, there has
been a debate about options for reform. It is suggested that management reforms
may offer the best way fonmrd in improving the performance of health rervlces.
Policy makers should take advantage of the decentralised nature of the Swedhh
system to inltlate and evaluate different reforms In dlfhnent county councils.

Sweden; Health service reform; Management; Competltron; Decentrallsation

Introduction

In many developed countries, health services have come under critical

scrutiny in recent years [l]. In part this is because of increasing expenditure on
health services, much of it funded from public sources, and the pressure this
has put on governments seeking to control public spending. Also important
has been the perception that the resources allocated to health services are not

Revised version of a paper presented at the Conference: ‘Swedish Health Policy - A Comparative
Perspective (L Foreign Observers’ Views’ held in Hhberga, Uding5, Sweden on August 2%24,199O.

Ad&ws for awmspondwtce: Dr Chlls Ham, Kings Fund College, 2 Palace Court, London W2 4HS. U.K.
130

always deployed in an optimal fashion. At a time when the scope for increasing
expenditure is tightly constrained, this has prompted a search for ways of using
existing budgets more efficiently. A further concern has been the desire to
ensure access to health care of different groups in the population and to
provide services to these groups on an equitable basis. In some countries this
has been linked to a wish to enhance patient choice and to make service
providers more responsive to patients.
Underlying these specific concerns are a number of more fundamental
developments which have a significant bearing on the performance of health
services. Three are worth highlighting. First, there are demographic changes,
including the ageing of the population and the decline in the proportion of the
population of working age. These changes will both increase the demand for
health care and at the same time limit the ability of health services to respond
to this demand. Although there is some evidence to suggest that future
generations of people aged over 65 may be healthier than their predecessors,
the increase in the number of older people in the population, in particular
those aged over 75, can be expected to create pressure for additional spending
on health services.
Second, advances in medical science will also give rise to new demands
within the health services. These advances cover a range of possibilities,
including innovations in surgery, drug therapy, screening and diagnosis. The
impact of developments in health care technology is already evident in areas
such as transplant surgery and medical imaging. The pace of innovation is
likely to quicken as the end of the century approaches, with significant
implications for the funding and provision of services.
Third, public expectations of health services are rising as those who use
services demand higher standards of care. In part, this is stimulated by
developments within the health services, including the availability of new
technology. More fundamentally, it stems from the emergence of a more
educated and informed population, in which people are accustomed to being
treated as consumers rather than patients. This has implications both for the
quality of the facilities in which services are delivered and the standards of
personal service that are achieved.
Against this background, policy makers in a number of countries have
initiated a series of reviews of the performance of health services. In Holland,
the Dekker Report of 1987 has led to. a programme of reforms affecting the
funding and provision of services. These reforms seek to introduce competition
between insurers and providers. In future, there will be a system of basic
insurance for all covering essential health services, coupled with optional,
supplementary insurance for other services. The cost of basic insurance will be
met in part by incomes-related payments by employees and employers, and in
part by a nominal premium paid directly to insurers by subscribers. Dekker
proposed that the size of the nominal premium should vary between insurers to
stimulate competition on the demand side.
The other key element in the Dekker Committee’s proposals was that
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insurers should contract selectively with providers. This would mean insurers
purchasing services for subscribers from those doctors and hospitals able to
meet certain cost and quality requirements. Dekker argued that selective
contracting would stimulate competition between providers and would create
powerful incentives for efficiency. An important objective behind the reforms
is to encourage the substitution of care outside hospital for inpatient treatment
and to place greater emphasis on primary care and health promotion.
Following an extensive period of debate, the Dutch Government announced
that the Dekker reforms were to be implemented in stages over a number of
years.
The thinking behind the Dekker Report is similar to Mrs Thatcher’s plans
for the reform of the IV-IS. A review of the NHS conducted in 1988 resulted in
a white paper, Working for Patients, published early in 1989. The white paper
recommended no major change to the funding of health services. Its main
proposals concerned the delivery of health care where the key recommendation
was that hospitals should compete for funds in order to make services more
responsive to patients and to stimulate greater efficiency in the use of
resources.
To achieve this, the white paper proposed that the funding of services by
health authorities should be separated from their provision. Acting on behalf
of their communities, health authorities would purchase services from a range
of public, private and voluntary providers. These providers would include
hospitals which opted out of health authority control to become self-governing
NHS trusts. At the same time, large GP practices would be able to volunteer to
hold a budget for certain hospital services for their patients. The central
proposals of the white paper were thus designed to create the conditions for
managed competition in the health services [2].
Two other ideas lay at the heart of the white paper. The first was the
proposal that doctors should be made more accountable for their
performance. This was to be achieved through greater participation by
doctors in management and through tighter control of doctors by managers.
The second idea was that management should be strengthened, building on the
introduction of general management in the mid-1980s. The main elements in
the white paper were enshrined in the NHS and Community Care Act 1990,
and the reforms will be implemented progressively in the next few years.
The emphasis on more effective management finds strong ethos in Ireland in
the report of the Commission on Health Funding. Like Mrs Thatcher’s review
of the NHS, this rejected any fundamental reform of health service funding.
Much greater emphasis was placed on the need to manage the use of resources
effectively. In this context, the Commission argued for the establishment of an
executive agency to manage health services at arm’s length from the
Department of Health. At a local level, health boards would become advisory
bodies and general managers would be given greater powers to run services
within the framework of national policies and priorities. In hospitals, doctors
would be expected to play a bigger part in management and managerial
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controls over doctors would be strengthened. The Commission also suggested

