Health Systems in Transition: Norway

HiT summary: Norway, 2006 HiT Summary Health Systems in Transition European Observatory on Health Systems and Policies WHO Regional Office for Europe Scherfigsvej 8 DK-200 Copenhagen Denmark Telephone: +45 39 7 7 7 Fax: +45 39 7 8 8 E-mail: info@obs.euro.who.int www.euro.who.int/observatory European Observatory on Health Systems and Policies Norway Fig.  Total health care expenditure as a percentage of GDP, comparing Norway with selected countries and the EU average, 2002, WHO estimates Denmark Finland Iceland Norway Sweden EU prior to 1 May 2004 Source: European Health for All database, January 2006. Note: EU: European Union. 0 5 10 15 Introduction Government and recent political history Norway has been a constitutional monarchy since 1814, and the country became formally independent in 1905. The King is officially the highest executive authority, although in practice the government cabinet is at the head of the executive power. Norway is governed by a three-tiered parliamentary system, with each tier run by a popularly elected body: the national Parliament (Storting), the county councils and the municipalities. There were 19 counties and 431 municipalities in 2006. Central government, specifically the Ministry of Health and Care, is responsible for secondary health care. The municipalities are responsible for health promotion, primary health care, care of the elderly and care of the physically and mentally disabled. The counties are responsible for dental health care. Population The population of Norway passed 4.6 million in 2005. On average there are 15 persons per km2. The natural population growth rate, which steadily decreased from the start of the 1970s to less than 2 per 1000 in the mid-1980s, started to increase again, reaching an average of 3.4 per 1000 in the period 1996–2000, a figure well above average EU levels. At the beginning of 2004 the immigrant population in Norway was 349 000 and accounted for 7.6% of the total population. Average life expectancy There was a considerable improvement in life expectancy throughout the 20th century. In 2004 life expectancy at birth was 77.5 years for males and 82.33 years for females. This is a significant increase over the period 1946–1950, when the 2HiT summary: Norway, 2006 average figures were 69.25 years for males and 72.65 years for females. Leading causes of death Mortality due to diseases of the circulatory system has been significantly reduced during the last 30 years, and this is one of the major factors that have contributed to the rise in life expectancy. Diseases of the circulatory system are, however, still the leading cause of mortality, accounting for almost a third of deaths in 2003. Health promotion interventions, including those to prevent accidents, brought positive results in Norway. Mortality from external causes has been reduced by 20% during the last three decades. There has been some increase in mortality as a result of mental diseases and cancer during the same period. Recent history of the health care system The years following the Second World War can be described as a period of continual reform in the relationship between state and local government. The goal has been to find an acceptable balance of power between these two levels of government. Power continues to be devolved from central to local government, with the aim of focusing as much as possible on the municipal level and enabling counties/regions and municipalities to take over service provision. The administrative level, which is responsible for implementing and providing various services, has also been given responsibility for financing. In order to cover expenditures, the municipalities and counties draw on local taxes (mostly income and property taxes from individual taxpayers) in addition to block grants and earmarked grants from the state for high-priority reforms. With regard to specialized care, there was no general Act regulating the hospital sector until the Hospital Act was passed in 1969. Since its adoption, each of Norway’s 19 counties assumed responsibility for the financing, planning and provision of specialized health care. In 1974, the White Paper on Hospital Development in a Regional Public Health Service set out an overall fundamental strategy of health services at regional level. In 2002 the responsibility for specialized health care was transferred to central government. The country was divided into five regional health authorities with responsibility for organizing specialized health care within a health enterprise structure. Reform trends Taking an aggregate view of health care reform over several decades, the general focus of the 1970s was on equity questions and the build-up of health services; the 1980s on cost containment and decentralization; the 1990s on efficiency and leadership; and the beginning of the new millennium on structural changes in the delivery and organization of health care. Health expenditure and GDP In 2005, Norwegian health care expenditure was around 10% of GDP (Figure 1). Health care expenditure as a share of GDP has been increasing steadily during the last twenty years from 6.9% in 1980. In comparison with other Nordic countries in 2002, health expenditure as a percentage of GDP in Norway was lower than in Iceland (10.0) and higher than in Denmark (8.8), Finland (7.2) and Sweden (9.2). Overview Organizational structure of the health care system The health care system in Norway is organized on three levels: the central state, the five regional authorities and the municipalities. While the role of the state is to provide national health policy, to prepare and oversee legislation and to allocate funds, the main responsibility for the provision of health care services lies with the five health regions and the 431 municipalities. At the national level, the parliament serves as the political 3HiT summary: Norway, 2006 decision-making body. Overall responsibility for the health care sector rests at the national level, with the Ministry of Health and Care. The country’s 431 municipalities, whose sizes vary considerably, are responsible for the provision and funding of primary health care and social services. All citizens have the right to access to health care services in their community. Norway’s five regional health authorities are responsible for the financing, planning and provision of specialized care. This includes somatic care and mental health/substance abusers care, as well as other specialized medical services, such as laboratory, radiology and paramedical services. There are at present 31 health enterprises under the five regional health enterprises. Planning, regulation and management At the national level, the political decision-making body is the parliament. The executive body is the Ministry of Health and Care. The