Sweden: Industrial Relations in the Health Care Sector

  • Observatory: EurWORK
  • Topic:
  • Social dialogue,
  • Collective bargaining,
  • Social partners,
  • Industrial relations,
  • Published on: 13 February 2011

Mats Kullander and Oskar Eklund

Disclaimer: This information is made available as a service to the public but has not been edited by the European Foundation for the Improvement of Living and Working Conditions. The content is the responsibility of the authors.

A key challenge for the Swedish health care sector will be how to handle the liberalisation of the primary health care services, while still preserving the tax-funded welfare system. There are still substantial obstacles in terms of poorly diversified care and long waiting lines. Another key aspect is the issue of equality for both workers and patients. The issue of work related equality and many other work-related issues, have already been addressed through both agreements such as the FAS05 partnership agreement and through specific measures such as the so called “equality pools”.

1. Key developments and trends in the health care sector

1.1 Please provide information on key trends in health care policy

The most important change that has occurred in the Swedish health care system during the past five years is undoubtedly the liberalisation of the primary health care services, including the geriatric care. In 2009 the parliament passed a new law (LOV 2008:962) that enabled the public to choose between public and private primary health care. According to the law, funding of the care institutions will follow the choice of the care seekers and counties are required to treat private and public care institutions equally. Thus, this is a way to increase freedom of choice and competition, while retaining a tax-based funding.

1.2. Please provide information on the views of the major social partner organisations (trade unions and employer organisations) on trends and changes in the care sector.

On the employers’ side, Ulf Lindberg from the employers’ organisation Almega, argued that the reform was necessary and rational. The government’s decision to put this choice in the hands of the care seekers was therefore embraced by Almega and the employers’ side, who also argued that it would create a more efficient and competitive choice-based industry (Lindberg, 2009-02-23). On the employees’ side, the Swedish Municipal Workers’ Union’s (Kommunal) vice president Lars-Åke Almqvist, dismissed the reform because it would take away the counties’ right to determine and distribute the tax funding for care services. He also argued that the form, range or concentration of care services should be controlled by democratic and public institutions, not by profit seeking private companies (Kommunal webarticle).

The Swedish Association of Health Professionals (Vårdförbundet), the largest dedicated trade union in the health care sector, stated that it is important for care-seekers to have a large and diverse supply of care providers to choose from so that care can be given according to the needs of the patients. In this context, the liberalisation was considered a good reform for the patients. The union however still argues that the reform has not dealt with the issue of diversity and providing care according to needs.

2. Industrial relations structures in the sector

2.1 Does the health care sector include any specificities in relation to the freedom of association, the right to collective bargaining and the right to strike?

There are no health care specific regulations or practices in relation to freedom of association and so forth. All rights and obligations are stipulated in the semi-dispositive Employment Codetermination in the Workplace Act (MBL 1976:580). The purpose of the statute is to give employees and their representatives the right to participate in and negotiate with their employers. The law also ensures freedom of association, the right for employees to receive information from employers as well as the rights and obligations of collective bargaining, strikes, mediation etc. Although the act ensures all these basic rights and obligations, the Swedish system relies on partners to self-regulate via collective bargaining. The self-regulation is made possible because collective agreements have the status of civil law agreements. This means that issues such as equality between the genders, wages, work environment policies and other issues that are specific to the sectors are regulated in the sectoral collective agreements without intervention from the state.

2.2 Please provide details on the structure of trade union representation in the health care sector. For each trade union provide:

The wider health services sector, here defined as NACE 86-87, has 565,872 employees (2009 figures) in 24,857 companies (Statistics Sweden 2010-06-07). This corresponds to around 14% of the total number of employees in the Swedish economy. An overwhelming share of these companies (73%) is one man companies with zero registered employees. Almost 90% of the employees are however working at work places with more than 500 employees.

