Original Article

International Journal of Health

Services
What Is Happening 0(0) 1–8
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DOI: 10.1177/0020731418822236
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om1
Bo Burstr€

Abstract
Election to the parliament was held in Sweden on 9 September 2018. None of the
traditional political blocks obtained a majority of the vote. The nationalist Sweden
Democrats party increased their share of the vote from 13% in 2014 elections to
17% of the vote in 2018. As no traditional political block wants to collaborate with
the Sweden Democrats, no new government has yet been formed, more than
2 months after the election. Health care was a prominent issue in the elections.
Health care in Sweden is universal and tax-funded, with a strong emphasis on equity.
However, recent reforms have emphasized market-orientation and privatization in
order to increase access to care, and may not contribute to equity. In spite of a
majority of the population being opposed to profits being made on publicly funded
services, privatization of health and social care has increased in the last decades. The
background to this is described. Health is improving in Sweden, but inequalities
remain and increase. The Swedish Public Health Policy from 2003 has been revised
in 2018, on the basis of a national review of inequalities in health. The revised policy
further emphasizes reducing inequalities in health.

Keywords
sweden, health care, health inequalities

Recent Elections
The recent elections on September 9, 2018, resulted in no evident majority to
form a new government (Table 1). After the previous elections in 2014, the

1
Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
Corresponding Author:
Bo Burstr€om, Department of Public Health Sciences, Karolinska Institutet, SE 171 77, Stockholm, Sweden.
Email: bo.burstrom@ki.se
2 International Journal of Health Services 0(0)

Table 1. Election Results, Parliamentary Elections September, 2018.

Share of Number of
Party Votes (%) Mandates

The Moderate party 19.84 70

The Centre party 8.61 31
The Liberal party 5.49 20
The Christian Democrats 6.32 22
The Social Democratic party 28.26 100
The Left party 8.00 28
The Green party 4.41 16
The Sweden Democrats 17.53 62
The Feminist Initiative 0.46 –
Other parties 1.07 –
Source: Valmyndigheten [Electoral authority], Sweden.

Social Democratic Party and the Green Party formed a minority government
with support of the Left Party. In the current election, this block of parties got
144 of the 349 mandates in the parliament, compared to 143 mandates for the
other block, the bourgeois coalition (the “Alliance”), made up of the Moderate
Party, Center Party, Liberal Party, and Christian Democrats. The nationalist
Sweden Democrats got 17.53% of the vote and 62 mandates in the parliament.1
Therefore, none of the established political blocks got a majority of the votes,
and none could naturally form a government. Discussions are ongoing regard-
ing collaboration between different parties.
Both of the established political blocks have declared that they do not wish to
collaborate with the Sweden Democrats to form a new government. The only
party open for such collaboration is the Christian Democrats. Hence, more than
2 months after the election, no new government is yet in place.

Increased Support for the Sweden Democrats

The Sweden Democrats party was founded in 1988 and describes itself as social-
ly conservative with a nationalist foundation. Others have described it as right-
wing, populist, and anti-immigration.2 Support for Sweden Democrats has
increased considerably since the last election, from 12.86% to 17.53%.1 The
party had 1.4% in the 2002 election, which doubled to 2.9% in 2006 and
increased to 5.7% in 2010.3
According to a party preference survey in May 2018,4 the recent increased
support has come from previous supporters of the Social Democratic Party
(2.5%) and the Moderate Party (2.2%) but also from other parties in the
Alliance. The support for Sweden Democrats is twice as high among males
Burstr€om 3

compared to females, twice as high among those with low- or middle-level edu-
cation compared to those with high-level education, and higher among persons
born in Sweden than those born outside Sweden. There was no particular
age gradient.4
These results confirm results from a 2014 study characterizing persons who
sympathize with Sweden Democrats.3 Persons sympathizing with Sweden
Democrats had low- or middle-level education, had a working class or farming
background, and were more often employed in the private sector. Unemployed
persons and persons with disability pensions or on sickness benefits were over-
represented among sympathizers. Regarding age, the support for Sweden
Democrats was high among persons less than 30 years old in the countryside,
while in bigger cities the support was higher among retired persons. The support
primarily comes from persons born in Sweden but to some extent also from
persons born outside Sweden.3

Why Did the Support for Sweden Democrats Increase?