that competition between hospitals could be used as a spur to efficiency. At the
time of writing, the Irish Government is still considering its response to the
Report.
In Germany, concern at increasing health care costs has resulted in a
number of reforms. Of particular importance was the establishment by law in
1977 of Concerted Action, a national conference of 60 participants from all
major sectors of health care. The conference meets twice a year and
recommends growth rates for different types of expenditure. Concerted
Action has become the major forum in which the main participants in health
services meet in public to decide upon future developments.
The most recent health reform legislation was enacted in 1988 and came into
operation in 1989. The principal aim of the legislation is to achieve stability in
the rate of social insurance contributions. This is to be pursued mainly by
control over expenditure on drugs, increases in user charges, and changes to
the services included in the social insurance scheme. Also under discussion is
the future role of the sick funds, including ways of equalising contribution
rates between funds and increasing consumer choice.
As these examples illustrate, health care reforms vary in their content from
country to country. This reflects the different traditions, values and
circumstances of the countries concerned. Nevertheless, a number of common
themes can be identified. These are:
(1) incremental adjustments to methods of funding rather than fundamental
changes of direction;
(2) interest in a number of countries in the use of competition between
providers as a means of increasing efficiency;
(3) a commitment to strengthen the management of services and to hold
service providers more accountable for their performance.
International experience also indicates that there are no quick-f= solutions
to the problems that have emerged in the financing and delivery of services. A
recurring issue in almost all countries is dissatisfaction with existing
approaches and a search for new policy instruments. This includes interest
in finding a middle way between planning and competition in order to tackle
weaknesses in service delivery. We shall return to discuss the relevance of
international experience for Sweden later in the paper.

Swedish health services

Viewed in the international context, Sweden stands out as a country which

has made a major commitment to the development of the welfare state. This
commitment is evident in many areas of Swedish society but nowhere more so
than in the health services. All Swedish citizens are entitled to receive
comprehensive health services on the basis of need. No groups in the
population are excluded from the health care system. The comprehensive
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income support arrangements that exist mean that patients are not deterred
from seeking treatment by the nominal user charges that are levied.
Furthermore, Swedish law states clearly that services should be available on
an equal basis. Equality of access to health care reflects a broader set of values
within the social democratic tradition.
Expenditure on health services in Sweden is high by international standards
(see Table 1). In large part, this reflects Sweden’s standard of living. As
Maxwell [3] and others have shown, wealthier countries consistently spend
more on health services than poor countries, whatever their method of
funding. As one of the world’s richest countries, it is not surprising that
Sweden invests heavily in health care.
Consistent with the commitment to the welfare state, over 90% of
expenditure derives from public sources. During the 198Os, agreements
between national and local government have limited the increase in public
expenditure on health services. As a consequence, there was a reduction in the
proportion of GDP consumed by health care from 9.5% in 1980 to 9% in 1987
[4]. The control exercised over expenditure has put significant pressure on the
county councils and has left little room for service development.
An important feature of the Swedish system to the outside observer is the
strong emphasis placed on democratic control. The county councils have long
been the agencies responsible for financing and managing services and their
role has been enhanced in recent years. The corollary is that national
government has become less involved than in the past in the health services.
Decisions on priorities and policies rest firmly with the county councils leaving
the Ministry of Health and Social Affairs and the National Board of Health
and Welfare to establish the legal framework and to steer the development of
services from the centre.
Within the county councils, elected politicians work closely with managers
and doctors in running services [5]. In the post-war period, the expansion of
health services concentrated on the acute hospital sector. This resulted in a
significant investment in new hospitals and a considerable development of
Table 1
Health expand&urn as a percmbge ofGDP: ~lacted countries (from Schkber and Poulller (41)