responsibility of the national bodies is to determine policy, prepare legislation, undertake national budgeting and planning, organize informal channels, and approve institutions and capacity expansion. The municipalities provide primary health care, including nursing care for the disabled and the elderly, while responsibility for specialized health care lies with the regional health authorities that are owned by the central government. Dental care is still part of the county’s responsibility. The health care system is mostly publicly owned, although there are some contracts with private agencies, mainly between municipalities and GPs, and between the regional health authorities and specialist physicians. The Ministry of Health and Care provides instructions to the regional health authorities through a “letter of instruction”, which is prepared individually for each of the five authorities and can be seen as a “government supplement”. The governance of the municipalities relating to primary health care is in practice an interplay between a number of different ministries, such as the Ministry of Health and Care, the Ministry of Labour and Social Inclusion, and the Ministry of Local Government and Regional Development. Decentralization Decentralization has been one of the characteristics of the Norwegian health care system but the hospital reform of 2002 changed the system from a decentralized to semi-centralized one. The regional health authorities, represented by the state, are responsible for specialized health care, while the municipalities are responsible for primary health care. In their organizational structure, the regional health authorities and the health enterprises may be seen as state-owned companies. Principal health policy objectives and frameworks are determined by central government and form the basis for the management of the enterprises, while day-to-day management is the responsibility of the general manager and the executive board. The municipalities are run by locally elected politicians together with their administrative staff. Health care is one of many areas for which they are responsible. The municipalities are free to set up their own organizational structure. Health care financing and expenditure Main sources of financing Sources of revenue for health care in Norway include taxation, national social insurance systems and private expenditure. The Norwegian health care system is primarily funded through taxes which are raised at municipality, county and central levels. Following parliament’s approval, the central government sets the municipalities’ and counties’ maximum tax rates. There is no specific health tax in Norway, and the regional health authorities cannot themselves draw taxes. During the last 20 years, the proportion of public expenditure on health has been steady at around 85%. 4HiT summary: Norway, 2006 Complementary sources of financing All residents of Norway or people working in the country are insured under the National Insurance Scheme (NIS), which is run by central government. The NIS is financed by contributions from employer, employees, self-employed people and state funding. People insured under the NIS are entitled to retirement, survivors’ and disability pensions, basic benefits and attendance benefit in case of disability, rehabilitation or occupational injury. There are also benefits for single parents, cash benefits in case of sickness, maternity, adoption and unemployment, and medical benefits in case of sickness and maternity, as well as funeral benefits. Health care expenditure by NIS in 2002 was almost NKr 20 000 million, or approximately 10% of total NIS expenditure. Voluntary health insurance does not play any significant role in Norway. Out–of-pocket payments With regard to health care services, inpatient care in general hospitals does not involve out- of-pocket payments, but these are payable for consultations with private specialists, ambulatory care, GPs, X-rays, laboratory tests and drugs. Most of these out-of-pocket expenditures are included in the cost ceiling scheme that was introduced in the early 1980s. The ceiling is set each year: in 2006 it was NKr 1615. When the cost ceiling has been reached in any calendar year, most of additional out-of-pocket expenses is reimbursed by the NIS, and remaining treatment in that calendar year is therefore free of charge. In 2005 around 1 million Norwegians reached this ceiling. According to OECD, the share of out-of- pocket expenditure in the Norwegian health care system has been stable during the last two decades at about 15%. Health care expenditure According to the OECD database, health care expenditure expressed in US$ PPP per capita was US$ 3616 in Norway in 2002, which was higher than for neighbouring countries, Sweden (US$ 2594), Denmark (US$ 2655), Finland (US$ 2013) and Iceland (US$ 2948). Recent figures for 2006 indicate that Norway’s health expenditure measured in US$ PPP is second to the United States. Health care delivery system Primary health care The municipalities are responsible for providing primary health care and ensuring the wellbeing of the population, as well as good social and environmental conditions. Furthermore, they are responsible for providing information on health and encouraging lifestyle activities for the community that promote public health and individual health and wellbeing. The decision regarding the amount of local funds that can be spent on the health sector is left to the discretion of local politicians. Primary health care and general practice are well established in Norway. General physicians form the central part of the primary health care system, and the most common structures comprise teams of two to six physicians. In 2001, each municipality was given the responsibility to provide a physician for every citizen; a regular general practitioner scheme was established. The municipalities meet this obligation through contracts with general physicians. According to the Ministry of Health and Care, the scheme is functioning well, with 98% of the population having a regular general physician. The provision of emergency care (that includes the general physicians) is also an important task for the municipalities. Public health services Municipalities are responsible for health promotion, the prevention of illness and injuries and, in relation to that, the organization 5HiT summary: Norway, 2006 and management of school health services, health centres and child health care. The central government has five central public health institutions, which are professional and administrative bodies under the authority of the Ministry of Health and Care; these comprise: Norwegian Directorate for Health and Social Affairs, Board of Health, National Institute for Public Health, Norwegian Medicines Agency and Norwegian