  • Unions usually have a central organisation at the sectoral and bipartite level, where all negotiations and bargaining with the employers’ side are conducted. In addition to this the unions usually have representatives at regional and at company level. These representatives usually interact with the management directly and not through any employers’ organisation. The unions also appoint regional and company level health and safety representatives that monitor issues related to the work environment. Thus dialogue exists at all levels, but collective bargaining is usually left for the sectoral partners.
  • The Swedish Association of Health Professionals (Vårdförbundet) is the only trade union dedicated to health care workers in the health care sector. It is a non-partisan organisation with 110,000 members of whom 94,600 are nurses, 7,000 biomedical scientists, 5,600 midwives and 2,800 radiographers. Vårdförbundet is a member of the national white-collar worker peak organisation the Swedish Confederation for Professional Employees (TCO) and it is representing the Swedish nurses in the International Council of Nurses Associations.
  • The Union for Publicly and Privately Employed Salaried Employees (SKTF)is one of the most important unions for the publicly and privately employed workers within the municipalities, the counties, and the churches. It has more than 160,000 members employed in schools, at hospitals, in churches and in private companies, however, information on the share of employees in health care is not available. The members are primarily administrative workers. The union is a member of the national white-collar peak organisation Swedish Confederation for Professional Employees (TCO).
  • The Swedish Municipal Workers’ Union (Kommunal) has 570,000 members and it is the largest trade union in Sweden. It organises workers within child, health and elderly care as well as in numerous different municipality related areas of the labour market such as public transport and public facility services etc. Around 80% of the union’s members are female workers, of which one third are employed in the care sector. One third of the members are aged 30 or younger. The overall trade union density in the municipal sector (including all activities in the domain of Kommual, see above) is about 90% and therefore higher than the average in the economy of 68% (Sweden: Industrial Relations Profile). The union organises 80,000 health care workers and 170,000 geriatric care workers. Kommunal is a member of the national blue-collar worker peak organisation the Swedish Trade Union Confederation (LO).
  • The partnership organisation, Public Employees` Negotiation Council (OFR), represents both the Association for Health Professionals and SKTF in the collective bargaining with the employers’ organisation SALAR. OFR represents 15 unions and 550,000 members and it coordinates the positions for many of the unions in the public sector.

The interrelationship between the trade unions in the health care sector:

  • Specify whether there are differences between public and private operators in terms of trade union representation

According to Margareta Johansson at Kommunal, the unions have stronger representation at the public health institutions than at the private ones. She says that this is because it is harder to reach potential members employed in the private health care companies.

  • Are there rivalries and competition between trade unions in the sector? What is the relationship between more traditional organisations and emerging professional associations of health care workers?

There are no substantial rivalries between the different unions in the sector, because they almost always represent different groups of care workers. Municipal care workers and assistants are, for instance, members of the Municipal Workers’ Union (Kommunal), while nurses employed at hospitals are members of the Association of Health Professionals (Vårdförbundet). Thus, the factors that determine which union a worker will be a member of, are the boundaries in and between the different professions.

  • Have there been major reorganisations/splits/mergers of trade unions in the sector within the past five years?

No major reorganisations, splits or merges have been done on the employee side in the sector within the past five years.

2.3 Please provide information on the structure of employer organisations in the health care sector. For each employer organisation provide:

  • Like in the case of trade unions, the collective bargaining is conducted at a sectoral level in a bipartite setting.
  • The Swedish Association of Local Authorities and Regions (SALAR) is an employer organisation for municipalities and county councils. It supports and represents all of Sweden’s 290 municipalities, 18 county councils and two regions in issues such as welfare and quality of life development. SALAR is a strong and important player in the Swedish health care sector. It represents all the hospitals and the publicly owned health care centres and it signs collective and partnership agreements with most of the unions active in the sector.
  • The Federation for Municipal and Private Organisations (PACTA) is a mix between a peak organisation and an employers’ organisation that represents private companies, such as private health care companies, who want to use the same agreements and settlements as the municipal work places. The organisation is therefore well-connected and well-integrated with SALAR in collective bargaining and PACTA’s members use SALAR’s agreements. The organisation has 500 member companies employing 43,000 employees and it has, together with SALAR, an important role in the negotiations with the employees’ organisations.
  • The Association of Private Care Providers (Vårdföretagen) is an employer and industry organisation for private Swedish care providers. The organisation has 2,000 member companies employing 55,000 people. It is also a member of Almega, which is the largest employers’ organisation that is supporting service companies in Sweden.
  • The Independent Employers’ Organisation for Co-operative Businesses (KFO) organises Swedish co-operative businesses and non-profit organisations. It has approximately 3,600 members with 90,000 employees of which 4,500 are health care workers.
  • The Swedish Organisation for Local Enterprises (KFS) is an employers’ organisation for companies in the municipal and county council sector. The organisation has 600 members employing 35,000, of which around 1,200 are working in the health care sector throughout Sweden. 80% of the member companies are publicly owned and 20% are privately owned.

