Governing at the expense of care: diverging growth in administrative and clinical staffing in Swedish health care over 10 years.

Concerns have been raised that Swedish health care resources are increasingly directed toward administrative and managerial functions rather than clinical care. This development may be linked to the growing use of private providers within the publicly funded system. Our study investigates how administrative and managerial staffing has changed over the period between 2014 and 2024 relative to clinical staff categories in Swedish health care. We also investigate to what extent this change can be explained by the increasing use of privately provided care. A purposive database was constructed covering employed staff in governing functions, clinically active staff holding a professional licence or certificate, and regional expenditure on privately provided health care across twenty of Sweden's regional administrations for the study period (one small region with overlapping municipal responsibilities was excluded). Fixed effects panel regression, controlling for region and year, was used to estimate the association between spending on privately provided care and the number of administrative staff. All staff categories increased in number over the study period, but at markedly different rates: desk-officers grew fastest at 38 percent (27 percent adjusted for population), followed by managers at 28 percent (18), while clinical categories grew more modestly, with physicians increasing by 22 percent (13) and nurses showing the weakest growth at 10 percent (1). Growth in administrative and managerial staff varied considerably across regions but did not show a statistically significant association with regional spending on privately provided care once a common time trend was accounted for. Our findings suggest that Swedish health care has undergone a compositional shift toward administrative roles at a faster pace than clinical roles, a development not attributable to increased private provider use. Future studies should address questions about how administrative growth relates to the value it generates within the health system.