Swedish care debate pits competition against Attendo scandal

Sweden’s healthcare argument over “private versus public” provision keeps missing the more important monopoly in the room: the region. Even when a clinic is run by a private operator, the region typically remains the dominant buyer, rule-setter and risk allocator. That turns “market” provision into something closer to subcontracting under political price controls.

A debate article in Dagens Medicin by Isac Riddarsparre, an ST doctor affiliated with the think tank Synaps, points to Västra Götalandsregionen’s attempted closure of three small hospitals in Bäckefors, Lysekil and Strömstad. The region argued it could not run the facilities sustainably. Yet when it opened the door to competitive procurement, other actors were willing to operate them within the region’s budget constraints. The lesson, Riddarsparre argues, is that regions often declare services “impossible” before testing whether different organisational models can deliver the same output at lower cost.

That claim sits uneasily next to a very different kind of critique in Aftonbladet’s debate pages. Joachim Berner describes his mother’s care at Nilstorpsgården on Lidingö, run by Attendo, after she developed symptoms consistent with scabies following prior sanitisations. Berner’s letter to Attendo CEO Martin Tivéus is a portrait of operational failure: staff dismissing concerns, delayed specialist assessment, and basic administrative dysfunction (even a missing mailbox key). His conclusion is blunt: a listed care company under shareholder pressure is “not capable” of running dementia care safely.

Taken together, the two pieces inadvertently map the actual incentive structure.

In a normal market, a provider that mishandles infection control or basic care loses customers and revenue quickly, and insurers or owners tighten standards because they internalise costs. In Swedish elderly care and much of healthcare, the region (or municipality) is the payer and gatekeeper. The end user—the patient and family—has limited exit. The operator’s real customer is the public buyer, which evaluates performance through contract metrics, inspections and procurement cycles.

That creates a predictable game. Providers optimise for what the buyer measures and reimburses. Regions, facing budget constraints and political blame, design compensation models that push cost and staffing risk down the chain while reserving the right to change rules. When failures occur, the political system can frame it as a “private” scandal—yet the underlying price and staffing envelope was set by the public monopsony.

So the key question is not whether care is “private” or “public”, but whether responsibility is aligned with control. As long as politicians set the tariff, define the reporting burden, and can rewrite terms mid-contract, Sweden will keep producing pseudo-markets: profits can be earned in good years, but regulatory shocks and capacity shortfalls are socialised.

Competition can still be useful—as Riddarsparre suggests—because it reveals information about alternative production methods. But without a buyer that bears the cost of its own specifications, competition becomes a procurement theatre: many bidders, one payer, and the same structural bottleneck.

The most damning detail may be the simplest: a dementia patient’s suffering is real-time, while the accountability loop is quarterly, contractual and political. The system is optimised for the latter.