$Unique_ID{COW03458} $Pretitle{441} $Title{Sweden On Sweden. Health care} $Subtitle{} $Author{Stig Hadenius and Ann Lindgren} $Affiliation{Swedish Institute} $Subject{sweden system education swedish care income research percent countries programs} $Date{1990} $Log{Various Views of Swedish Life*0345801.scf Research*0345802.scf Table B.*0345801.tab } Country: Sweden Book: On Sweden Author: Stig Hadenius and Ann Lindgren Affiliation: Swedish Institute Date: 1990 On Sweden. Health care All residents of Sweden are covered by the national health insurance system, which provides medical care, pharmaceuticals, hospitalization and a variety of other services free or at very modest cost to the patient. Dental care is also largely covered. The low level of infant mortality is sometimes cited as an indicator of Sweden's high living standard. At 5.9 per 1,000 live births, infant mortality is among the world's lowest. One contributing factor is that practically all mothers and their infants take advantage of the free preventive health care available at prenatal and child health care centers. Like other countries, Sweden built many big hospitals during the 1960s and 1970s that were designed to provide a good health care infrastructure to large regions. As it turned out, however, these facilities were often expensive and impersonal, even though they maintained high medical standards. During the 1980s there was a trend toward decentralizing the health care system as much as possible. This has included expanding the availability of non-hospital outpatient care by building more community health care centers, staffed by district nurses and physicians. All employees in Sweden are entitled to cash benefits that compensate them for lost income during illness. This means that the Social Insurance Office pays them 90 percent of their normal income (up to a certain ceiling). To qualify for such payments, a person merely has to phone and tell the office that he or she is sick. There is no waiting period, and the benefit is paid from the first day of illness. If a person is ill for more than a week, however, a doctor's certificate is required as evidence of illness. In 1988 the average number of sick-call days per employee was 26.1, a clear increase from 19.6 in 1983. According to statistics, the level of absenteeism due to illness is higher in Sweden than in comparable countries. This has caused major problems both for the health insurance system and employers. Short-term absences are the main cause of serious disruptions in production. But people with longer-term illnesses account for the highest costs to the sick pay system, which is jointly financed by employers and the central government. Self-employed people pay their own social insurance fees, not only for sick pay, health care and parental insurance, but also for pensions and other benefits. Old Age Care and Pensions Average life expectancy at birth is 74 years for men and 80 years for women in Sweden - among the highest such longevity figures in the world. Although elderly people are healthier and better able to take care of themselves than ever before, the growing number of "very elderly" - those over 80 - places a heavy burden on the medical care system. A complicating factor in the situation of the elderly is the recent trend toward closing old age homes and other institutions that previously cared full-time for the frail and infirm elderly, in favor of providing an increasing proportion of practical and medical care in their own homes. Many elderly people are thus able to continue living outside of institutions, thanks to home help (personal care) services. Every municipality employs workers who help the elderly as necessary with such chores as cleaning, grocery shopping, cooking and personal hygiene. Pensioners pay a fee for this service which varies according to their financial situation. As indicated earlier, the expansion of these home care programs has been hurt by labor shortages. Other benefits aimed at enabling the elderly to live as independently as possible are housing allowances, home adaptation grants or an apartment in a building where on-call services are available. Everyone in Sweden who reaches age 65 is entitled to a basic pension, regardless of whether he or she has been gainfully employed. Most people also receive an income-related supplementary pension (ATP). There are limited provisions for some employees aged 60-65 to work shorter hours and receive partial pensions. People who have physical or psychological disabilities are eligible for public pensions at even earlier ages, provided that sheltered or semi-sheltered employment is unadvisable or unavailable. In the ATP system, employers pay a fee equal to a specified percentage of each employee's income into a national pension fund. The employee earns inflation-indexed pension points related to income level. Like the basic pension, ATP is usually payable from age 65. The amount of ATP is calculated using a person's 15 best years of income as a benchmark. A basic pension plus full ATP should provide a total income equivalent to two thirds of a person's buying power while employed. Taxes Through a process of political decision-making, the Swedes have chosen to create a very large public sector. It provides them with free education, heavily subsidized health care and social welfare services as needed. Many people are also eligible for generous cash grants and allowances at different times during their lives. Most of these benefits are taxpayer-financed. Not surprisingly, then, Sweden has a reputation for high taxes. In 1988 the overall tax burden was 55 percent of GDP - among the highest such levels in the world. This tax burden has been the subject of extensive debate in recent years. Public opinion surveys indicate that the Swedes generally accept the fact that they have to pay for the benefits they expect from the public sector. But there has been broad criticism of high marginal