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The Health Systems in Transition ( HiT) country reports provide an analytical description of each health system and of reform initiatives in progress or under development. They aim to provide relevant comparative information to support policy-makers and analysts in the development of health systems and reforms in the countries of the WHO European Region and beyond. The HiTs are building blocks that can be used: to learn in detail about different approaches to the financing, organization and delivery of health services; to describe accurately the process, content and implementation of health reform programmes; to highlight common challenges and areas that require more in-depth analysis; and to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in countries of the WHO European Region. This analysis of the Swedish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. This series is an ongoing initiative and material is updated at regular intervals.

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The Health Systems in Transition (HiT) country reports provide an analytical description of each health system and of reform initiatives in progress or under development. They aim to provide relevant comparative information to support policy-makers and analysts in the development of health systems and reforms in the countries of the WHO European Region and beyond. The HiTs are building blocks that can be used: to learn in detail about different approaches to the financing, organization and delivery of health services; to describe accurately the process, content and implementation of health reform programmes; to highlight common challenges and areas that require more in-depth analysis; and to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in countries of the WHO European Region. This analysis of the Swedish health system reviews recent developments in organization and governance, health financing, health care provision, health reforms and health system performance. This series is an ongoing initiative and material is updated at regular intervals.

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BACKGROUND: This article addresses the role of audit and feedback (A&F) to support change behaviour and quality improvement work in healthcare organisations. It contributes to the sparse literature on primary care centre (PCC) managers´ views on A&F practices, taking into account the broad scope of primary care. The purpose was to explore if and how different types of A&F support change behaviour by influencing different forms of motivation and learning, and what contextual facilitators and barriers enable or obstruct change behaviour in primary care. METHODS: A qualitative research approach was used. We explored views about the impact of A&F across managers of 27 PCCs, in five Swedish regions, through semi-structured interviews. A purposeful sampling was used to identify both regions and PCC managers, in order to explore multiple perspectives. We used the COM-B framework, which describes how Capability, Opportunity and Motivation interact and generate change behaviour and how different factors might act as facilitators or barriers, when collecting and analysing data. RESULTS: Existing forms of A&F were perceived as coercive top-down interventions to secure adherence to contractual obligations, financial targets and clinical guidelines. Support to bottom-up approaches and more complex change at team and organisational levels was perceived as limited. We identified five contextual factors that matter for the impact of A&F on change behaviour and quality improvement work: performance of organisations, continuity in staff, size of organisations, flexibility in leadership and management, and flexibility offered by the external environment. CONCLUSIONS: External A&F, perceived as coercive by recipients of feedback, can have an impact on change behaviour through 'know-what' and 'know-why' types of knowledge and 'have-to' commitment but provide limited support to complex change. 'Want-to' commitment and bottom-up driven processes are important for more complex change. Similar to previous research, identified facilitators and barriers of change consisted of factors that are difficult to influence by A&F activities. Future research is needed on how to ensure co-development of A&F models that are perceived as legitimate by health care professionals and useful to support more complex change.

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Aim To study (a) the covariation between patient reported experience measures (PREMs) and registered process measures of access and continuity when ranking providers in a primary care setting, and (b) whether registered process measures or PREMs provided more or less information about potential linkages between levels of access and continuity and explaining variables. BACKGROUND: Access and continuity are important objectives in primary care. They can be measured through registered process measures or PREMs. These measures do not necessarily converge in terms of outcomes. Patient views are affected by factors not necessarily reflecting quality of services. Results from surveys are often uncertain due to low response rates, particularly in vulnerable groups. The quality of process measures, on the other hand, may be influenced by registration practices and are often more easy to manipulate. With increased transparency and use of quality measures for management and governance purposes, knowledge about the pros and cons of using different measures to assess the performance across providers are important. METHODS: Four regression models were developed with registered process measures and PREMs of access and continuity as dependent variables. Independent variables were characteristics of providers as well as geographical location and degree of competition facing providers. Data were taken from two large Swedish county councils. Findings Although ranking of providers is sensitive to the measure used, the results suggest that providers performing well with respect to one measure also tended to perform well with respect to the other. As process measures are easier and quicker to collect they may be looked upon as the preferred option. PREMs were better than process measures when exploring factors that contributed to variation in performance across providers in our study; however, if the purpose of comparison is continuous learning and development of services, a combination of PREMs and registered measures may be the preferred option. Above all, our findings points towards the importance of a pre-analysis of the measures in use; to explore the pros and cons if measures are used for different purposes before they are put into practice.