Radiation Protection Authority. The county governors are responsible for the overall supervision of health services in their counties. The aim is to decentralize the provision of public health services as much as possible in order to guarantee the shortest possible distance between provider and consumer. The White Paper Report No. 16 (2002–2003), Prescriptions for a healthier Norway: a broad policy for public health, outlines the national public health strategies for the next 10 years. It sets the agenda for a healthier Norway, achieved through a policy that contributes to more years of healthy life for the population as a whole and a reduction in health inequalities between social classes, ethnic groups and genders. Secondary and tertiary care In 2002, the Norwegian Hospital Reform was implemented, and the responsibility for secondary care was transferred from the counties to the five regional health authorities, forming a health enterprises structure. The purpose of the health enterprises is to deliver specialized health care services of high quality and equity to anyone in need, regardless of age, gender, location, income or ethnic origin, as well as facilitating research and innovation. Each regional health authority has a statutory duty to provide equal access to hospital services for those who live in its catchment area. Each hospital is now a discrete legal entity, with a managerial board responsible for all its activities. The regional health authorities may contract out 2 3 4 5 6 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Denmark Finland Norway Sweden EU Fig. 2 Beds in acute hospitals per 000 population in Norway and selected countries, 990–2004 Source: European Health for All database, January 2006. HiT summary: Norway, 2006 some services to private hospitals or agencies. The regional health authorities are financed via global budgets, activity-based financing (fee-for- services and DRG-reimbursement) and patients’ out-of-pockets payments. Each region has a different degree of tertiary level services, where most of the tertiary level services are conducted in hospitals situated in urban areas. Long-term care The organization of long-term care is the responsibility of the municipalities in Norway. There are types of long-term care services: nursing homes, sheltered (adaptable) houses, and home-based services. Since the mid-1990s, there has been a significant increase in the number of people using nursing and care services provided by the municipalities. Human resources and training Compared to other OECD countries, Norway has a high number of health care personnel. In 2002, the density of practising physicians in Norway was 3.4 per 1000 population. Coverage has been improving in the last 4–5 years, and nursing coverage is the second highest in Europe after Finland. Four public universities in Norway run medical education programmes, based on grades from a tertiary education diploma. After the 6-year basic medical education, there is an internship period of 18 months. This period has traditionally been an important regional policy tool, and internship positions have been concentrated in rural areas. There are 30 basic specialties, eight medicine and five surgery branch specialties. The average minimum time required to obtain a specialty is five years. There are 27 educational institutions in Norway, offering basic nursing education, 22 of these are university colleges, and the remainder are located in health care institutions. There is standard minimum entry requirement for nursing education (this normally means that the student must have completed three years of tertiary education). With the introduction of the hospital reform in 2002, there has been an increased focus on leadership and management training within the public hospital sector. The Norwegian Board of Health is the government agency that decides on disciplinary measures in the event of medical malpractice. Pharmaceuticals The Norwegian Medicines Agency is responsible for preparing recommendations concerning the acceptance of drugs into the reimbursement scheme, based on established criteria. There is a price and profit scheme in operation for prescription drugs. Prices are regulated according to the European Economic Area (EEA) rules, and the pharmacies’ margins are set by parliament. Price regulation for generics is subject to the same regulations as their original counterparts. Table  Inpatient utilization and performance in acute hospitals in the WHO European Region, 2004 or latest available year Hospital beds per 000 population Admissions per 00 population Average length of stay in days Occupancy rate (%) Denmark 3.2a 17.8c 3.6a 84.0c Finland 2.2 19.9 4.2 74.0i Norway 3.1 17.3 5.2 86.4 Sweden 2.2 15.1 6.1 77.5h EU15 average 4.0a 18.0c 6.9a 77.0c Source: European Health for All database, January 2006. Notes: a 2003; b 2002; c 2001; d 2000; e 1999; f 1998; g 1997; h 1996; i 1995; EU: European Union; EU15: Member States before 1 May 2004. 7HiT summary: Norway, 2006 Non-prescription (over-the-counter) drugs are not subject to price and profit regulation. Direct- to-consumer advertising on prescription drugs is not allowed. Financial resource allocation Payment of health care facilities The main source of funding to the municipalities consists of block grants from the state and local taxes. The state has a distribution formula, which determines the amounts distributed to the municipalities. The grant is calculated using a weighting system to compensate for variations in the demand for municipal services, and cost differences in respect of producing such services. The most important weighting is age-related, as the demand for health care and care for the elderly depends to a large extent on demographic characteristics. There are three sources of funding for emergency services: block grants from the municipalities, out-of-pocket payments and reimbursements from the NIS. Nursing homes and sheltered houses are funded by block grants from the municipalities and out-of-pocket payments. The regional health authorities are funded by state grants with a block grant element and an activity-based element. Somatic inpatient care (and some day surgery procedures from 1999), have been financed through the Activity Based Financing (ABF) scheme since 1997 (based on the DRG-system). There is also tariff reimbursements from the NIS based on fee-for- service for ambulatory care, X-rays and laboratory services. The regional health authorities are free to set up their own funding system for their health enterprises and other institutions. Payment of health care professionals Norwegian health care personnel are mainly salaried employees. The main exceptions include self-employed personnel such as physician specialists with RHA agreements paid by fee-for- service from the NIS, out-of-pocket