Pragmatic Health Reform:
Second-Order Strategies from Europe
Swedish Experiences on chronic care
Johan Calltorp, MD, PhD
Professor of Health Policy and Management
The Vårdal Research Foundation
Former Director of Health Services, Western
Health Services Region, Sweden
johan.calltorp@comhem.se +46 8 708327490
Johan Calltorp AcademyHealth
2007-06-04
Basic assumption
• Health services ”production methods” are
increasingly becoming international
• Health services delivery is still shaped
very much by culture, tradition, social and
economic context
• It is increasingly important to develop
methods to compare between countries for
learning and understanding of the issues
Johan Calltorp AcademyHealth
2007-06-04
Europe and North America
• Within Europe more detailed comparisons of
health systems begin to develop due to the
dynamics of the European Union.The European
Observatory on Health Systems and Policies is
an important actor
• Also integration between the European systems
will increase – but the pace is slow because of
”cultural” conditions
• It is of great interest to develop methods to
compare health services between Europe and
North America
Johan Calltorp AcademyHealth
2007-06-04
The Swedish health system
• Dominantly public regarding financing,
ownership and delivery of services
• Minor “private” elements integrated in the
public financing – mostly working on contracts
from the county councils
• Local strong base for the delivery of services
with 21 county councils responsible for
financing (80 % of total), planning and
delivery of services
• A regional planning regarding highly
specialized care since the 1960´ s
Johan Calltorp AcademyHealth
2007-06-04
The Swedish health system,cont.
• Physicians salaried since 1970 – relatively
small differentials between specialities and
parts of the country
• The system is mainly budget based and
controlled, little “incentive” thinking
• A public health perspective in planning and
well developed intersectorial cooperation has
been important for health results and
outcome
Johan Calltorp AcademyHealth
2007-06-04
Distribution of resources over
population groups in Sweden
Age
0-15
16-64
65-
Population
18,1
64,5
17,4
100
Over 75
40%
Final year of life 25%
Resources
6
36
58
100
Of total resources
Johan Calltorp AcademyHealth
2007-06-04
Indicators of mortality and morbidity
Life expectancy
at birth 1998
Male
Female
Sweden
76,9
UK
74,6
US
73,9
Median
74,6
OECD countries
81,9
79,7
79,4
80,5
Potential years of life lost
per 100.000 pop. 1997
Male
Female
4.199
5.319
7.351
6.055
2.594
3.302
4.213
3.135
Anderson and Hussey, Health Affairs, May/June 2001
Johan Calltorp AcademyHealth
2007-06-04
Johan Calltorp AcademyHealth
2007-06-04
A division of responsibility for
care of the elderly and chronic
patients
• County councils are responsible for all
needed medical care – inpatient and
outpatient specialized care and primary
care
• Municipalities are responsible for “nursing
care” in the home and “sheltered living”
• Advanced home health care is developed
rapidly but unevenly over the country
Johan Calltorp AcademyHealth
2007-06-04
Decentralization, but still
national coordination and steering
through many formal and informal
mechanisms
• Legislative and economic control by gvnmt.
• Supervision and control by authorities
(medical, pharmaceutical, disciplinary)
• Well developed patient data bases ( based
on “personal numbers”)
• Technology Assessment (SBU), QA focus
in several national bodies
Johan Calltorp AcademyHealth
2007-06-04
Development of specific “tools”
for medical quality “management”
• Around 60 national medical quality
registries based on diseases/diagnoses
monitoring major acute and chronic
disorders
• Detailed and structured “medical treatment
protocols” (guidelines, pathways)
developed nationally for big patient groups
(heart disease, stroke, anxiety/depression),
cooperation between research/profession
Johan Calltorp AcademyHealth
2007-06-04
Local/regional/national dynamics
• National resource constraints during 1990´s
“triggered” structural reforms of hospital
mergers, closures and integration of
services (“seamless care)
• Spending presently approx 9,8 % of GDP
• A pattern of local initiatives and
experiments and key national coordination
• The process that county councils merge to
regions has a resource and quality drive
Johan Calltorp AcademyHealth
2007-06-04
Health reform examples through
the described dynamics
“The local care” (närsjukvård)
• Basic care, close to home, mostly for
chronic “multidisease” patients
• To increase continuity, access, quality
• To enhance “functional” cooperation
between specialized hospital care, primary
care and the municipality care. Locally
tailored.
• Linked to hospital restructuring. Problems
in remote areas with few people.
Johan Calltorp AcademyHealth
2007-06-04
Western Health ServicesRegion
1,5 million pop. 17 hospitals, 60 health centres, dental care
Johan Calltorp AcademyHealth
2007-06-04
Examples of innovations
• Specialist “on site” consultations to primary
care and to municipality social services
• Information network building, IT-support on
distance, shared patient charts etc.
• On-line booking systems to radiology,
specialized diagnostics, surgery etc.
• Pharmaceutical rounds – analyzing and
acting towards overuse and underuse
Johan Calltorp AcademyHealth
2007-06-04
Examples of innovations
• Advanced home health care is developed
through the structured cooperation
mechanisms. Teams of doctors, nurses,
technicians are organized jointly by county
council and municipality
• For terminal care enhancements in pain
treatment and palliation at home
• Cooperation regarding psychiatric
“multidiagnose” patients enhanced as well
Johan Calltorp AcademyHealth
2007-06-04
Health reform example:
Stroke guidelines and quality
registry
• A national treatment protocol developed –
medical results, evidence, health economy
• A detailed “condition – treatment” content
• Covers all from prevention to rehabilitation
• Prioritized actions
• A “not to do” list (methods to stop doing)
• Monitoring through the national quality
registry
Johan Calltorp AcademyHealth
2007-06-04
Health reform example:
Cancer care
• No specific “cancer hospital” tradition, oncology
as a speciality in main hospitals and forming of
cancer teams
• “Regional oncology centers” developed since 20
years – epidemiology, information, feed-back
• Presently an incremental development of regional
cancer treatment programs – medical protocols,
quality supervision, organizational cooperation,
forming “virtual” cancer clinics in each region.
Johan Calltorp AcademyHealth
2007-06-04
Chronic care in Sweden means:
• Functionally integration between actors specialized care, primary care, municipality
services
• Active use of new “medical management
methods” like quality registries, treatment
protocols, feed-back of practice variations.
• Local/regional dynamics for new ideas and
organizational development interplay with
national coordinating mechanisms
Johan Calltorp AcademyHealth
2007-06-04