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In the context of current economic difficulties across Europe, accurate budgeting and resource allocation have become increasingly important. Vaccination programmes can respond to the needs of governments to budget with confidence. It may be more reliable and accurate to forecast budget and resource allocation for a vaccination programme than for unpredictable seasonal disease peaks of infections such as rotavirus gastroenteritis, influenza, and pneumonia. In addition, prevention through vaccination involves low levels of investment relative to the substantial benefits that may be obtained. In France, total lifelong vaccination costs, per fully compliant individual, ranged from €865 to €3,313, covering 12 to 16 diseases, which is comparable to, or lower than, costs of other preventive measures. In addition, effectively implemented vaccination programmes have the potential to generate substantial savings both in the short and in the long term. For example, vaccination programmes for rotavirus, meningitis C, human papillomavirus, influenza, and pneumonia have all been shown to significantly reduce the disease burden, and thus the associated costs, in the first years following vaccination implementation. These programmes demonstrate the potential for health authorities to obtain early, and often substantial, return on investment.

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BACKGROUND: A number of reforms have been implemented in Swedish health care to support integrated care for frail older people and to reduce utilization of hospital care by this group. Outcomes and process indicators have been used in pay-for-performance (P4P) schemes by both national and local governments to support developments. OBJECTIVE: To analyse limitations in the use of outcome and process indicators to incentivize integrated care for elderly patients with significant health care needs in the context of primary care. METHOD: Data were collected from the Region Skåne county council. Eight primary care providers and associated community services were compared in a ranking exercise based on information from interviews and registered data. Registered data from 150 primary care providers were analysed in regression models. RESULTS AND CONCLUSION: Both the ranking exercise and regression models revealed important problems related to risk-adjustment, attribution, randomness and measurement fixation when using indicators in P4P schemes and for external accountability purposes. Instead of using indicators in incentive schemes targeting individual providers, indicators may be used for diagnostic purposes and to support development of new knowledge, targeting local systems that move beyond organizational boundaries.

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In parallel to market-like reforms in Swedish primary care, the gathering and compilation of comparative information about providers, for example through survey tools, has been improved. Such information is increasingly being used to guide individuals' choice of provider and payers' assessments of provider performance, often without critically reflecting about underlying factors affecting the results. The purpose of this study was to analyze variation in patient satisfaction, with respect to organizational and structural factors, including the mix of registered individuals, among primary care providers, based on information from a national patient survey in primary care and register data in three Swedish county councils. Systematic variation in patient satisfaction was found with respect to both organizational and structural factors, including characteristics of registered individuals. Smaller practices and practices where a high proportion of all visits were with a doctor were associated with higher patient satisfaction. Also practices where registered individuals had a low level of social deprivation and a high overall illness on average were associated with higher patient satisfaction. Factors that are of relevance for how well providers perform according to patient surveys are more or less possible to control for providers. This adds to the complexity for the use of such information by individuals and payers to assess provider performance.

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BACKGROUND: The choice between different attention-deficit/hyperactivity disorder (ADHD) medications depends on different drug attributes. Economic evaluations of drugs often disregard the utility of other attributes compare with the drugs' efficacy. AIMS: The aim of this study was to assess patient's preferences and elicit willingness-to-pay (WTP) for different drug attributes in the treatment of ADHD. METHODS: 285 patients (117 parents for children below 15 years, 52 adolescents 15-17 years and 116 adults aged 18 years and above) from Sweden, Denmark and Norway completed a questionnaire concerning their ADHD drug treatment, and answered questions on their preferences using a discrete choice experiment (DCE). Included attributes were effectiveness, side-effects, dosing and price. RESULTS: Effectiveness was the most important attribute, followed by side-effects and the number of dosings per day (all P < 0.001). The estimated monthly WTP for a drug generating full effectiveness, no side-effects and once-daily dosing was €790 for adolescents and €360 for adults. The estimated WTP for ADHD drugs with characteristics similar to existing drugs on the market was higher or in line with market prices (€37-180 for adolescents and €16-80 for adults). Regarding experience with current treatment, 19% of all patients in the study reported good functioning during the morning, day and evening. CONCLUSIONS: The gap between the monetary valuation of existing products and an optimally valued product suggest that there is room for improvements in the clinical management of ADHD. The results suggest that DCE is a method that can be used to value not only hypothetical scenarios but also can be used to value and distinguish between real-life scenarios.