The interrelationship between the employer organisations in the health care sector:

  • Specify whether there are employer organisations specific for public and private operators in the health care sector.

The public health care operators are organised in SALAR, while private, cooperative and non-profit operators are organised in the Association of Private Care Providers (Vårdföretagen), the Independet Employers’ Organisation for Co-operative Businesses (KFO) and the Swedish Organisation for Local Enterprises (KFS).

  • Are there rivalries and competition between employer organisations in the sector?

There are rivalries between the employers’ organisations that represent the private operators.

  • Have there been any major reorganisations/splits/mergers of employer organisations in the sector within the past five years?

Yes, SALAR was created in 2007 after a merger between the municipality and county associations.

2.4 Please provide information on the structure of collective bargaining in the health care sector (covering nurses and care workers). Please explain whether the structure is different for public and private providers.

At what level are collective agreements in the health care sector concluded (multi-employer / single employer bargaining)?

  • Almost all collective agreements concerning wages and working conditions in Sweden are, negotiated at the sectoral, multi-employer level under bipartite conditions. Self-regulation through collective bargaining is therefore strong and the inclusion of the government is virtually non-existent. Unorganised employers can, and usually do, sign application agreements (hängavtal) with the trade unions. As a result, the share of employees in the economy that is covered by collective agreements is 91% (EIRO IR-profile Sweden). Thus, all health care partners mentioned above sign collective agreements on a central sectoral level every two or three years. These agreements stipulate everything from wage increases to working conditions and equality at the work place. Individual wage agreements are, within frames, set through local negotiations. In addition, local agreements regarding company-specific issues can be signed at the company level.

Estimate the coverage rate of collective bargaining in terms of a) companies and b) employees.

Since collective bargaining takes place at the sectoral level and unorganised employers can sign application agreements, the collective bargaining rate for employees in the economy as a whole is 91% (EIRO IR-profile Sweden). The share of employees in the health care sector that is covered by collective agreements is almost 100% according to both Kommunal and Vårdförbundet. The reason that the coverage rate is so high is that an overwhelming majority of the employees in the sector are employed in public sector institutions. The coverage rate is therefore, naturally, also high among the employers.

Is there a practice of extending multi-employer agreements to employers who are not affiliated to the signatory employer associations?

Yes, application agreements are commonly used at smaller unorganised work places.

In case of sectoral collective bargaining, are there derogation practices and opt-out rules from collective agreements and to what extend have these been used?

The collective agreements can contain an opt-out clause. This was the case in the agreement (HÖK08) signed in May 2008 between OFR and SALAR/PACTA. The agreement can therefore be withdrawn during the last year (2010-2011) if one of the partners feels that this is necessary. To our knowledge, this has never happened.

2.5 Is there a forum for social dialogue dealing with matters of the health care sector? (Bi-partite and/or tripartite social dialogue; national, regional or local level?)

There is no health care specific forum for social dialogue. Rather, the dialogue takes place in the work place committees or in-between the sectoral organisations in a bipartite setting. All concrete measures are agreed upon within the frame of the collective or partnership agreements.

The Employment Codetermination in the Workplace Act (MBL 1976:580) gives employees the right to receive information about the plans for the staff and the production as well as the financial status of the company. The union representatives are also allowed to inspect documents and other data before important decisions are made. Issues related to the work environment, working conditions, equality, reducing work related hazards, etc, on the company level are generally discussed in elected work councils, employee councils, cooperation committees or directly between trade union representatives and the management.

In addition to the collective agreements, partners or the sectoral level usually sign partnership agreements (samverkansavtal) that stipulate how they will cooperate to improve the business. The agreements usually outline when and where dialogue is to take place, who is to participate and what issues that are to be on the agenda.