1987
Canada 8.6
Denmark
Finland t5
France 8:6
8.2
zTy 1.4
Netherlands
Norway ;::
Sweden
U.K. Z-Y
U.S.A. 11:2

OECD mean 7.3

134

specialist services. Much lower priority was given to primary care although this
has begun to change.
In large part, the emphasis placed on hospital services can be explained in
terms of the high value attached to specialist care. With many patients,
politicians and doctors supporting the growth of the acute sector, it has proved
difficult to increase the percentage of expenditure devoted to services outside
hospitals [6,7l. Furthermore, the availability of beds means that they are used,
and this has helped to perpetuate the emphasis given to hospital provision.
As a number of studies have shown, Sweden currently spends a high
percentage of its health care budget on institutional care. For example, the
OECD analysis of the financing and delivery of health care showed that
institutional spending comprised 72.6% of total public health spending in
Sweden in the 198Os, compared with an OECD mean of 54.2%. In the same
period, Sweden provided 14 inpatient beds per 1000 population, compared
with an OECD mean of 9.3, although it should be noted that many of these
beds were for long-term care. The OECD analysis also demonstrated that
Sweden had the highest use of beds of all OECD countries with 4.8 inpatient
days per capita [8].
The corollary of a high investment in institutional services has been low
expenditure on primary care. As the OECD analysis showed, ambulatory
spending comprised 10.2% of total public health spending in the 198Os,
compared with a mean of 21.3%. However, priorities have shifted in recent
years as the need to contain expenditure has prompted a reappraisal of
spending patterns. A report published by the government in 1985 echoed
earlier analyses in calling for a change of emphasis to give higher priority to
services provided outside hospital [7l.
Expenditure trends in the 1980s indicate that this policy has had some
success [8]. Nevertheless, many patients continue to refer themselves directly to
hospital rather than going through a GP. Indeed, Swedish citizens have a
statutory right to go directly to specialists. This has obvious expenditure and
service implications and acts as a brake on the policy of shifting the balance of
care away from hospitals. A further factor is that county councils have tended
to favour hospitals in their resource allocation policies. In contrast to Finland,
where primary care and hospital care are run by separate organisations,
primary care services have to compete with hospitals for resources. This has
made it more difficult to give greater priority to primary care and has helped
perpetuate the predominance of secondary care.
Despite the high level of investment in acute hospital services, Sweden has
waiting lists for a number of treatments. Attention has focussed in particular
on waiting times of up to 2 years for hip replacements, cataract surgery, and
coronary artery bypass grafts. National government created special earmarked
funds for tackling waiting times in 1987 but this was not continued because of
objections from the county councils to the use of this form of funding. This
illustrates the influence of the county councils in the nmning of health services
and the limited power of the centre.
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Medical staff working within hospitals exercise a key influence on the use of
resources and the setting of priorities. Senior doctors take on the role of clinic
chiefs and provide medical leadership to their colleagues. Recent developments
have sought to strengthen the role of clinic chiefs in the management of
services. These developments have centred on appointing as clinic chiefs those
doctors best able to do the job, providing management training, and making
appointments on a fixed-term basis. Increasingly, too, clinic chiefs are taking
greater responsibility for the management of resources with support from
nurses and managers based in clinics.
An aspect of Swedish health services worth highlighting is the lack of
integration between primary care, hospital care and social care. With county
councils responsible for health services, and municipal councils responsible for
social care, it has not proved easy to develop an integrated approach to service
planning and service provision. The problems of coordinating services across
different agencies have been felt most acutely in the case of elderly people.
County councils have complained that hospital beds have been blocked
because of inadequate social services support. In the absence of such support,
many counties have developed nursing homes for the elderly, often in the past
in large institutions providing services which are increasingly recognised to be
both expensive and inappropriate. To overcome these problems, an agreement
has been reached in principle to transfer responsibility for non-acute care of
the elderly from the county councils to the municipal councils in 1992.
Statistics indicate that Swedes enjoy good health by international standards
(see Table 2). Infant mortality rates are among the lowest in the OECD
countries, life expectancy is among the highest, and the quality of life is
generally high. Nevertheless, as recent government reports have demonstrated,
Sweden still faces significant health problems [6,7]. These problems derive
from hazards in the environment, unhealthy lifestyles, and health inequalities
related to differences in income and class.
In an attempt to address these problems, the government has lent its support
to the WHO’s ‘Health For All by the Year 2000 strategy’. This includes a
strong emphasis on the structural and environmental influences on health, a
commitment to reduce social class differences in morbidity and mortality,
recognition of the need for intersectoral action at both national and local
levels, and a policy of supporting public participation in health and health