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Life expectancy in Sweden is high and the country performs well in comparisons related to disease-oriented indicators of health service outcomes and quality of care. The Swedish health system is committed to ensuring the health of all citizens and abides by the principles of human dignity, need and solidarity, and cost-effectiveness. The state is responsible for overall health policy, while the funding and provision of services lies largely with the county councils and regions. The municipalities are responsible for the care of older and disabled people. The majority of primary care centres and almost all hospitals are owned by the county councils. Health care expenditure is mainly tax funded (80%) and is equivalent to 9.9% of gross domestic product (GDP) (2009). Only about 4% of the population has voluntary health insurance (VHI). User charges fund about 17% of health expenditure and are levied on visits to professionals, hospitalization and medicines. The number of acute care hospital beds is below the European Union (EU) average and Sweden allocates more human resources to the health sector than most OECD countries. In the past, the Achilles heel of Swedish health care included long waiting times for diagnosis and treatment and, more recently, divergence in quality of care between regions and socioeconomic groups. Addressing long waiting times remains a key policy objective along with improving access to providers. Recent principal health reforms over the past decade relate to: concentrating hospital services; regionalizing health care services, including mergers; improving coordinated care; increasing choice, competition and privatization in primary care; privatization and competition in the pharmacy sector; changing co-payments; and increasing attention to public comparison of quality and efficiency indicators, the value of investments in health care and responsiveness to patients needs. Reforms are often introduced on the local level, thus the pattern of reform varies across local government, although mimicking behaviour usually occurs.

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Life expectancy in Sweden is high and the country performs well with respect to disease-oriented indicators of health service outcomes and quality of care. The Swedish health system is committed to ensuring the health of all citizens and abides by the principles of human dignity, need and solidarity, and cost–effectiveness. The state is responsible for overall health policy, while the funding and provision of services lie largely with the county councils and regions. The municipalities are responsible for the care of older and disabled people. The majority of primary care centres and almost all hospitals are owned by the county councils. Health care expenditure is mainly tax funded (80%) and is equivalent to 9.9% of gross domestic product (2009). Only about 4% of the population has voluntary health insurance. User charges fund about 17% of health expenditure and are levied on visits to professionals, hospitalization and medicines. The number of acute care hospital beds is below the European Union average and Sweden allocates more human resources to the health sector than most OECD countries. In the past, the Achilles heel of Swedish health care included long waiting times for diagnosis and treatment, and divergence in quality of care between regions and socioeconomic groups. Recent principal health reforms relate to: concentrating hospital services; regionalizing health care services, including mergers; improving coordinated care; increasing choice, competition and privatization in primary care; privatization and competition in the pharmacy sector; changing co-payments; and increasing attention to public comparison of quality and efficiency indicators, the value of investments in health care and responsiveness to patients’ needs.

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Recent reforms in Swedish primary care have involved choice of provider for the population combined with freedom of establishment and privatisation of providers. This study focus to what extent individuals feel they have exercised a choice of provider, why they exercise choice and where they search for information, based on a population survey in three Swedish counties. The design of the study enabled for studying behaviour with respect to differences in time since introduction of the reform and differences in number of alternative providers and establishments of new providers in connection with the reform. About 60% of the population in the three counties felt that they had made a choice of provider in connection with or after the introduction of a reform focusing on choice and privatisation. Establishments of new providers and having enough information increased the likelihood whereas preferences for direct access to a specialist decreased the likelihood of making a choice. The data further suggests that individuals were rather passive in their search for information and tended to choose providers that they previously had been in contact with. This is in line with results from previous studies and poses challenges for county councils governance of reforms.

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The number and costs associated with reported sharps injuries in Swedish hospitals and the potential cost offset by introducing safety devices with needle and syringe was estimated from a health care perspective. Data about reported sharps injuries were collected from infection control nurses at 18 Swedish hospitals and information about the procedures following such injuries from doctors at Swedish hospitals and published articles. Unit costs were derived from the Southern Regional Health Care Board, SEK 2007. On average, 3.14 injuries per 100 full-time equivalent positions are reported annually in Swedish health care. Approximately 60% involves hollow-bore needles. The cost of occupational sharps injuries in Sweden was estimated at euro1.8 million (SEK 16.3 million) or euro272 (SEK 2513) per reported injury, of which euro1 million was for hollow-bore sharps injuries. The expected number of injuries that could be avoided by introducing safety devices was estimated at 3125 injuries and the corresponding expected cost offset at euro850,000. Most costs are associated with investigation as opposed to treatment. The cost per reported injury in Sweden seems to be lower than in other EU countries and the US, due to more thorough investigation and treatment procedures in countries with confirmed transmission of pathogens to healthcare workers.

