Exploring health system resilience during the COVID-19 pandemic in Sweden: an interrupted time series analysis of service utilisation and sociodemographic differences

The COVID-19 pandemic strained health systems worldwide, diverting resources and disrupting routine healthcare services. These disruptions may lead to health risks from delayed or reduced care. Health system resilience (HSR) – a critical factor in maintaining health services during crises – refers to a system’s ability to anticipate, prepare for, absorb, respond to, recover from, and adapt to disruptions. To be effective, HSR must also be equitable, ensuring that all socioeconomic groups have access to healthcare services during crises. Sweden’s approach, which relied on public adherence to government recommendations rather than enforcing restrictions, presents a unique case for studying HSR. This study aims to evaluate aspects of HSR in Sweden during the COVID-19 pandemic by analysing changes in essential health service utilisation across different phases of the pandemic, and by examining sociodemographic differences in utilisation by education and sex. This study utilises interrupted time series analysis to evaluate changes in healthcare service utilisation across various levels of the Swedish health system with stratification by education and sex. Primary care was measured through diabetes diagnoses, emergency care through appendicitis cases, inpatient care through hospital admission for inflammatory bowel disease (IBD), and cancer diagnostics through diagnosis rates. Data were obtained from various population based Swedish health registries through the SWECOV project. The findings highlight varying degrees of disruptions and resilience across different sectors. Emergency care, primary care, and symptom-based cancer diagnosis showed signs of recovery after an initial drop, whereas cancer screening, was more affected. In the case of inpatient care for IBD, the number of admissions declined, though the length of hospital stays remained unchanged. Education level did not impact healthcare utilisation for most indicators, and differences between men and women were generally small. The Swedish HSR during the COVID-19 pandemic was challenged but remained intact in most healthcare sectors. The health system on different levels also managed to a large degree cater for the diagnoses covered in this study, largely independent of educational level and sex. As data availability increases with time further research will help gain a deeper understanding of the outcomes of the pandemic on health services unrelated to COVID-19, including the role of education in influencing healthcare utilisation.