Why did Sweden Democrats increase in the recent election? There are many
theories on this, including that the migrant issue has not been dealt with by the
established parties. A large influx of refugees in 2015 put great strain on services
and generated changes in public opinion. Early in 2015, about 4,000 persons per
month sought asylum, but the number increased rapidly to 39,136 persons in
October. At the end of 2015, a total of 162,877 persons had sought asylum
during the year.5 By the end of November 2015, the government made drastic
and restrictive changes to policies: time-limited residence permits, restricted
family reunification, and ID checks on entry points into Sweden. In opinion
polls at the end of 2015 and early 2016, an increasing proportion of the public
thought that Sweden accepted too many refugees. In addition, an increasing
proportion did not agree with the government policies: some thought that too
many refugees were still let into the country; others considered the new restric-
tive policies too harsh. The other political parties were also divided on this issue,
but the Sweden Democrats argued for even stricter policies to reduce the
number of migrants.5
Some explanations of the increased support for Sweden Democrats in
Sweden also draw parallels to the explanations of Trump’s success in the
United States and of the increased support for nationalistic movements in
other European countries.6 Some Sweden Democrats argue that Swedish society
is being transformed quickly; that the countryside has been neglected and all
focus is on larger cities; that unemployment has increased especially in some
groups; and that restrictions in social welfare are due to the influx of refu-
gee immigrants.
Sweden Democrats have stronger support in rural areas, small towns, and
disadvantaged areas of bigger cities.3 In the recent election, about 25% of the
4 International Journal of Health Services 0(0)

members of the blue-collar trade union (LO) voted Sweden Democrats. A higher
proportion have low education, and more are men (but also increasingly more
women). The new Sweden Democrat voters have come mainly from Social
Democrats, Conservatives, and Christian Democrats but also from voters for
other parties.4

Impact of Elections on Policy in Health Care and

Welfare Services
Health care and to some extent other welfare services were prominent election
issues. Some of the main concerns were access to care, waiting times, and the
closing down of small hospitals, in addition to local issues regarding health care.

Swedish Health Care Policy and Organization

Health care in Sweden is universal, tax-funded, and governed by the Health and
Medical Services Act from 1982, which states as its goal that “Health and
medical services are aimed at assuring the entire population of good health
and of care on equal terms.”7 The act goes on to state that persons with greater
needs should be prioritized before those with lesser needs. Hence, the emphasis
on equity in health and need-based health care is strong in policy documents.
However, the policies implemented in recent decades have rather emphasized
increased market-orientation and privatization, as a means of increasing access
to care. Therefore, it has been debated whether these reforms contribute to or
counteract the policy emphasis on equity.8–10
Sweden has 3 administrative levels: municipalities, county councils and
regions, and the national level. The recent elections covered all 3 levels. In
opinion polls, a large majority of the population want to have a tax-funded
welfare system and oppose profits being made on such services.11 However, the
view of the people is not represented in parliament. Only the Left Party has been
unambiguous in demanding a regulation of the profits made in the wel-
fare sector.
The responsibility for health care in Sweden is decentralized to the 20 county
councils and regions, which collect taxes and operate independently of the
national level. Similarly, social services, schools, care of children, and care of
the elderly are the responsibility of municipalities, which also collect taxes.
Many municipalities and county councils are led by bourgeois coalitions,
before and after the recent elections.

Increasing Privatization of Publicly Funded Welfare Services

Since the 1980s and early 1990s, there has been a movement to increase the
private provision of publicly financed welfare services, inspired by the
Burstr€om 5

Reagan and Thatcher governments,11 and the intensity of this movement has
varied with the political leadership at the national, regional, and local levels.
Bourgeois coalitions have had more emphasis on privatization, but also Social
Democrats have allowed and contributed to privatization of welfare services. The
expansion of private providers has been particularly rapid between 2000 and 2015:
the increase was 247% in education, 130% in elderly care, and 106% in health
care. The overwhelming part of the private providers operate for profit.11

How Has the Increase in Privatization of Services Occurred?