payments and block grants from the RHA; and regular GPs paid by fee-for-service from the NIS, out-of-pocket payments and capitation from the municipalities. The main salary negotiations for public health care professionals are normally set between the state/municipalities as employers and the health care personnel member organizations. Health care reforms The purpose of the Municipalities Health Care Act of 1984 was to coordinate health and social services at the local level, to strengthen these services in relation to institutional care, to strengthen preventive care, and to pave the way for better allocation of health care personnel. The Act provides the municipalities with a tool by means of which comprehensive health services are provided in a coordinated way. In 1988 the Municipalities Health Care Act was further expanded and responsibility for nursing homes was transferred from the counties to the municipalities. In 1997, Norway introduced Activity Based Funding (ABF), based on the DRG (diagnosis related group) system. The introduction of ABF was followed by a substantial increase in the number of cases treated and a reduction in waiting times. The system includes approximately 500 different treatments for hospitalization, day surgery and some day medical procedures. This system does not include outpatient treatments where there are special reimbursement rates from NIS, patients who pay for themselves (for instance, foreign patients) and mental hospitals. DRG weightings and reimbursement are equal in all hospitals, irrespective of cost structure, case mix or type of hospital. A current national set of cost weightings is estimated on the basis of costs in selected hospitals. 8HiT summary: Norway, 2006 The General Practitioners Scheme imple- mented in 2001 is based on a system through which patients register with a physician of their choice. Basic principles include the individual’s right to choose whether or not to participate in the system, their right to choose another physician as their GP (twice in a year) and the right to a second opinion by another general physician. The aim of the reform was to improve the quality of the local medical service, to ensure continuity of care and encourage a more personal patient–physician relationship. This reform also embodies a new model for employing GPs, based on contracted physicians in private practice where capitation, fee-for-service and out-of-pocket payments form the income base. The hospital reform in 2002 aimed to increase efficiency and consisted of three main strategies: the ownership of the hospitals was transferred to the central government sector; hospitals were organized as enterprises; and the day-to-day running of the enterprises became the responsibility of the general manager and the executive board. Preliminary results of the hospital reform show some positive outcomes, such as decreased waiting lists and improved management skills. In 2001 a new law was passed allowing greater freedom to establish pharmacies, which led to vertical integration of pharmacy chains owned by wholesale companies, and allowed pharmacies to substitute a physician’s prescription with another (e.g. generic) brand. This reform resulted in an increased market share for generics. More recent efforts to regulate the pharmaceutical market include the index price system introduced in 2003 allowing the retailer to gain extra margins if they choose a cheaper drug rather than an expensive one. This reform was replaced in 2005 by a step-price system that cut the reimbursement of off-patented drugs. The Tobacco Law of 2004 banned smoking from 1 June 2004 wherever food and/or drinks are served and where these items are consumed. The main purpose of the Act was to protect employees and other guests against passive smoking. Municipalities maintain the supervision of the legislation on smoke-free restaurants. Conclusions Norway has been successful in implementing numerous reforms in primary and secondary health care, financing, mental and public health sectors, pharmaceuticals and other sectors. Several preconditions for the country’s successful health policy can be highlighted. Norway’s decision-making process has been consensus-oriented. Most decisions have been made through negotiations with interested parties, with the Norwegian Medical Association as one of the key players. The policy process can be characterized as a combination of central command and control (defining the policy goals, monitoring the outcomes, etc.) and local freedom to choose the most suitable means (the ‘tight- loose’ principle), and policy-making is separated from implementation (the ‘steering, not rowing’ principle, whereby politicians are concerned more with strategy and less with implementation). In addition, political commitment to place the health system at the top of the agenda has been a driving force in Norway. There are some remaining challenges that need to be addressed in future.  Integration of health and social care services. Two Royal Commissions on legislation of social and health sectors and on organization of different levels in health care sectors were created in 2003. Their objective is to identify means for improving coordination at different levels and sectors. This applies especially with regard to elderly and disabled people with complex diagnoses and chronic conditions, who would benefit from stronger integration of health and social services.  Further development of patient classification systems based on hospital stay or activity groups. This would facilitate the gathering of comparative information from the hospitals. 9HiT summary: Norway, 2006 HiT Summary Norway Health Systems in Transition European Observatory on Health Systems and Policies The Health Systems in Transition profile (HiT) on Norway was written by Jan Roth Johnsen at the Norwegian Directorate for Health and Social Affairs. The editor of the Norwegian HiT was Vaida Bankauskaite. The following people contributed to some of the writing of the Norwegian HiT: Odd Arild Haugen, Harald Siem, Olav Molven, Olav Slåttebrekk, John Arne Røttingen, Tore Grønlie, Simen Neby, Haldor Byrkjeflot, Terje Hagen, Steinar Madsen, Aina Schiøtz, Stein Husebø, John William Glad, Knut Engedal, Hanne Lundemo and Christine Furuholmen (the author of the Norwegian HIT 2000). The European Observatory on Health Systems and Policies is grateful to Grete Botten (University of Oslo) and Geir Sverre Braut (Norwegian Board of Health) and the Norwegian Ministry of Health and Care Services, for reviewing the report. The Health Systems in Transition (HiT) profiles are country-based reports that provide an analytical description of each health care system and of reform initiatives in progress or under development. The HiTs are a key element that underpins the work of the European Observatory on Health Systems and Policies. The Observatory is a unique undertaking that brings together the WHO Regional Office for Europe, the governments of Belgium, Finland, Greece, Norway, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, CRP-Santé Luxembourg, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. This partnership supports and promotes evidence-based health policy- making through comprehensive and rigorous analysis of health care systems in Europe.  