Bob Bell, MD, and Stefan Superina
Why Compare Countries?
Canadians are accustomed to hearing that their health system is going to hell in a handbasket. Recently a provincial minister suggested that her province’s system is on life support. Physicians claim that wait times are putting patients’ lives at risk, that we spend too much money on bureaucracy and that they cannot do their jobs because of a lack of technology.
Economists suggest that healthcare costs too much in Canada and everyone agrees that we are wasting money on IT boondoggles.
Inevitably Canadian experts point to other systems that they suggest may be more effective than ours. A common theme from physicians and representatives of banks and insurance companies is that we need more private pay for medically necessary services. But doctors and financial folks are less than reliable in these claims since doctors and insurers gain substantial benefit from private payment schemes.
Critics point to the Commonwealth Fund that finds that Canada is one of the worst health performers in the western world (ahead of only France and the USA in their 2017 study). However, the information used by the Commonwealth is overwhelmingly derived from surveys of patients and providers (about 90% of indicators are survey based) and survey response rate in Canada is about 20%. If the survey for Australia had a high proportion of responses from privately insured patients or private hospital providers, the results for the country could be skewed dramatically in a positive direction.
Accordingly, this blog which is fully aware of shortcomings in Canadian health care and committed to improvement in our publicly funded system, is determined to compare several countries to Canada, using hard data whenever possible from OECD comparisons, from government websites or from peer reviewed publications.
The first country analysis was for Australia. That review focused on the fact that 45% of Australians have private health insurance. We will not repeat the findings here. However, we did not find support for the hypothesis that extensive investment in private services improves access for public services.
The second country in this series is Sweden. Critics of Canadian healthcare point to Sweden with envy, especially referencing their wait time guarantee or Vardgaranti. So, we set off on a journey to evaluate Sweden’s system, compare it to Canada’s and see where the inevitable lessons can be learned.
Thanks for joining us on this health travelogue.
Organization and Cost of the Swedish Healthcare System
Sweden is a wealthy Nordic country with a population of nearly 10M people and GDP per capita about $9,000 USD annually greater than Canada’s (all data 2016). Sweden is known for generous social benefits such as extensive paid maternity leave (480 days with 420 days paid at 80% of base salary) and subsidized daycare costing about $300 per month per child.
Swedish health care is highly decentralized with 20 + city councils (elected on a four-year cycle) responsible for organizing hospital, primary and specialist care. There are also 290 municipalities, and this level of government is responsible for homecare, nursing home delivery and care of disabled individuals.
The national government sets standards and policy direction that the city councils and municipalities must follow.
Most care is provided by publicly employed physicians. A small number of private physicians charge higher rates that are approved by council. Most hospitals are operated by the council. About 10-15% of in-patient care is provided by hospitals operated by private corporations that received funding equivalent to the local council operated facilities.
Services provided by GPs and specialists as well as hospital care require a small co-pay (up to $12 Cdn./day for hospital, 0- $30 Cdn./visit for primary care depending on council, and about $40 Cdn. for a specialist visit) that is income sensitive and contributed directly to the health budget.
The health budget is maintained by local council income taxes as well as contributions from the national budget designed to equalize revenues across the councils.
Swedes pay far more than Canadians for their health system, but they also receive more for their money.
In 2016, mean Swedish health spending per capita in USD was $6808 compared to $4641 in Canada. Public spending through tax dollars was 84% of total health costs in Sweden ($5719 USD) compared to 72% in Canada ($3342 USD).
This difference ($2377 USD or $3185 Cdn. per capita) would increase Ontario’s health budget to over $100B Cdn from its current $62B (and increase our deficit by more than $40B annually) if we were to spend the same per capita on health as Sweden does.
This comparison is not entirely fair since Swedes receive more drug coverage and dental coverage from public coverage than Canadians. Dental coverage up to 23 is covered by city councils and over 23 is subsidized nationally. Pharma coverage prevents anyone from paying more than $250 out of pocket annually.
Despite the high cost of publicly funded care, Swedes have fewer hospital beds per 1000 than Canada (2.5 versus 2.7). Sweden spends 21% of its healthcare budget on in-patient care. Canada spends even less (the lowest of eleven wealthy western nations) at 17%.
However, Swedish seniors have access to 71 long-term beds per 1000 population >65 years (compared to 54 in Canada). Sweden also spends 26% of its annual health expenditures on long-term care (the highest of any wealthy nation) compared to 14% in Canada.
This may explain why hospital overcrowding is not a well-publicized problem in Sweden while it represents a major challenge for Canadian healthcare. Presumably the large expenditure on long-term care would prevent patients waiting in hospital for long-term care placement.
Sweden has more physicians than Canada (4.2/1000 versus 2.7 in Canada). However, both Swedish generalist and specialist physicians are the lowest paid in the eleven wealthiest western countries (generalist paid about $87,000 USD versus $146,000 in Canada; specialists paid $98,000 USD versus $186,000 in Canada).
Outcomes of Care and Utilization of Services
Life expectancy is equivalent in Canada and Sweden. Sweden excels in perinatal mortality, infant mortality and low birth weight infants. The Swedish public perinatal services are world renowned for their inclusive approach, including care for recent arrivals and refugee claimants. Canada certainly has an opportunity to learn from the Swedish maternal and perinatal systems.
Utilization of total joint replacement, cataract surgery and coronary revascularization are virtually identical in the two countries.
Access to Care and Waiting Times
Similar to Canada, long wait times for specialist consultation and wait times for surgery care have been a problem in Sweden despite the high cost of care. In response to concern about waiting, the national government introduced the care guarantee or Vardgaranti in the early 1990’s which promised access to a specialist consultation within 90 days and access to surgery within a further 90 days.