taxes on personal incomes and their distorting effects on the economic situation of both individuals and the country. Even at ordinary income levels, marginal taxes have eaten up 60-70 percent of any nominal pay increases in recent years. In the view of many economists, Sweden's steeply progressive State income taxes have created a disincentive for creative or ambitious people to work harder. They have thus harmed the national economy, especially during periods of labor shortages like the late 1980s. They have also created a built-in temptation to conceal income and to exchange services without reporting them. In some ways, the tax system also contradicts Sweden's traditional egalitarian principles. Ordinary employees are hard-hit by marginal taxes, while company owners and others whose income consists largely of capital gains have sometimes been able to limit their taxes by strategic planning. Homeowners and other borrowers have enjoyed windfalls, while the supposed income-leveling effects of the tax system have been limited to people unable to claim deductions or buy real estate. [See Table B.: Central government revenue and expenditure, national budget 1990/91, in billion kronor] In response to these and other criticisms, late in 1989 the Social Democratic Cabinet reached agreement with the Liberals on a major tax reform package scheduled to take effect in two steps during 1990 and 1991. Its main feature is to exempt more than four out of five Swedish employees from all State income taxes. Instead they will pay only local income taxes, which average about 30 percent. There will be a 50 percent ceiling on the marginal tax rate. The capital gains tax will be a uniform 30 percent, thereby eliminating minimum holding periods that have distorted securities markets. Corporate income taxes will be cut from 52 percent to 30 percent, but the investment reserve system is being abolished and other corporate tax deductions are being tightened. To make up for lost revenue, the government is extending the 25 percent value-added tax to a wide variety of services that were not previously included and is increasing VAT to this level in cases where it used to be lower. The State is also imposing taxes on private pension savings and on pollutant emissions, while tightening the rules on taxation of fringe benefits and real estate. Living Standard and Well-Being [See Various Views of Swedish Life: Courtesy Swedish Embassy, Washington DC.] A country's living standard is hard to measure because it involves not only statistics but also subjective judgments about the relative value of lifestyle components and cultural preferences. It is clear, however, that Sweden is an affluent country. Slums are virtually nonexistent, and very few people live in physically unhealthy environments. Most Swedes enjoy a comfortable housing standard, with well-equipped kitchens and good-quality furnishings. The number of telephones, VCR's, cars, boats and second homes per person is among the world's highest. At the same time, Sweden's GDP per capita is not as far ahead of the OECD average as it used to be. In terms of the goods and services their take-home pay will buy, the Swedes have fallen behind several other OECD countries. Studies indicate that they may have a lower average standard of cuisine than some other Europeans and that restaurants and drinking establishments in Sweden are relatively expensive. Most Swedes prefer to spend their evenings at home, at club meetings or at study circles instead of gathering in a cafe. Such observations reflect divergent cultural patterns as much as differences in living standards. Comparisons between income statistics are also deceptive because many services that the Swedes do not buy with their cash income are provided to them by the public sector. They include, among others, generous social insurance benefits, means-tested grants for people in hardship situations, child allowances and free education through the doctoral level. Finally, many Swedes regard other components of a high living standard as more important than money: for example a low rate of violent crime; good public transit; and the time to enjoy a summer cottage, a boat or a hike amidst unspoiled waterways, forests and mountains. At five weeks a year, the minimum paid vacation is longer than in most other countries. About 80 percent of blue collar workers can afford an annual vacation trip, and numerous Swedes travel to foreign countries, both in Europe and further afield. Crime and Punishment In the spring of 1988 a Swede serving a life sentence in prison after being convicted of serious espionage against Sweden was granted an unescorted furlough from the penitentiary. He slipped out of sight and soon managed to flee the country without difficulty. This and other cases have resulted in a lively debate about the Swedish correctional care system. Critics have accused the authorities of incompetence and laxity. How could a notorious convicted spy be left unguarded? But others argue that those cases that have attracted heavy media attention are exceptional, or that they are part of the price Sweden must pay for its open society and humane correctional policy. In fact, the overwhelming majority of convicts who receive short-term prison furloughs come back. In 1988/89 more than 43,000 such furloughs were granted, and only some 1,300 prisoners failed to return on time. The question is whether this is a high or a low figure - especially because many of those who violate furloughs commit new crimes. During the 1980s an average of about 15,000 people were sent to prisons each year. The death penalty was abolished in 1921. The most serious punishment available - life imprisonment - is usually commuted to a fixed term of 12-16 years. One of the most common crimes among the people who serve time in prison is drunk driving, not because this offense is any more common in Sweden than in comparable countries, but because the