Table 2
Hdth Indlcaton: wlacted countrhs (from OECD [a])

U.K. Sweden U.S.A. Canada

Infant mortality rate Male 12.2 ::: 12.8 10.4

Female 9.4 10.2 7.8

Life expectancy at birth Male 71.3 73.5 70.9 72.0

Female 77.3 79.6 78.4 79.0
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services. These objectives were enshrined in law in 1985 and form the basis of
current efforts to build up health services outside the hospitals.
In 1988, the government published a review of progress made towards the
WHO’s targets and identified newly emerging problems such as AIDS [9]. As
the review noted, the ability of the health care system to respond to health
needs was constrained by limits on expenditure in the 1980s. Equally
significant were problems of recruiting staff to work in the health and
welfare services in the face of competition from other employers. The
expenditure constraints imposed in the 1980s made it difficult for county
councils to increase salary levels in line with those of the private sector. With
employment low and female participation in the labour force high,
competition for staff was intense. As the health services entered the 199Os,
this posed a major challenge to policy makers.
As this brief description has suggested, ,there are some real strengths in the
Swedish health services. In summary, these strengths are:
- the provision of comprehensive services to the whole population on the basis
of need;
- a commitment to Health For All by the Year 2000 and healthy public policy
at national and local levels;
- a strong emphasis on democratic control and accountability;
- the control exercised over expenditure, including the reduction achieved in
the percentage of GDP allocated to health services in the 1980s;
- the high standard of hospitals and the level of investment in acute services;
- the initiatives taken to manage clinical activity in hospitals, focussing on the
role of clinic chiefs.
Set against these strengths are a number of weaknesses. These include:
- lack of integration between primary care, hospital care and social care;
- a primary care system in which GPs do not act as gatekeepers and which
results in a high proportion of direct referrals to hospitals;
- the existence of waiting lists for some treatments;
- a strong emphasis on hospital care to the relative neglect of primary and
community health services;
- limited choice for patients.
These weaknesses are compounded by a number of underlying develop-
ments. As we noted at the beginning of the paper, these include demographic
pressures (the ageing population and labour market shortages), advances in
medical technology, and increasing public expectations. The last of these
developments is generating demands in Sweden for a system which permits
patients to make a choice between providers and offers services that are
responsive to consumer wants.

Reforming Swedish health services

In response to the weaknesses that have emerged, it is possible to identify a

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number of directions in which reforms might proceed. These include clarifying

the role of the centre in relation to the county councils; strengthening
management in the county councils; managing clinical activity more
effectively; and introducing competition. In the final section of this paper,
each path of reform is elaborated.

The role of the centre

In formal terms, the Ministry of Health and Social Affairs is the centre of
Swedish health services but the Ministry is a small body whose main role is to
provide support to the minister and to frame legislation. Of greater importance
is the National Board of Health and Welfare which acts on behalf of the
Ministry in implementing the provisions of legislation and in overseeing the
running of health services. However, the number of staff employed in the
Board has fallen considerably (from 1200 in 1970 to approximately 400 in
1990) as part of the policy of shifting responsibility for health services firmly in
the direction of the county councils. Also at a national level, the County
Councils’ Federation acts as the collective voice of the county councils and has
grown in importance in recent years. The Federation is thought of by some as
the unoficial Ministry of Health, so powerful has it become during the 1980s
DOI.
To the outside observer, the role of the Ministry of Health and Social
Affairs and the National Board of Health and Welfare appears very weak. Not
only do county councils have the support of local communities through the
ballot box, but also they raise most of the money they spend through local
taxes. The centre has few levers with which to shape what happens in the
county councils and has to operate through influence, persuasion, and the
quality of its ideas and advice. As the fate of the national waiting list fund
suggests (see above), county councils are able to resist the use of new
instruments designed to give the centre more control over the development of
services.
It can be argued that a shift back from decentralisation is now required.
This would involve the Ministry reasserting its position as the agency with
national responsibility for health services and supporting the National Board
of Health and Welfare in playing a bigger part in implementing national
policies. This calls for a strengthening of the policy-making role at the centre
but more importantly it means enabling the National Board of Health and
Welfare to monitor and review the performance of county councils.
One possibility is that the county councils would agree an annual contract
with the National Board setting out policy objectives to be pursued in the
counties. These objectives would be based on a national assessment of key
areas for action in the health services. At the end of the year, performance
against contract would be assessed and a contract for the following year would
be negotiated.
A review process of this kind would also enable the National Board to
138