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BACKGROUND: Anaemia is a common complication of chemotherapy. As anaemia can lead to e.g. fatigue, depression, social isolation and chest pain it diminishes physical capacity and quality of life. It is generally accepted that symptomatic anaemia should be corrected. Treatment options include red blood cell transfusion (RBCT), erythropoietin (EPO) administration or a combination of both. OBJECTIVE: The objective of this study was to carry out a cost-effectiveness analysis of treatment with EPO (epoetin alfa), compared to treatment with RBCT for patients with chemotherapy-induced anaemia in Sweden from a health care perspective. METHOD: A model was developed for estimating incremental costs and QALY gains associated with EPO treatment compared to treatment with RBCTs, based on a model commissioned by the UK National Institute for Health and Clinical Excellence and adjusted to reflect Swedish treatment practice. Data regarding patient characteristics, response rates, and RBCT was derived from a Swedish observational study of EPO treatment in cancer patients with chemotherapy related anaemia. Swedish guidelines and unit costs were used throughout the study. A systematic review of EPO for treatment of anaemia associated with cancer was used to estimate QALY gains associated with changes in Hb-concentrations in our model. RESULTS: The model's results validate well to real world data from three major hospitals in Sweden. The cost per QALY gained from administration of EPO was estimated at EUR 24,700 in the base case analysis. Practicing an EPO treatment target Hb-level of 12 g/dl yields a cost per QALY about 40% lower than practicing a Hb-target level of 13 g/dl, which is in agreement with updated recommendations of using a 12 g/dl target. CONCLUSION: The estimated cost per QALY falls well within the range acceptable in Sweden when practicing a Hb-target level of 12 g/dl. The incremental cost of elevating Hb-levels above 13 g/dl is very high in relation to the incremental QALY gain achieved.

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OBJECTIVE: Anaemia is a common complication of renal failure. It can be treated with erythropoietin (EPO) administration, red blood cell transfusion (RBCT), or a combination of both. EPO has been registered for the treatment of renal anaemia in Sweden since the beginning of the 1990s, and is the primary treatment regimen for anaemia related to renal failure. The objective of this study was to carry out a cost-effectiveness analysis from a provider perspective of a treatment strategy comprising EPO and complementary RBCT compared to the traditional treatment of RBCT alone for patients with anaemia associated with renal failure in Sweden. MATERIAL AND METHODS: Incremental costs and quality-adjusted life-years (QALYs) associated with EPO (epoietin-alpha) treatment compared to the traditional therapy of RBCT were estimated. The QALY gains were estimated using a modified version of a Markov model, which is used by the UK National Institute of Clinical Excellence in their evaluations of EPO treatment in the UK. Swedish treatment practice (i.e. EPO doses and iron supplementation), patient characteristics and unit costs were used throughout the study. RESULTS: The estimated cost per QALY gained from administration of EPO to renal patients falls within the range acceptable in Sweden for both haemodialysis and peritoneal dialysis patients. CONCLUSIONS: EPO administration to renal patients is much more costly in Sweden than in the UK, primarily due to the higher dosage of EPO and iron supplementation used in Sweden. However, Swedish patients reach higher haemoglobin levels, and thereby achieve higher QALY gains, compared to patients in the UK.

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BACKGROUND: Policy implementation in the context of health systems is generally difficult and the Kenyan health sector situation is not an exception. In 2005, a new health sector strategic plan that outlines the vision and the policy direction of the health sector was launched and during the same year the health sector was allocated a substantial budget increment. On basis of these indications of a willingness to improve the health care system among policy makers, the objective of this study was to assess whether there was a change in policy implementation during 2005 in Kenya. METHODOLOGY: Budget allocations and actual expenditures compared to set policy objectives in the Kenyan health sector was studied. Three data sources were used: budget estimates, interviews with key stakeholders in the health sector and government and donor documentation. RESULTS: Budget allocations and actual expenditures in part go against policy objectives. Failures to use a significant proportion of available funds, reallocation of funds between line items and weak procurements systems at the local level and delays in disbursement of funds at the central level create gaps between policy objectives and policy implementation. Some of the discrepancy seems to be due to a mismatch between responsibilities and capabilities at different levels of the system. CONCLUSION: We found no evidence that the trend of weak policy implementation in the Kenyan health sector was reversed during 2005 but ongoing efforts towards hastening release of funds to the districts might help solving the issue of low absorption capacity at the district level. It is important, however, to work with clear definitions of roles and responsibilities and well-functioning communications between different levels of the system.

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The Health Systems in Transition (HiT) country profiles provide an analytical description of each health system and of policy initiatives in progress or under development. They aim to provide relevant comparative information to support policy-makers and analysts in the development of health systems and reforms in the countries of the WHO European Region and beyond. The HiT profiles are building blocks that can be used: to learn in detail about different approaches to the financing, organization and delivery of health services; to describe accurately the process, content and implementation of health reform programmes; to highlight common challenges and areas that require more in-depth analysis; and to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in countries of the WHO European Region. This series is an ongoing initiative and material is updated at regular intervals.

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