penalties against it are severe and enforcement is relatively effective. In 1990, a new law lowered the legal minimum blood alcohol content required for a drunk driving conviction to 0.02 percent. As in many other countries, substance abuse is a social problem that has many ramifications for both crime and punishment. Most crimes of violence are connected with drug or alcohol consumption. The recent growth of narcotics traffic has led to an increase in crimes of violence. In 1988, for instance, there were 129 murders in Sweden, compared with 79 three years earlier. Drug abuse is behind a large proportion of burglaries. Between 25 and 50 percent of those currently serving prison time are drug users. Among the most important tasks of the correctional system is thus to control drug abuse, while maintaining as far as possible the system's prevailing liberal ideology and respect for personal privacy. The basic concept behind the Swedish correctional system is that people who are convicted of crimes should not only be punished but should also be rehabilitated. By means of education, training and treatment, they should be given a chance to readjust to society. Convicts can generally expect to serve only half the nominal sentence for minor offenses or two thirds of the sentence imposed for serious crimes, provided they behave well during their subsequent probation period. Non-institutional correctional care is an important part of the system. Some offenders are sentenced to probation instead of prison, because in many cases this has proven more effective in enabling them to return to normal life. New forms of sanctions other than prison or the traditional income-related fines are also being discussed and tried out. The most important is community service, a technique already used in other countries. For example, young first offenders are being sentenced to perform a certain number of hours of environmental clean-up, park maintenance or gardening work instead of being fined or imprisoned. The Court System The Swedish judicial system is completely separate and independent from legislative bodies. The courts are organized on three levels. Local courts are the first level of the system, and courts of appeal are the second. The Supreme Court, which is the highest level, only accepts cases considered to be of special significance in setting precedents. Unlike such countries as the United States, law graduates choose between two completely separate careers. One is a civil service career as a judge or prosecutor; the other is a career as an attorney, usually in the private sector. The system of lay assessors has old traditions in Sweden. These are ordinary citizens appointed by politically elected bodies, who participate in serious criminal cases both at the local and appeals court level. Unlike jury members in English-speaking countries, their task is to render verdicts together with legally trained judges and also participate in decisions on sentencing. In other words, they do more than simply decide whether a defendant is guilty or not. In addition to the general courts, there is a parallel system of administrative courts. Some of these specialize in cases involving taxes, social insurance, involuntary commitment of substance abuse patients and so on. Education and Research [See Research: Courtesy Swedish Embassy, Washington DC.] On December 10 every year, the king of Sweden presents the Nobel Prizes in literature and the sciences at a ceremony usually held at the Stockholm Concert Hall. There are other awards in the same fields that are worth as much money as the Nobel Prizes (as of 1990 each full prize totals 4 million kronor), but very few enjoy greater prestige. Leading universities around the world are sometimes rated by the number of Nobel laureates among their professors and alumni. The literature prize can be of crucial importance not only to the author who wins it, but to the global reputation of the culture he or she represents. In the late 19th century, Swedish industrialist Alfred Nobel made a fortune by commercially exploiting his own inventions and those of others in such areas as explosives and synthetic chemicals. His idea of using this fortune to endow annual prizes in literature (awarded by the Swedish Academy), the sciences (awarded by Swedish scientific institutions) and peace (awarded by a committee of the Norwegian Parliament; Norway belonged to a union with Sweden until 1905) has had a strong positive effect on Swedish research. Education and research are especially important in helping a small country like Sweden defend its position against international competition and maintain its national identity. Primary and Secondary Education Compulsory primary schooling was introduced in Sweden as early as 1842. Its goal was to enable all children - regardless of social class, sex, economic standard and geographic location - to learn how to read and write. It took decades before this goal was achieved, however. There were also wide gaps between the well-to-do and other social classes in terms of opportunities for further studies. The former were usually able to pursue academically oriented secondary schooling, while pupils from less affluent families often went straight to work or had to settle for shorter, less prestigious vocational and commercial training programs. The Swedish school system is free of charge. A series of reforms since World War II has created a nine-year compulsory school where all children receive essentially the same education, starting at age 7. The school system emphasizes the development of personal identity and critical reasoning skills. It exposes pupils to the labor market during their early teens by allowing them to participate in a job orientation program which takes place outside the school for a week or two every year. More than 90 percent of those who finish compulsory schooling continue directly into upper secondary school, which offers both vocational