gather intelligence about innovation and experimentation in different counties

and to disseminate good practices systematically throughout the health
services. The Board might be able to perform this function more effectively if it
were itself organised on a regional basis with support from a central policy
analysis team. In this way, the centre would have available a wider range of
mechanisms for carrying out its role and it would be able to work alongside
county councils in making progress on those issues (like the reduction of
waiting lists and the integration of health and social care) that really matter to
national government.

Management in the county councils

Reforms at this level might address a number of issues. One concern is to

clarify the respective roles of managers and politicians. The existence of a
number of full time paid politicians in each county means that there is overlap
between what politicians do and what top managers do. This does not help in
creating the conditions in which managers can really manage. Making it clear
that the role of politicians is to establish a strategic framework within which
managers have the space to exercise leadership and drive in the development of
services would help in tackling the weaknesses that exist. This could involve
each council determining what matters are to be reserved for politicians and
what matters should be delegated to managers. In this way it would be possible
to move from an administered public service to a dynamic public management
culture.
Both politicians and managers would be assisted in this process by the
introduction of a personnel package which supports the development of an
effective general management function. This could involve fixed term
contracts, a system of annual performance review, and performance related
pay. The performance of top managers would be assessed by politicians in
terms of their effectiveness in achieving the objectives set by politicians.
Successful performance would be rewarded with enhanced pay. These
arrangements could be further supported by an investment in management
training and development. This could include work with or alongside private
sector managers as part of a policy of developing ‘excellence’ in public sector
management. Delegating more responsibility to managers within agreed policy
parameters could be used to drive forward innovations to strengthen health
services. As an example, managers’ objectives could include the development
of initiatives to increase patient choice and make services more responsive to
consumers. It might be also possible to include a reduction in waiting lists as
one of the criteria against which the performance of managers would be
assessed. As with the contract negotiated between the centre and each county
council, the aim would be to develop new and more effective instruments for
implementing change in key areas.
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Managing clinical activity

A strong case can be made for building on the work that has gone into
developing the role of clinic chiefs and decentralising management responsi-
bility within hospitals. A number of health care systems are moving in this
direction and in some respects Sweden is already ahead of the field. There is,
however, a need to match the development of clinical management with a
strengthening of general management in hospitals. This would involve
upgrading management posts and salaries to attract the best people.
Managers could come from a variety of backgrounds, including medicine,
but they would be appointed solely for their management ability. Once in post,
managers would work closely with clinic chiefs to ensure that resources are
used effectively and efficiently. This would require support in terms of
improved information systems to enable doctors and managers to compare
performance with what is achieved elsewhere. One of the tasks of managers
would be to negotiate tough but realistic workload agreements with clinical
chiefs. These arrangements could include incentives to create a stimulus to
improved performance. Managers would also work with chiefs to ensure that
doctors fulfilled adequately their contractual obligations.
Introducing better management at this level would go a long way towards
the development of a stronger corporate culture in Swedish hospitals.
Challenging the power of individual clinicians to direct the way in which
services develop and engendering a sense of commitment and loyalty to the
organisation as a whole are critical to the success of any attempt to reform
health services. The appointment of managers able to win and retain the
support of medical staff and to carry credibility with other key players is
probably the most important single change that is needed.