Inequalities in health. Reducing these inequalities is a social priority; however, the effects of policies to reduce them are often not well documented. How these inequalities in health will be addressed in the future is a profound challenge for the Norwegian health care system.  Finding the optimal structure of the muni- cipalities and regional self-government.  Finally, interventions to reduce alcohol and drug abuse especially among young Norwegians, problems related to an ageing population and its impact on the health care services, globalization in terms of potential pandemic disease and information technology in the health sector. Health care policy has been a political priority in Norway, and a decentralized health system contributes to the involvement of individual users in the policy-making process. The implementation of recent, and earlier, reforms in the health sector shows significant political commitment. The development of the health system in Norway illustrates the possibilities for the successful achievement of political and social goals.

Ðåôåðàò îáçîðà: Íîðâåãèÿ, 2006 1 Åâðîïåéñêàÿ îáñåðâàòîðèÿ ïî ñèñòåìàì è ïîëèòèêå çäðàâîîõðàíåíèÿ Ñèñòåìû çäðàâîîõðàíåíèÿ: âðåìÿ ïåðåìåí Ðåôåðàò îáçîðà Ââåäåíèå Ãîñóäàðñòâåííûé ñòðîé è íîâåéøàÿ ïîëèòè÷åñêàÿ èñòîðèÿ С 1814 г. Норвегия является конституцион ной монархией. Государственную независи мость страна получила в 1905 г. Номиналь ной главой исполнительной власти являет ся король, но практически власть возложе на на кабинет министров. Управление в Нор вегии представляет собой трехуровневую парламентскую систему, каждый уровень которой возглавляют избираемые населени ем власти: национальный парламент (Стор тинг), советы провинций (фюлькестинги) и муниципалитеты. В 2006 г. Норвегия насчи тывала 19 провинций (фюльке) и 431 муни ципалитет. К ведению государственного уровня, то есть Министерства здравоохранения, отно сится вторичная (специализированная) по мощь. Муниципалитеты отвечают за попу ляризацию здорового образа жизни, первич ную медикосанитарную помощь, уход за престарелыми, инвалидами и больными с психическими расстройствами. Органы вла сти провинций отвечают за стоматологичес кую помощь. Íàñåëåíèå В 2005 г. население Норвегии превысило 4,6 млн человек. Плотность населения в сред нем составляет 15 человек на кв.км. Пока затель естественного прироста, который с начала 70х годов стабильно снижался и к середине 80х годов составлял менее 2 на 1000 населения, начал снова расти и в 1996– 2000 гг. поднялся до 3,4 на 1000 населения, что намного выше, чем в среднем в странах ЕС. К началу 2004 г. в стране проживало 349 000 мигрантов, что составляло 7,6 % от об щего числа населения. Åâðîïåéñêàÿ îáñåðâàòîðèÿ ïî ñèñòåìàì è ïîëèòèêå çäðàâîîõðàíåíèÿ Åâðîïåéñêîå ðåãèîíàëüíîå áþðî ÂÎÇ Àäðåñ: Scherfigsvej 8 DK-2100 Copenhagen Denmark Òåëåôîí: +45 39 7 7 7 Ôàêñ: +45 39 7 8 8 Ýëåêòðîííàÿ ïî÷òà: info@obs.euro.who.int Ñàéò â èíòåðíåòå:www.euro.who.int/observatory Äàíèÿ Ôèíëÿíäèÿ Èñëàíäèÿ Íîðâåãèÿ Øâåöèÿ ÅÑ (äî 1 ìàÿ 2004 ã.) Ðèñ. 1. Ñîâîêóïíûé îáúåì ôèíàíñèðîâàíèÿ çäðàâîîõðàíåíèÿ (% îò ÂÂÏ) â Íîðâåãèè, íåêîòîðûõ äðóãèõ ñòðàíàõ è â ñðåäíåì â ñòðàíàõ ÅÑ (ñòàòèñòèêà ÂÎÇ, 2002 ã.) Èñòî÷íèê: Åâðîïåéñêàÿ áàçà äàííûõ «Çäîðîâüå äëÿ âñåõ», ÿíâàðü 2006 ã. Ïðèìå÷àíèå: ÅÑ - Åâðîïåéñêèé ñîþç 0 5 10 Ðåôåðàò îáçîðà: Íîðâåãèÿ, 2006 2 Ñðåäíÿÿ ïðîäîëæèòåëüíîñòü æèçíè В XX веке средняя продолжительность жиз ни в стране заметно увеличилась. В 2004 г. ожидаемая продолжительность жизни у муж чин составила 77,5 года, у женщин – 82,33 года. Это значительно превысило показате ли 1946–1950 гг., когда в среднем продолжи тельность жизни мужчин была 69,25 года, а женщин – 72, 65 года. Îñíîâíûå ïðè÷èíû ñìåðòè За последние 30 лет в стране значительно сни зилась смертность от сердечнососудистых заболеваний – и это один из решающих фак торов увеличения продолжительности жизни. Вместе с тем сердечнососудистые заболева ния попрежнему лидируют среди причин смерти – в 2003 г. на их долю приходилась почти треть всех смертей. Положительное воздействие оказали мероприятия, направ ленные на укрепление здоровья, включая программы предотвращения несчастных слу чаев. Показатель смертности от внешних причин снизился на 20% за три последние десятилетия. В то же время смертность от пси хических и онкологических заболеваний не сколько выросла. Íîâåéøàÿ èñòîðèÿ çäðàâîîõðàíåíèÿ Годы после Второй мировой войны можно охарактеризовать как период непрерывно го реформирования системы взаимодей ствия центральных и местных властей с це лью установления приемлемого баланса разделения полномочий между этими дву мя уровнями власти. Центр продолжает де легировать полномочия местному уровню с целью переноса максимального акцента на муниципальный уровень и расширения полномочий провинций и муниципалите тов в обеспечении населения медицинской помощью. Местные власти, помимо фун кций по организации и охвату населения различными услугами, получили финансо вые полномочия. Муниципалитеты и вла сти провинций покрывают затраты не только за счет государственных фондов и субсидий, выделяемых на ключевые ре формы, но и местных налогов (в основном, подоходного и имущественного налога с физических лиц). В секторе специализированного меди цинского обслуживания отсутствовал госу дарственный стандарт для больниц, пока в 1969 г. не был принят Закон о стационар ной помощи. После вступления закона в силу все 19 провинций Норвегии приняли на себя обязательства по финансированию, планированию и оказанию специализиро ванной помощи. Официальный правитель ственный документ 1974 г. о развитии ре гиональной больничной помощи заложил основы стратегии развития регионального здравоохранения. В 2002 г. ответственность за оказание специализированной медицин ской помощи была передана правительству Норвегии. Территорию страны поделили на пять медикотерриториальных округов, ко торые отвечают за организацию специали зированной помощи в системе предприятий здравоохранения. Íàïðàâëåíèÿ ðåôîðì Если обобщить реформы здравоохранения последних нескольких десятилетий, то в 70х годах реформы были направлены на обеспечение общедоступной медицинской помощи и формирование служб здравоох ранения; в 80х – на сдерживание расхо дов и децентрализацию; в 90х – на повы шение эффективности и определение при оритетов в здравоохранении; в начале но вого тысячелетия – на структурные изме нения в организации и предоставлении ме дицинской помощи. Ðàñõîäû íà çäðàâîîõðàíåíèå