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Online doctors expose deficiencies in the Swedish healthcare system

elderly man having online video consultation with doctor
The photo shows an elderly man having an online video consultation with a doctor. Peter Bergwall's study shows that most young people in cities are the most common users of online healthcare services. Photo: Mostphotos.

Swedish healthcare is supposed to be guided by a principle of need, treating the most urgent cases first. Political reforms in recent decades have also introduced freedom of choice as a guiding principle. The rise of online doctor services on the healthcare market has made it clear that the two principles clash, suggests sociologist of law Peter Bergwall, who recently defended his dissertation on online medical services.

Peter Bergwall began his dissertation work in 2016 with surveys of how online medical services were perceived by the public. At the time, internet doctors were a marginal phenomenon unknown to most people. The survey questions concerned both the patient's view of integrity and equal care.

"The respondents viewed online doctor services as any other service within e-commerce. This surprised me because I thought the issue of fair and equal care would be important," Bergwall says.

In recent years, online medical services have grown exponentially, gaining further momentum during the pandemic.

"The growing use of online doctors has made ethical conflicts clear," Bergwall says.

The online doctor services themselves are not problematic. Their services suit the modern market and are symbolic of the healthcare system we have developed. The problem, according to Bergwall, is how freedom of choice should be combined with needs assessment and cost-efficiency. The online doctors are used most by healthy young people in the metropolitan regions and least in Norrbotten (the region furthest north), where people could benefit most from the service. People in Stockholm spend three to four times more money on online doctor visits than Norrbotten residents.

"We have created a system where everyone wants the healthiest patients because it is most cost-effective for the therapist."

But why is the service not used more by people in sparsely populated areas with poorly developed healthcare?

"Online doctors have made a niche for themselves aimed at patients with uncomplicated medical needs. Today, they are primarily a complement to physical healthcare. However, they cannot compensate for the falling number of healthcare centres in less populated areas. The online doctors' ad campaigns are principally targeting patients in metropolitan areas."

What do you think should be done to ensure that both principles, free choice and cost-effective assessment of need, are followed?

"As the principles are applied today, they are almost incompatible. We also have 21 healthcare authorities, namely the regions [self-governing local authorities responsible for healthcare, among other things], with very different possibilities to comply with these principles. The progress of online doctors indicates that we also need better national coordination of primary care."

Do you think that the freedom of choosing healthcare provider should be abolished?

"Freedom of choice is essentially something positive. But we need to think about what we mean by freedom of choice and what degree of freedom is possible in a needs-driven healthcare system."


Peter Bergwall

Peter Bergwall earned his doctoral degree at the Sociology of Law Department, Lund University, in 2021. His thesis "Exploring Paths of Justice in the Digital Healthcare: A Socio-Legal Study of Swedish Online Doctors" investigates healthcare services provided via smartphone apps.