I had the opportunity to visit Sweden on a study abroad program with Texas Woman’s University last month.
Having lived and worked in India until I was a young adult, I experienced healthcare delivery in another country (besides the US) both as a patient and a provider. So, I did not expect the Swedish healthcare system to surprise me, but it did! I have often pondered about the claim “the US healthcare system is the best in the world”. As a healthcare administrator, I know on many levels that is not true. We undeniably have some of the greatest technology, innovation, talent, and infrastructure in the world. Yet our health outcomes and quality metrics are far from the best and many living in this country still do not have access to the basic healthcare they need. And in terms of cost, we are among the most expensive in the world!
Sweden is a social democracy with a population of about 10 million. Unions and employers have figured out a harmonious congruence with the government and everyone focuses on economic prosperity. Healthcare services are centralized and provided by the government through counties and municipalities and funded through individual taxes. This does result in a high rate of taxation, up to 45%. But it not only covers healthcare, but also social insurance like unemployment, and free elderly care and education including higher education and college. They have an extensive network of primary care facilities and fewer hospital beds per capita than the US. Sweden has among the highest life expectancy and lowest infant and maternal mortality rates in the world, among other admirable quality outcomes.
I am not an economist or policy expert and this article does not attempt to start a debate on which country is doing healthcare better. I merely want to share my observations from the trip and hope to provide a different and thought-provoking perspective.
Healthcare is based on the principle of social equity. Regardless of the taxes you pay, you have access to the same level of care and services like everyone. This does lead to access issues in terms of wait times, especially for seeing a specialist where the government mandated time is 90 days. About 15% of the population have purchased private insurance, which is slowly emerging. It “buys” them a place at the head of the waitlist.
Healthcare is considered a right and not a privilege, without discrimination. In 2013 a law was implemented to provide healthcare for the undocumented population. There are still loopholes being worked out here due to the recent influx of refugees, but the intent to uphold that law is still prevalent.
Elderly care is based on dignity - respecting freedom of choice. Every senior has access to free homecare – not just healthcare but also laundry, housekeeping, transportation and other functions. This allows them to remain in their homes for as long as they desire. We visited a beautiful facility that was privately run and had independent living apartments along with a nursing home where seniors could transition to the appropriate level of care. As low as 15,000 elderlies utilize this opportunity as most of them prefer to live in their own homes.
Since we do most certainly have the highest cost of healthcare, here maybe some contributing factors.
o The cost of drugs in the US is arguably one of the leading costs of care. Sweden has had a centralized government owned pharmacy and only in 2009 did private pharmacies begin to emerge, but they are still a very small proportion. This allows the government to regulate the costs of drugs from inflating.
o The government has also laid down high cost ceilings for any services that a provider can charge so the overall costs cannot sky rocket.
o Another interesting contrast was with the delivery of care. The system runs very lean and there are not many “layers” of staffing. In fact, we had to explain to them what healthcare administration was! They use clinicians as administrators - nurses and doctors. Do not have mid-level providers or extenders like we do in the US. The nurses even make home visits like community health workers. I can imagine some of the inefficiencies this model has but it didn’t seem to be cost prohibitive to them.
o Litigation does not seem to be a prevalent issue. I am not sure if it is a mindset or a cultural difference, but we did not hear of any lawsuits that drive up the cost of liability and practice insurance like in this country. Reported medical errors seem to be minimal.
Pay for performance has been an ongoing discussion in the US and we are still trying to find the best “model”. In Sweden, doctor’s compensation is a fixed model - 65% by patients listed (not seen), 20% actual patient visits, and 15% on their quality metrics. The inequity that exists between specialist’s compensation in US is non-existent there.
From a public health perspective, we did observe a lot of smoking and drinking in Stockholm. It maybe more of an urban occurrence as the overall country statistics have shown a decline, and their incidence of related cancers is not as high. Their demographic and ethnic diversity is surly unlike the US, so health outcomes could be more predictable and influenceable.
Despite my admiration of the Swedish lifestyle, I was surprised to hear that mental health is the biggest cause of sick leave in the country. So, there are strides to be made in that area. It also validates, in my mind, the fact that environment can only contribute so much, most mental illness is genetic.
The most striking observations for me personally were lifestyle and society related. As healthcare providers we know in the US, only about 15% of healthcare is delivered in the hospital setting. Most health outcomes are governed by genes, lifestyle and social determinants of health. People in general seemed to be happy and more carefree. We were introduced to the social practice of “Fika” which is an afternoon cup of tea and bread while you catch up with friends! I saw kids running naked in parks while the American mom in me screamed inside my head “watch out for pedophiles!” and people taking a swim after work in the clean waters.
Some interesting observations:
o 480 days of parental leave policy was implemented in 1974! And in the US, we are still discussing this in 2018. In fact, we do not even have mandatory paid leave for women yet. Even as a ranked healthcare executive, I took unpaid leave for both my children. It was a refreshing sight to see men with strollers in parks in the middle of the day.
o In the US, we work hard and play hard but in reality, most of us work much harder than we play! Which is why “work life balance” seems to be such a hot topic. The high level of stress and mental health challenges we face could be attributed to this lifestyle. Sweden mandates four consecutive weeks’ vacation to all its working population. In fact, you get a bonus in lieu of the vacation but as you can imagine very few take that offer. As a hospital administrator, I cannot imagine the staffing nightmares this policy may cause us, leave alone other industries, but it seems to work for them!
o Many employers are testing the six-hour work day and reduced pay for reduced work to offer even more flexibility to professionals.
o People care for the environment! Use of chemicals in daily life and food is minimal. Organic food is reasonably affordable for the public and people often grow their produce in urban gardens. People walk and bike much more than they drive cars in Stockholm. Some areas in the city are blocked off from vehicular traffic, preserving the historic buildings and curbing air pollution.
o Everyone looks fit! America is fat - obesity which is linked to cardiovascular diseases and cancer among many other problems, is an epidemic. Are diet pills, exercise DVDs and weight loss programs really the solution or do we need to rethink health and wellness?
While we are trying to find the best solution to access, quality, and cost of healthcare, we cannot ignore to address some of the cultural aspects that intrinsically affect health and wellness of Americans. Whether you are a cynic, skeptic or a realist – I hope that there are things that resonate with you from my travel diary! It was an enriching experience, professionally, culturally and personally.
Mitali Paul is CEO of Sugarland Rehab Hospital and Adjunct Faculty with Texas Woman’s University.