è ÂÂÏ В 2005 г. объем финансирования здраво охранения в Норвегии составил примерно 10% от ВВП (рис.1). Последние 20 лет наблю дается стабильное увеличение доли ВВП, рас ходуемой на здравоохранение (с 6,9 % в 1980 г.). В сравнении с другими странами Се верной Европы, доля ВВП, выделенная на здравоохранение Норвегии в 2002 г., была больше, чем в Дании (8,8%), Финляндии (7,2%) и Швеции (9,2%), но меньше, чем в Исландии (10 %). Ðåôåðàò îáçîðà: Íîðâåãèÿ, 2006 3 Êðàòêîå ñîäåðæàíèå ðåôåðàòà Îðãàíèçàöèîííàÿ ñòðóêòóðà ñèñòåìû çäðàâîîõðàíåíèÿ Здравоохранение Норвегии имеет трехуров невую структуру: центральный орган власти, пять медикотерриториальных округов и му ниципалитеты. Органы центральной власти отвечают за национальную политику в здра воохранении, разработку и внедрение нор мативноправовой базы, распределение бюджета, в то время как организация меди цинской помощи и обслуживания – это ос новная задача властей пяти медикотеррито риальных округов и 431 муниципалитета. Парламент страны является государствен ным законодательным органом. Министер ство здравоохранения отвечает за сектор здравоохранения на национальном уровне. На муниципалитеты (в стране их 431, и их размеры значительно разнятся) возложены финансирование и организация первичной медикосанитарной помощи и социального обслуживания. Все граждане имеют право доступа к службам здравоохранения по мес ту жительства. Пять окружных комитетов здравоохранения Норвегии отвечают за фи нансирование, планирование и организа цию специализированной медицинской по мощи. К ней отнесены лечение больных с со матическими заболеваниями, психическими расстройствами, алкоголизмом и наркома нией, а также другие виды специализирован ной помощи, включая лабораторные, рент генологические и парамедицинские услуги. В настоящее время в пяти медикотеррито риальных округах насчитывается 31 пред приятие здравоохранения. Ïëàíèðîâàíèå, íîðìàòèâíî- ïðàâîâàÿ áàçà è óïðàâëåíèå На центральном уровне законодательным ор ганом власти является Парламент, исполни тельным – Министерство здравоохранения. Центральный уровень отвечает за разработ ку политики, нормативноправовой базы, со ставление национального бюджета, планиро вание, организацию информационной сети, поддержку институциональной базы и улуч шение материальнотехнического оснаще ния. Муниципалитеты обеспечивают первич ное медикосанитарное обслуживание, вклю чая сестринский уход за престарелыми и ин валидами. В то время, как ответственность за специализированную помощь лежит на ок ружных комитетах, сами комитеты подчиня ются центральной власти. Стоматологичес кая помощь остается в ведении властей про винций. Система здравоохранения преимуще ственно государственная с небольшой долей частного сектора – в основном, это частные врачи общей практики, работающие по кон тракту с муниципалитетами, и врачиспеци алисты на контракте с окружными комитета ми здравоохранения. Формой государствен ного управления являются инструкции, ко торые Министерство здравоохранения гото вит и направляет индивидуально для каждо го медикотерриториального округа. Общее стратегическое руководство муниципальны ми службами первичной медикосанитарной помощи на практике осуществляется в рам ках взаимодействия ряда министерств, таких как Министерство здравоохранения, Мини стерство труда и социального обеспечения и Министерство по вопросам местного самоуп равления и регионального развития. Äåöåíòðàëèçàöèÿ Децентрализация была одной из характерис тик норвежской системы здравоохранения до 2002 г., когда после проведения больничной реформы система стала наполовину центра лизованной. Окружные комитеты здравоох ранения от имени государства отвечают за специализированное медицинское обслужи вание, муниципалитеты – за первичную ме дикосанитарную помощь. По организационной структуре окружные комитеты здравоохранения и предприятия здравоохранения напоминают государствен ные компании. За организацию повседнев ной работы на местах отвечают генеральный директор и исполнительный комитет, а структура и основные политические цели и задачи предприятий здравоохранения опре деляются центральными органами власти. Ðåôåðàò îáçîðà: Íîðâåãèÿ, 2006 4 Глава муниципальной власти и кабинет избираются голосованием населения, здраво охранение – это лишь одно из направлений их деятельности. Муниципалитеты имеют право устанавливать свою организационную структуру. Ôèíàíñèðîâàíèå çäðàâîîõðàíåíèÿ è çàòðàòû íà íåãî Îñíîâíûå èñòî÷íèêè ôèíàíñèðîâàíèÿ Источники финансирования здравоохра нения в Норвегии – это налоги, государ ственная система страхования и платные услуги. Преимущественно финансирова ние системы здравоохранения идет за счет налогов на муниципальном, провинциаль ном и центральном уровнях. По решению парламента центральные органы власти устанавливают границы налогообложения на муниципальном уровне и в провинци ях. В Норвегии нет отдельного налога на здравоохранение, и окружные комитеты здравоохранения не имеют права вводить свои налоги. Последние 20 лет доля госу дарства в финансировании здравоохране ния практически не менялась, оставаясь на уровне примерно 85%. Äîïîëíèòåëüíûå èñòî÷íèêè ôèíàíñèðîâàíèÿ Все граждане Норвегии и работающие жи тели страны охвачены государственной си стемой страхования (ГСС) под управлени ем центрального правительства. ГСС фи нансируется за счет государства, работода телей, работающего населения и предпри нимательства. По страховке ГСС гражданам начисляют пенсионные пособия, пенсии по инвалидности и утрате кормильца, базовый соцпакет и выплаты по уходу при инвалид ности, реабилитации или производствен ных травмах. Система также начисляет по собия родителямодиночкам, денежные выплаты по болезни, беременности, безра ботице и на усыновление, а также льготы по медицинскому обслуживанию, беременно сти и похоронные пособия. В 2002 г. расхо ды ГСС на здравоохранение составили по чти 20000 млн норвежских крон, или при мерно 10% от общей суммы выплат ГСС. Добровольное медицинское страхование в Норвегии развито слабо. Îïëàòà ìåäèöèíñêèõ óñëóã çà ñ÷åò ïàöèåíòîâ Лечение и уход в больницах общего профи ля является бесплатным для населения, но больные должны оплачивать консультации частнопрактикующих специалистов, по мощь на амбулаторном этапе, лечение у врачей общей практики, рентгенографию, лабораторные анализы и лекарственные препараты. Большая часть выплат за меди цинскую помощь входит в Перечень плат ных медицинских услуг, который был со здан в начале 80х годов и устанавливал пре дельный уровень расходов граждан на эти услуги. Предельный уровень расходов ут верждается каждый год. В 2006 г. он соста вил 1 615 норвежских крон. Если в течение календарного года сумма расходов доходит до предельного уровня, то в оставшийся период до конца года лечение становится бесплатным, так как ГСС компенсирует разницу. В 2005 г. расходы на медицинские услуги достигли предельного уровня у при мерно у 1 млн норвежцев. По данным