Competition and accountability

The idea of public competition as a strategy for responding to patients’

demands and icreasing efficiency has been gaining currency. Saltman and von
Otter [l 1,I 21 have spelt out the key elements of public competition,
emphasising the role of patients in choosing among publicly employed GPs
and hospitals. As Saltman and von Otter note, public competition depends on
the existence of financial incentives to reward providers who are successful in
attracting patients. The corollary is that GPs and hospitals that fail to attract
patients lose out financially. In essence, then, providers compete for a bigger
market share within fixed global budgets.
A number of counties have begun experimenting with such an approach
including Stockholm and Koppaberg (the so-called Dallamodel). Although the
idea of public competition is attracting a good deal of interest, in practice there
are likely to be a number of constraints on the ability of county councils to
stimulate competition between hospitals outside the major cities of Stockholm,
Gothenburg and Malmo. One obvious limitation is that in many areas a single
140

hospital is the major provider of acute services to the local population and to
make use of an alternative would require patients to travel long distances. A
further difficulty is that there is no real incentive for politicians to remove
resources from a cherished local hospital and to transfer the resources
elsewhere when both staff and the public may oppose such a move. A more
realistic alternative may be to make providers more accountable for their
performance through better management.
One way of doing so would be to separate responsibility for purchasing
services and providing services within county councils. In other words, one
group of managers and politicians would be responsible for purchasing health
care and another group would be responsible for managing and providing
services. The purchasers could be based at the county level or in districts within
counties. Purchasers would concentrate on analysing the need for health care
and developing a purchasing strategy to meet needs. Operational management
would be firmly in the hands of service providers.
Purchasers would negotiate contracts or service agreements with providers
specifying the cost, quality, and quantity of services to be delivered. The
service agreement would be a key instrument for improving performance and
for ensuring accountability. Agreements would be public documents and
would help to create greater openness and transparency in the purchasing and
provision of services. By establishing purchasers at arm’s length from
providers, it ought to be possible to develop a counterweight to the power
of professional interests and to overcome the problem of ‘provider capture’
which has bedevilled health care systems wherever agencies combine
responsibility for paying for and delivering health care.

Conclusion

The ideas outlined in the previous section essentially involve incremental

changes to the status quo. The rationale behind this, to return to an earlier
point, is that health services in Sweden perform well and do not need major
restructuring. A further consideration is that the Swedish policy style is not
given to sudden changes of direction. A process of step by step reforms is likely
to be more in keeping with this style.
Few of these ideas are original. In part, they emerge from study of health
care reforms internationally [I] and in part they are based on reflections on the
Swedish health services over a number of years. These reflections have
reinforced the feeling that public health care systems have been administered
rather than managed in the past and that doctors have been left with
considerable freedom to determine how to carry out their work. Neither of
these features is tenable in a period in which resources (human as well as
financial) are constrained and medical possibilities continue to expand. Ideas
based upon competition are in good currency and are being tried in some
places, but it would be a mistake to move only in this direction when effective
 141

planning and management have hardly been tried. Competitive initiatives need
to go hand in hand with changes to management arrangements at the centre, in
the county councils and within hospitals.
One of the strengths of the decentralised nature of the Swedish system is the
scope it allows for innovation and experimentation. This makes it possible for
policy makers to promote a number of ‘natural experiments’. Individual
counties or districts within counties can pioneer a new approach to service
delivery enabling other counties to learn from this experience in advance of
widespread application and implementation. Policy makers should take
advantage of this aspect of the Swedish system to initiate and evaluate
different reforms in different places. This would enable the strengths and
weakness of the reforms to be assessed before they are taken up throughout the
system.

Acknowledgement

Thanks are due to Mats Brommels for his comments on the first draft of this
paper.

References

I Ham, C. et al., Health Check, Ring’s Fund Institute, London, 1990.

2 Ham, C. et al., Managed Competition, Ring’s Fund Institute, London, 1989.
3 Maxwell, R.J., Health and Wealth, Lexington, Massachusetts, 1981.
4 Schieber, G.J. and Poullier, J.P., International health care expenditure trends: 1987, Health
Affairs, 8 (1989) 169-177.
5 Ham, C., Governing the health sector: power and policy making in the English and Swedish
health services, The Milbank Quarterly, 66 (1988) 389-414.
6 National Board of Health and Welfare, Health in Sweden, Stockholm, 1982.
7 National Board of Health and Welfare, The Swedish Health Services in the 199Os, Stockholm,
1985.
8 OECD, Financing and Delivering Health Care, Paris, 1987.
9 National Board of Health and Welfare, Public Health Report, Stockholm, 1988.
10 Ham, C., Steering the Oil Tanker, King’s Fund Institute, London, 1987.
11 Saltman, R. and von Otter, C., Public competition vet-us mixed markets: an analytic
comparison, Health Policy, 11 (1989) 43-55.
12 Saltman, R. and von Otter, C., Revitalising public health care systems: a proposal for public
competition in Sweden, Health Policy, 9 (1987) 21-40.