Despite the guarantee, access continues to be a concern, with all parties agreeing that they need to improve access to surgery and consultation in the recent national election.
Current analysis of the national wait time database shows that 80% of specialist consultations are carried out within 90 days and that 68% of surgeries are achieved within the care guarantee of 90 days.
Unlike in Canada where wait times for common procedures can be readily reviewed on several provincial websites, access to various procedures in Sweden is not available on government web sites. The OECD (see surgical wait time definitions) has commented on difficulty in interpreting Swedish wait time data since results are reported in intervals rather than in days.
However, analysis of some surgical wait times is available in the academic literature. For example, all cataract surgery undertaken in Sweden from 2009 to 2011 was partitioned into three degrees of severity with most cases (>90%) grouped into Group 2 and 3. The mean wait time for surgery of these groups of patients was 3.4 months.
This is virtually identical to current wait times for priority 4 cataract patients in Ontario who currently have a mean wait time of 95 days. In Nova Scotia mean wait time for cataract surgery is currently 79 days, BC is 63 days and Saskatchewan is 38 days.
The only data available to describe total hip and total knee surgery wait times in Sweden is one year of information from the OECD which lists hip and knee replacement mean waiting times as 82 and 101 days.
These times are better than Canadian provincial times- Ontario’s times for hip replacement average 118 days and knee replacement averages 129 days. Nova Scotia hip replacement time is 154 days, and for knee replacement 196 days. In British Columbia median hip wait time is 112 days and knee is 126 days. In Saskatchewan hip 163 days, knee 168 days.
Wait time for coronary bypass surgery is similar in Sweden and Canadian provinces. Swedish wait time averages 26 days, compared to 29 days in Ontario, 21 days in Nova Scotia, BC 10 days and Saskatchewan 4 days.
On the other hand, cancer surgery seems less well organized in Sweden. There is considerable inter-county variation in wait times for cancer treatment in three common surgical cancers and access for surgery of two of these common cancers is slower than in Canadian provinces.
For breast cancer, median wait time to surgery from specialist appointment in Sweden is 20 days (16 days mean wait in Ontario, 17 days in Nova Scotia, 21 days in BC and 20 days in Saskatchewan).
For prostate cancer in Sweden, median surgical wait is 175 days from the time of referral to surgery. Using Ontario mean wait times to see a specialist for Priority 4 prostate cancer (29 days) and Ontario time to surgery (56 days) the equivalent Ontario mean time from referral to surgery is 85 days.
Since Ontario publishes both Wait 1 (time to see the specialist) and Wait 2 (time from specialist to surgery) this is the only province compared for prostate cancer and colon cancer Wait 1 plus Wait 2 times.
In colon cancer, Swedes wait a median time of about 56 days for surgery from the start of referral (Wait 1 + Wait 2) whereas Ontarians wait on average 17 days to see the specialist and 18 days for surgery for colon cancer- 35 days in total.
The national government was concerned by these lengthy cancer wait times and the variation in access between the 20 + counties. In 2016 a process was initiated to standardize care pathways in five different complex cancer diagnoses.
This may demonstrate the value of a jurisdiction wide cancer agency like Cancer Care Ontario. Cancer agencies across Canada have introduced standardized pathways for most cancers for the past ten to fifteen years.
Despite the concern about delays in access to cancer surgery, The Lancet publication of results from Concorde-3, a multi-national review of cancer survival, showed that cancer outcomes in both Canada and Sweden are amongst the best in the world.
Private Care in Sweden
There are two elements of private care in the Swedish system. Private companies run hospitals which are paid for publicly by the state. In general, these facilities receive similar funding to the public hospitals. About 10 to 15% of hospitals are owned by private interests.
It is not universally agreed that private hospitals compete on a level playing field with some observers suggesting that the drive for profitability results in “cherry-picking”.
About 10% of Swedes have private insurance that reduces co-pays for clinical care or pharmaceuticals and can provide faster access to private specialists who have arrangements with insurance companies to see their privately insured patients. There are a few private clinics offering services at greater cost than the public system but no full-service private hospitals and no private hospital system that is not funded publicly.
Both Sweden and Canada have commendable publicly funded health systems that have minimal dependence on private care. Private hospitals provide about 10% of services in Sweden but are paid rates equivalent to publicly administered hospitals.
Both countries have good outcomes in public health and cancer outcomes. Sweden has superior maternal and perinatal care, likely related to poorer outcomes in remote communities in Canada.
Sweden also spends far more than Canada on long-term care. The current hospital overcrowding, hallway medicine challenge in Canada is largely due to patients waiting in acute care hospitals for admission to long-term care. Clearly, if Canada expands long-term care, hospital overcrowding would be alleviated.
Access to care is a concern in both countries. Total joint access seems superior in Sweden, cataract and cardiac surgery access is similar in both countries and cancer surgery access likely is superior in Canada.
Sweden could definitely learn about standardization for cancer care from provinces which have disease specific agencies.
Swedish health care costs considerably more than Canadian health care. However, more services are covered including dental care and more generous pharmaceutical coverage. Access to long-term care is also better funded in Sweden.
Both countries are currently committed to incremental improvement in their publicly funded systems rather than making transitions to parallel privately funded care systems.
Canadians should admire the accomplishments of the Swedish health system. That admiration should be tempered however, by the fact that our system is far more cost effective and provides at least equal access to care according to most measures available. As Canada deals with under-investment in long-term care and an aging population, it is likely that our costs will rise but not as high as Sweden’s.
Image Credit: ©Rawf8 – Alamy Stock Photo