Организации экономическо го сотрудничества и развития (ОЭСР) доля доплат граждан за медицинские услуги в Норвегии последние два десятилетии сохра няется на уровне 15% от затрат на здравоох ранение. Çàòðàòû íà çäðàâîîõðàíåíèå Согласно базе данных ОЭСР, в 2002 г. в Норвегии затраты на здравоохранение в расчете на душу населения составили 3616 долл. США, что выше, чем в соседних стра нах: Швеции (2594 долл. США), Дании (2655 долл. США), Финляндии (2013 долл. США) и Исландии (2948 долл. США). Дан ные 2006 г. свидетельствуют о том, что по затратам на здравоохранение в долларах США на душу населения Норвегия уступа ет только США. Ðåôåðàò îáçîðà: Íîðâåãèÿ, 2006 5 Ìåäèöèíñêîå îáñëóæèâàíèå Ïåðâè÷íîå ìåäèöèíñêîå îáñëóæèâàíèå Муниципалитеты отвечают за первичную ме дикосанитарную помощь, обеспечение бла гополучия населения, а также за социально бытовые условия и состояние окружающей среды. Кроме того, они отвечают за медико санитарное просвещение и оздоровительные мероприятия среди населения, направленные на популяризацию здорового образа жизни, укрепление здоровья и благополучие челове ка. Объем финансирования здравоохранения из местного бюджета муниципалитеты опре деляют сами. В Норвегии хорошо развита система пер вичной медикосанитарной помощи и общей практики. Врачи общей практики являются центральным звеном этой системы и в боль шинстве случаев работают группами по 2–6 человек. В 2001 г. на муниципалитеты была возложена обязанность обеспечить каждого жителя лечащим врачом; введена система прикрепления пациентов к врачу общей практики. С учетом прикрепленных пациен тов муниципалитеты начали заключать кон тракты с врачами общей практики. По дан ным Министерства здравоохранения эта си стема хорошо работает и у 98% населения есть постоянный врач общей практики. Оказание скорой помощи, где также уча ствуют врачи общей практики – еще один из важных разделов деятельности под руковод ством муниципалитетов. Îáùåñòâåííîå çäðàâîîõðàíåíèå Муниципалитеты отвечают за укрепление здоровья населения, профилактику заболева ний и травм и поэтому в их ведении находят ся организация и контроль за деятельностью медицинских служб в школах, оздоровитель ных центрах и детских учреждениях здраво охранения. К центральному уровню управле ния относятся пять специализированных ме дикоадминистративных организаций здра воохранения под началом Министерства здравоохранения, а именно: Директорат Нор вегии по здравоохранению и социальному обеспечению, Государственный совет по здравоохранению, Норвежский институт об щественного здравоохранения, Норвежское медицинское агентство и Норвежское управ ление по радиационной безопасности. На уровне провинций функции контроли рующего органа в секторе здравоохранения возложены на губернаторов. Цель такого под хода – максимальный уровень децентрализа ции в системе медицинского обслуживания, что в значительной мере приближает постав щика медицинских услуг к потребителю. Официальный документ Правительства № 16 за 2002–2003 гг. «Рекомендации по оз доровлению Норвегии: основные принципы политики общественного здравоохранения» определяет национальную стратегию разви тия общественного здравоохранения в бли жайшее десятилетие. В нем изложена страте гия оздоровления страны, которая направле на на увеличение здоровых лет жизни насе ления в целом и сокращение неравенства в от ношении здоровья между отдельными груп пами населения: социальными, этнически ми, гендерными. Ñïåöèàëèçèðîâàííîå îáñëóæèâàíèå В 2002 г. в Норвегии прошла больничная ре форма, в результате которой ответственность за организацию специализированной помо щи перешла от властей провинций к пяти ок ружным комитетам здравоохранения – они образуют систему так называемых «предпри ятий здравоохранения». Основная цель пред приятий – оказание высококачественной специализированной помощи равного досту па вне зависимости от возраста, пола, места проживания, дохода и этнической принад лежности больного, а также поддержка науч ноисследовательских и инновационных проектов. Закон обязывает каждый окружной комитет здравоохранения обеспечить равный доступ к стационарной помощи всему насе лению, проживающему на территории, вхо дящей в данный медикотерриториальный округ. В настоящее время каждая больница – это юридически самостоятельный субъект, управляемый советом директоров, который отвечает за все направления деятельности. Окружные комитеты здравоохранения могут Ðåôåðàò îáçîðà: Íîðâåãèÿ, 2006 6 заключать договора с частными клиниками или агентствами на выполнение тех или иных услуг. Финансирование окружных комитетов здравоохранения осуществляется из средств государственного бюджета, на основе опла ты по результатам деятельности (оплата за услугу и в соответствии с клиникостатисти ческими группами), а также оплаты медицин ских услуг за счет населения. Медикотерриториальные округа разнят ся по уровню оказания высокоспециализиро ванной помощи. В основном такую помощь оказывают больницы, расположенные в крупных городах. Äîëãîâðåìåííàÿ ïîìîùü Организация долговременной помощи в Нор вегии находится в ведении муниципалитетов. Она включает: помощь в домах сестринского ухода, интернатах/приютах, и уход на дому. С середины 90х годов значительно увеличилось количество людей, обращающихся за услуга ми по уходу и выхаживанию, которые находят ся в ведении муниципалитетов. Ìåäèöèíñêèå êàäðû è îáó÷åíèå ìåäèöèíñêèõ ðàáîòíèêîâ По сравнению с другими странами, входящи ми в ОЭСР, в Норвегии высокий уровень обеспечения медицинским персоналом. В 2002 г. численность практикующих врачей в стране составляла 3,4 на 1000 человек насе ления. Последние 4–5 лет стабильно улучша ется охват населения медицинскими услуга ми, а по охвату населения услугами среднего медицинского персонала Норвегия стоит на втором месте в Европе, уступая лишь Фин ляндии. В Норвегии четыре государственных уни верситета предлагают программы высшего медицинского образования. Базовый курс обучения – 6 лет, затем 18 месяцев интерна туры. Интернатура традиционно является важным элементом региональной полити ки – интернов направляют в учреждения, сконцентрированные в сельской местности. Специализация насчитывает 30 базовых, а также восемь клинических и пять хирурги ческих специальностей. В среднем мини Äàíèÿ Øâåöèÿ Ðèñ. 2. ×èñëî áîëüíè÷íûõ êîåê íà 1000 íàñåëåíèÿ â Íîðâåãèè è íåêîòîðûõ äðóãèõ ñòðàíàõ, 1990–2004 ãã. Èñòî÷íèê: Åâðîïåéñêàÿ áàçà äàííûõ «Çäîðîâüå äëÿ âñåõ», ÿíâàðü 2006 ã. Ôèíëÿíäèÿ ÅÑ Íîðâåãèÿ 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 6 5 4 3 2 Ðåôåðàò îáçîðà: Íîðâåãèÿ, 2006 7 мальный курс обучения для получения одной из специальностей занимает пять лет. 27 учеб ных заведений в стране предлагают базовый курс для медицинских сестер. Из них 22 – это факультеты университетов, а остальные рабо тают на базе медицинских учреждений. В большинстве случаев стандартное требование для поступления на факультет медицинских сестер – это, как минимум, три