It may seem paradoxical that although a large majority of the Swedish popula-
tion do not want private, for-profit provision of tax-funded welfare services, the
actual development over the last decades has been precisely an increase of such
services. What explains such a development?
The rapid increase of publicly funded private providers has been facilitated
by different developments, described by several authors.8,9,11,12 One aspect has
been to build ideological support for the idea of private provision, accomplished
through commercial think tanks. Another has been administrative changes since
the 1980s and 1990s inspired by New Public Management ideas in budgets and
reimbursement systems, introducing a purchaser-provider split for reimbursing
both private and public service providers. Thirdly, changes in legislation have
enabled a rapid expansion of private providers and reduced the power of munic-
ipalities and county councils in their capacity to plan and allocate services.11

Building of Ideological Support

Lobbying by pro-market organizations in the business community has played an
important role in paving the way for the increase of private providers.11 In
explaining the expansion of for-profit welfare delivery in Sweden, Svallfors
and colleagues argue that capital and the commercial organizations not only
attempt to influence other parties’ actions directly but also to influence how they
think. The business community has become a new important actor in the polit-
ical landscape – not only at the top level but to a large extent through network-
ing, policy and advocacy, and concerted actions on a lower level. The previous
structure with political parties, corporatist organizations, and high-level nego-
tiations now plays a lesser role, in relation to the strategic and organized action
by the business community.11

Changes in Management and Reimbursement Systems

With the New Public Management ideas from the 1980s, an internal quasi-
market was created in health care, separating purchasers from providers and
introducing payment systems based on service production and performance.
6 International Journal of Health Services 0(0)

Providers, including the public providers, should compete on the market, and
patients became customers who should choose their providers. During the 1990s
there was a slow increase in the number of private providers, but the idea of
competition and commercial payment and reimbursement systems was
in place.9,11

Changes in Legislation to Facilitate Privatization

Health care services are still largely publically provided in Sweden, but in recent
decades the proportion of private providers (especially in outpatient services)
has increased. These private providers are operating for profit on public fund-
ing. Their number increased rapidly after 2010 when a law (LOV, Lagen om
valfrihet) was passed on free establishment of private providers and free choice
of provider in primary care. The law is mandatory for primary care and volun-
tary for specialist care. Free establishment of specialist care is implemented only
in some county councils (e.g., Stockholm county council).9 The stated intention
of the reform was to increase access to care. This arrangement basically allows
any private provider who meets the requirements and standards of the county
council to set up a clinic, treat patients, and send the bill to the county council.
This arrangement has no time limit and can go on as long as there is no serious
misconduct. The proportion of private providers varies greatly across county
councils and is highest in Stockholm county council, where two-thirds of pri-
mary care is performed by private companies.
The increasing privatization has important implications for the entire health
care system, as conditions differ between public and private providers to the
advantage of private providers, and the county councils are responsible for
funding the private providers before paying the public providers.9
Surprisingly, there has been very little public and political debate about the
increasing privatization of tax-funded health care services.

Health in Sweden
Population health indicators are favorable in Sweden, but inequalities in health
remain and partly increase.13 When many other countries performed national
(“Marmot”) reviews on health inequalities around year 2010, Sweden did not.
However, the government elected in 2014 (Social Democrats and Green Party,
with support of the Left Party) initiated a review of inequalities in health in
2015, which reported to the government in 2017. The final report14 highlights
that health inequalities are still an important issue in Sweden and that inequal-
ities in some respects are increasing. For instance, the gap in life expectancy
between high- and low-educated men indicates a difference of 6 years between
men with high and low education.14
Burstr€om 7

The final report of the commission is based on a number of sub-studies and

background reports, investigating the level and trends of inequalities in health,
organizational prerequisites, and governing structures which could be amended
to have an impact on inequalities. The proposals in the report underline the
importance of further emphasizing the work to reduce inequalities in health. The
report has resulted in a revision of the national Public Health Policy. The overall
aim is still the same (“To provide societal conditions for good health for all”).
The Public Health Policy is still based on the social determinants of health, but
the number of target areas has been reduced from 11 to 8, by joining some of the
previous target areas under the same heading. According to the final report,14
the focus should be on reducing inequalities in health, and the Public Health
Agency of Sweden should be charged especially with monitoring and follow up
on health inequalities. A national committee of all relevant government agencies
should be formed to address inequalities in health.
However, no new funds have been allocated for implementing the policy, and
it is still unclear what the proposed changes will lead to. Another issue is wheth-
er and how it will be implemented by a new government.

Declaration of Conflicting Interests

The author declared no potential conflicts of interest with respect to the research, author-
ship, and/or publication of this article.

Funding
The author received no financial support for the research, authorship, and/or publication
of this article.

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Author Biography
Bo Burstr€om, MD, PhD, is professor in Social Medicine at the Department of
Public Health Sciences, Karolinska Institutet and senior consultant to
Stockholm County Council, Sweden. His research interests are mainly in
inequalities in health, access to health care and social consequences of disease,
and on health and living conditions of socially and economically disadvantaged
groups. He has also done international comparative studies on the impact of
policy on inequalities in health.