Intended for healthcare professionals


Devolution in Swedish health care

BMJ 1999; 318 doi: (Published 01 May 1999) Cite this as: BMJ 1999;318:1156

Local government isn't powerful enough to control costs or stop privatisation

  1. Finn Diderichsen, Professor of social epidemiology and health policy research
  1. Department of Public Health Sciences, Karolinska Institutet, 17176 Stockholm. Sweden

    Editorial p 1155 Education and debate pp 1195 −1205 News p 1166 Personal view p 1221 Letters p 1215

    Spending on welfare in Sweden increased from 5% of gross domestic product in the 1930s to 40% in 1980. How can a democratic state justify spending nearly half of the population's income on health and welfare year after year? The political will to sustain this level of spending will survive only if the welfare state, particularly health care, is seen to be accessible, efficient, and equitable.1 And such expansion in spending is possible only if the administration of the system is strong and highly accountable. In 1982, in an attempt to protect these principles and to ensure closer matching to local values, needs, and priorities, the Swedish government devolved these responsibilities to county councils. It abolished many detailed national regulations for health care and laid down only general goals for county councils, such as health gain and equal access to care. The resulting system illustrates the tensions inherent in any system of devolution—and the ever present pressures that tend …

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