and academic study lines (majors). Many vocational study lines run for two years, while academic study lines usually take three years. According to plans, all upper secondary school study lines will become three-year programs during the early 1990s. Pupils receive no marks before the spring term of grade 8. There has been a lot of controversy over whether or not marks should be given at all. Those who oppose marks say that they create the wrong mentality - competition instead of cooperation. Marks are still used, however, in the upper grades of the compulsory school and in the upper secondary school. They serve as the main selection instrument for applicants to higher education programs. The almost total absence of private schools in Sweden and the great degree of uniformity in the curriculum have made the school system quite homogeneous and have provided more equal opportunity for students than in other countries. Comparative international studies also indicate that the Swedish schools maintain relatively high standards. In spite of this, many people are critical of recent trends in the educational system, especially at the compulsory school level. One common assumption is that pupils do not work hard enough and that their level of knowledge should be tested more often. There is a shortage of fully credentialed teachers. In many places, school buildings are in need of repair and teaching materials are outdated and in poor condition, even though the Swedish schools have good economic resources in international terms. The many children of immigrants have created new challenges for Sweden's schools. Where pupils used to be ethnically very homogeneous, today there is a mix of children from a large number of countries and language groups. One ambition is to give all children of immigrants a chance to study not only Swedish but also their own "home language." As a result, some schools offer lessons in up to 60 languages. Higher Education and Research Reforms in postsecondary education have been more limited than those at primary and secondary levels. As previously, Swedish universities and professional colleges provide both education for specific professions - as a rule in four-year undergraduate programs - and graduate programs that prepare students for careers in research. Important developments in recent decades have included the creation of new universities, as well as the establishment of a number of professional colleges. Higher education is now available at more than 20 locations in Sweden. Of those who complete upper secondary school, 35 percent continue directly to some form of higher education. There are no tuition fees, but students pay for their own course materials and their room and board while studying. The central government provides study grants and loans so that no one will have to abstain from higher studies for lack of money. In spite of this, people whose parents have had a higher education are far more likely to attend a university or professional school than those whose parents have less formal education. During the 1980s the central government and the business sector have devoted increasing resources to research and development. Swedish research expenditures per inhabitant are among the highest in the world. Two thirds of this money comes from business. Swedish research in the natural sciences and technology maintains particularly high standards. Research in the humanities and social sciences is largely dependent on government funding and enjoys more limited resources. The science research parks in Lund, Linkoping and elsewhere are successful examples of research cooperation between the business sector and institutions of higher learning. The question is whether companies will continue to fund research and development programs as heavily as they did during the 1980s. For cost reasons they may either choose to reduce overall research budgets or - for strategic reasons as well - move it to other countries. There is also debate as to whether basic and long-term research programs will be at a disadvantage compared with those that yield quick results and are more development-oriented. Adult Education Since the 1960s adult education has expanded very rapidly in Sweden. One out of three adults is enrolled in some kind of educational program. These programs are available through the regular educational system, at folk high schools or in courses run by employers, government agencies or one of the eleven nationwide adult education associations. The latter receive subsidies from central and local governments and are usually affiliated with a political party or special-interest organization. One of the most typical features of Swedish adult education is the use of study circles, which are generally eligible for national and local government subsidies. Pioneered by the adult education associations and also widely used in job-related training programs, a study circle is a group of five or more adults who meet regularly to study a subject of common interest for an agreed period. One of them acts as leader (not always the same as teacher) and the atmosphere is more informal than in most degree or certificate programs. Sweden's 128 folk high schools, most of them residential and targeted primarily to young adults, have roots going back to the 19th century. Owned by private organizations or municipal authorities, they each have their own educational profile and provide programs such as journalism, sports or religion. Every year, about 14,000 people attend full-term courses at folk high schools, and many more people attend their short courses. Employers in Sweden also provide extensive on-the-job training. To a growing extent, they are cooperating with the public education system by ordering various training packages. As mentioned earlier, there is large-scale labor market training - including both general education and vocational instruction programs - under government auspices.