2.6 Elaborate on the incidence of industrial action in past five years within the health care sector. (The nature of industrial action, number of employees involved, number of working days lost, reasons for conflict, outcomes)

  • In the previous bargaining round in 2008 the Swedish Association of Health Professionals (Vårdförbundet) sent 6,000 - 7,000 nurses and biomedical analysts out on a six week long strike (SE0805039I). The association argued that its members’ wages were too low in relation to other professions with less educated workers, such as assistant nurses. The strike primarily involved nurses, but also biomedical scientists and midwives. According to the association and SALAR, 13,300 operations and 35,000 examinations were cancelled as a result of the strike. In late May 2008, the partners finally settled an agreement (HÖK 08) that enabled wage increases of at least 4% during 2008, 3% during 2009 and 2% during 2010. A wage floor of 21,100 SEK (2,212 EURO) for employees that have been working for at least one year was also agreed upon in the collective agreement. In addition to this, the agreement encouraged local wage bargaining through individual negotiations.

The general opinion among nurses was however that the strike reached unsatisfactory results in terms of wage increases and that the profession still is underpaid in relation to for example assistant nurses. The Swedish Association of Health Profesionals has not yet signed a new agreement. Thus, it remains to see how the issue of wages is addressed in the upcoming collective bargaining.

3. Contribution of collective bargaining and social dialogue to addressing the challenges facing the health care sector

3.1 Please indicate whether multi-employer collective bargaining has contributed to address the challenges facing the health care sector since 2005. Has multi-employer collective bargaining introduced specific clauses or instruments to address these challenges? Please illustrate the most important of such clauses or instruments and include a brief assessment of their impact.

  • The 2008 collective agreement (HÖK 08) between SALAR and PACTA on the one side and the OFR with the Association for Health Professionals and SKTF on the other, is still used and it contained wage increases of at least 4% during 2008, 3% during 2009 and 2% during 2010. A wage floor of 21,100 SEK for employees that have been working for at least one year was also agreed upon in the collective agreement. The agreement also retained measures implemented in previous agreements. One example was the possibility for workers to participate in training, courses, conferences or other educational measures and still keep their salaries as if they were working. Paragraph seven also stated that if the training was shorter than seven working days, the worker should receive supplementary pay for the inconvenient working hours he or she would have worked, had he or she been at work.
  • Kommunal and SALAR/PACTA signed a new main agreement (HÖK 10) in the spring of 2010. It enabled wage increases of at least 4.65%, or 970 SEK, over the whole period of 2010 and 2011. The agreement was according to Kommunal’s president Ylva Thörn first and foremost “an improvement of equality”, as it secured new wage increases for low-income workers; it implemented the “equality pools” mentioned in section 3.3 and it successfully established bipartite committees with the task of increasing the number of full time employment contracts. The committees are going to map out the different working time agreements/schemes, local agreements and policies. The HÖK 10 agreements also retained the same principals of educational measures as the earlier agreements.
  • The partnership agreement FAS 05, implemented in 2005, still applies both to OFR, Kommunal and SALAR/PACTA. The agreement is negotiated between all partners within the municipal and county sectors. Thus, it encompasses health care, schools, public administration, etc. The agreement is one of the most important steps taken to improve the outcome of social dialogue and collective bargaining and it outlines the foundation for local work environment, improvement and cooperation agreements at the municipal and county levels. The purpose of the agreement is to encourage both employers and employees to work together with issues of occupational health and work environment, especially focusing on preventive work directed towards entire work places and towards leaders and union representatives. The improvement of equality and diversity is also, according to FAS 05, an important part of the cooperation. The agreement stipulates what tasks that are going to be managed within the partnership bodies at the work places. The tasks include the establishment of work environment policies, evaluation of the systematic environmental work and informational and educational planning, i.e. that the right people, receive the right training. FAS05 is an important framework agreement that ensures that the proper channels of dialogue and bargaining are established at the work places. It is then up to the local partners to negotiate and work with all relevant issues in bodies, committees and councils.

3.2 Please indicate whether single-employer collective bargaining and social dialogue practices at company level have contributed to addressing the challenges facing the health care sector since 2005. Has single-employer collective bargaining introduced specific clauses or instruments to address these challenges at company level? Please illustrate up to three cases and include your assessment of their impact.

Since all collective bargaining is carried out at the sectoral level, no specific clauses or instruments can be named or highlighted at this level of bargaining.

3.3 Please indicate whether social dialogue (national, regional, local level – bipartite/tripartite) has contributed to addressing the challenges facing the health care sector since 2005. Has this dialogue introduced specific instruments to address these challenges? Please illustrate the most important of these instruments, specify at which level they have been concluded, who was involved and include your assessment of their impact.

  • The both the FAS05 and the HÖK08/HÖK10 agreements have contributed to encourage social dialogue. Especially FAS05 sets the foundation on which local partners can sign local or company-specific agreements on work environment, equality, wages, etc. These agreements are with its accompanied work councils, bodies and committees the most important instruments to make improvements in the specified areas of interest. One example of how unions and employers’ organisations have used social dialogue to implement new measures in the collective agreements, are the so called “equality pools”.
  • In the previous bargaining round in 2007, a new solution called an “equality pool” was introduced by the Swedish Trade Union Confederation (LO). Up until then, employer and employee representatives had agreed on a certain wage increase for the upcoming three-year-period. The pool of money was then distributed evenly over the sector. Since female workers still, to this day, have lower absolute wages the system of wage increases was not encouraging the improvement of wage equality. The LO proposed to use the “equality pool” to increase the female workers’ pay relative to the male workers. The solution meant that Kommunal, among others, signed agreements where such pools were integrated. The pools were commonly structured in such a way so that sectors where there was a predominance of female workers would receive higher wage increases than sectors where male workers dominated. Assistant nurses benefitted the most from the new pool, but questions were soon raised as to the real impact for the majority of female workers. The manufacturing and industrial workers’ union (IF Metall) argued that the pools were too biased towards female dominated sectors. This meant that the female workers in male dominated sectors were relatively worse of as a result of this pool. LO and its unions, where Kommunal is included, have as a result of this, now reformed the equality pool into a “low-income pool” that simply gives larger wage increases to the low income workers of whom female workers are overrepresented. This solution was incorporated in the latest agreement (HÖK10) between Kommunal and SALAR/PACTA.

4. Commentary

There are challenges in providing choice-based care and cutting waiting lines within the Swedish health care system. The problem, as in all areas of the public sector, is to keep a balance between defendable socio-economic costs and good quality health care. The liberalisation of the primary care system is a new attempt to do this. However, health care has to be associated with costs in order to limit demand. To this date, costs have been put on the patients in the form of long waiting lines. Thus, if reform seeks to shorten these lines one can expect rising costs as the system is tax-funded.

Social partners can contribute by trying to increase the level of equality and decrease the level of stress within the sector by signing agreements such as the FAS05, but also by introducing new measures such as the “equality pools”.


  • Bergsmark, Bengt, 2008-03-26, ”Jämställdhetspotter – så blev det”, Kommunalarbetaren, Web article
  • Egerö, Anne-Marie, 2009, ”Nio perspektiv på jämställdhet”, National Meditation Office anthology, p. 50-60
  • EIRO, 2009-11-25, “Sweden: Industrial Relations Profile”, European Foundation for the Improvement of Livining and Working Conditions, country profile
  • Erlandsson, Johan, 2010-05-12, “Kommunals avtal med SKL klart”, Kommunalarbetaren, Web article
  • Ermretsson, Anders; Lindberg,Ulf; Lindgren, Anne-Marie, 2009-02-23, “Valfrihetsdiskussion utan skygglappar”, LO-tidningen, Debate article
  • FAS, 2010-06-17, Web page
  • Statistics Sweden (SCB), 2010-06-12, Company database (FDB)
  • Stockholm TT, 2008-05-28, “Besvikelse över vårdavtalet”, Svenska Dagbladet, Web article
  • Sjölander, Ann-Christin, 2010-05-14, ”Ett lyft för jämställdheten”, Kommunalarbetaren, Web article
  • SKTF, 2005-04-01, FAS 05 partnership agreement
  • The Association for Swedish Health Professionals (Vårdförbundet), 2010-06-14, Web page
  • The Association for Swedish Health Professionals (Vårdförbundet), 2010-06-14, Debate article
  • The Liberty of Choice System Act (Valfrihetslagen, LOV 2008:962)
  • The Swedish Government, 2010-06-14, “Vårdval”, Web article
  • The Swedish Municipal Workers’ Union (Kommunal), 2008-10-24, “Kommunal avvisar vårdval I hela Sverige”, Web article
  • TT; Öhman, Adam, 2008-05-28, “Vårdstrejken är över - parterna är överens”, Expressen, Web article


  • Sjöström, Kerstin – negotiator at the Association for Swedish Health Professionals (Vårdförbundet)
  • Johansson, Margaretha – ombudsman at the Swedish Municipal Workers’ Union (Kommunal)

Mats Kullander and Oskar Eklund, Oxford Research

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