законченных курса высшего образования. С началом боль ничной реформы в 2002 г. увеличилось вни мание к подготовке управленческих кадров в области государственной стационарной по мощи. Случаи врачебной ошибки рассматри вает Государственный совет по здравоохране нию, который определяет меры дисципли нарных взысканий. Ëåêàðñòâåííûå ñðåäñòâà Норвежское управление по контролю за ле карственными средствами составляет реко мендации относительно списка препаратов, за которые больным гарантирована компен сация по государственной системе страхова ния на основе установленных критериев. В отношении лекарственных средств, отпуска емых по рецепту, действует система базовой цены и надбавки. Регулирование цен соответ ствует нормам Европейской экономической зоны (ЕЭЗ), границы ценообразования уста навливает парламент. Ценообразование дже нериков подчиняется правилам ценообразо вания для патентованных средств. Лекарственные средства, отпускаемые без рецепта (через кассу) не относятся к списку государственной системы страхования. Не разрешается прямая потребительская рекла ма лекарственных средств, отпускаемых по рецепту. Ðàñïðåäåëåíèå ñðåäñòâ Ôèíàíñèðîâàíèå ó÷ðåæäåíèé çäðàâîîõðàíåíèÿ Основные источники финансирования му ниципалитетов – это целевые государствен ные субсидии и местное налогообложение. На уровне государства действует система рас пределения средств, в рамках которой опре деляют размеры финансовой помощи для каждого муниципалитета. Размер субсидии определяют, соизмеряя затраты на покрытие требуемых на территории муниципалитета услуг и разницу их стоимости. Самый важный фактор – возрастной, поскольку медицинс кое обслуживание и уход за престарелыми в значительной степени зависят от демографи ческих характеристик. Скорая помощь фи нансируется из трех источников: целевые субсидии для муниципалитетов, платные ус луги и компенсационные выплаты ГСС. По мощь в домах сестринского ухода и интерна тах финансируется из средств целевых субси дий для муниципалитетов и за счет платной медицины. Окружные комитеты здравоохранения финансируются за счет государственных суб сидий, которые включают гранты общего на значения и целевые дотации по результатам деятельности. Лечение и уход в больницах при соматических заболеваниях (а с 1999 г. и Òàáëèöà 1. Ïîêàçàòåëè ðàáîòû áîëüíèö â ñòðàíàõ Åâðîïåéñêîãî ðåãèîíà ÂÎÇ, 2004 ã. (â îòñóòñòâèå äàííûõ çà 2004 ã. ïðèâåäåíû ñàìûå ïîñëåäíèå èç èìåþùèõñÿ) ×èñëî ×èñëî Ñðåäíÿÿ Ñðåäíÿÿ áîëüíè÷íûõ êîåê ãîñïèòàëèçàöèé ïðîäîëæèòåëüíîñòü çàíÿòîñòü íà 1000 íàñåëåíèÿ íà 100 íàñåëåíèÿ ãîñïèòàëèçàöèè, äíè êîéêè (%) Äàíèÿ 3.2à 17.8c 3.6a 84.0c Ôèíëÿíäèÿ 2.2 19.9 4.2 74.0f Íîðâåãèÿ 3.1 17.3 5.2 86.4 Øâåöèÿ 2.2 15.1 6.1 77.5h ÅÑ 15 â ñðåäíåì 4.0a 18.0c 6.9a 77.0c Èñòî÷íèê: Åâðîïåéñêàÿ áàçà äàííûõ «Çäîðîâüå äëÿ âñåõ», ÿíâàðü 2006 ã. Ïðèìå÷àíèå: a 2003; b 2002; c 2001; d 2000; e 1999; f 1998; g 1997; h 1996; i 1995 ÅÑ: Åâðîïåéñêèé ñîþç; ÅÑ 15: ÷èñëåííîñòü ãîñóäàðñòâ-÷ëåíîâ äî 1 ìàÿ 2004 ã. Ðåôåðàò îáçîðà: Íîðâåãèÿ, 2006 8 некоторые хирургические вмешательства в дневных стационарах) финансируются по cхеме «Оплата по результатам деятельности», утвержденной в 1997 г. на основе клинико статистических групп (КСГ). Также действу ет система компенсаций ГСС, исходя из оп латы за услуги: амбулаторный прием, рентге нографию и лабораторные анализы. Окруж ные комитеты здравоохранения могут орга низовать свою систему финансирования тер риториальных предприятий здравоохранения и других служб, находящихся в их ведении. Îïëàòà òðóäà âðà÷åé Большинство работников медицинских уч реждений в Норвегии получают фиксирован ный оклад. Исключение преимущественно составляет частнопрактикующий персонал, например, врачитерапевты, работающие по контракту с окружными комитетами здраво охранения и оплачиваемые из средств ГСС, целевых грантов медикотерриториальных округов и за счет наличных платежей населе ния за медицинские услуги, а также врачи общей практики, оплачиваемые за счет ГСС по схеме «оплата за услугу», наличных плате жей населения за медицинские услуги и фон дов муниципалитетов в зависимости от чис ленности обслуживаемого населения. Деба ты относительно зарплат специалистов обще ственного здравоохранения, как правило, носят характер переговоров государства/ му ниципалитетов (то есть работодателя) с одной стороны и профессиональных врачебных ас социаций с другой. Ðåôîðìû çäðàâîîõðàíåíèÿ Закон 1984 г. о муниципальном здравоохра нении был призван координировать деятель ность медицинских и социальных служб на местном уровне, укрепить функции служб в отношении стационарной помощи, усилить профилактические мероприятия и заложить основу для более рационального использова ния медицинских кадров. На уровне муници палитетов закон выступает механизмом коор динации усилий при организации целого ряда услуг первичной медикосанитарной помо щи. В 1988 г. закон о муниципальном здраво охранении был дополнен, и тогда ответствен ность за дома сестринского ухода перешла с провинций на муниципальный уровень. В 1997 г. Норвегия ввела принцип «Опла та по результатам деятельности», основанный на клиникостатистических группах. Введе ние этого принципа привело к увеличению числа пролеченных случаев и сокращению периода ожидания лечения. Система покры вает примерно 500 различных схем госпита лизации, хирургию и некоторые медицинс кие процедуры в дневных стационарах. Сис тема не распространяется на амбулаторное лечение (для которого действуют специаль ные компенсационные выплаты ГСС), на ле чение больных, которые сами оплачивают свои затраты (например, иностранцы), и на психиатрические клиники. Надбавки и ком пенсации на основе клиникостатистических групп одинаковы во всех больницах незави симо от стоимости услуги, типа случая и типа больницы. Действующая сетка компенсаций рассчи тана на основе анализа затрат нескольких выбранных больниц. Схема работы общей врачебной практики, внедренная в 2001 г., основана на системе выбора больным врача общей практики и регистрации (прикрепле ния к нему) на постоянное обслуживание. Основные принципы этой реформы: больной может выбирать регистрироваться в системе или нет, менять лечащего врача (дважды в год) и при желании получить консультацию другого врача общей практики. Цель рефор мы: повысить качество медицинских услуг на местном уровне, обеспечить преемственность в лечении/уходе и способствовать развитию сотрудничества врача и пациента. Частью ре формы была новая модель найма врача общей практики: с частнопрактикующими врачами заключают контракт и их доход складывает ся из дотаций в зависимости от подушевого норматива, надбавок за оказанные услуги и наличных платежей населения за медицинс кие услуги. Больничная реформа 2002 г. была направ лена на повышение эффективности работы стационаров. Реформа базировалась на трех стратегических изменениях: больницы пере ходили в собственность центральных органов власти, получали статус предприятий, и уп Ðåôåðàò îáçîðà: Íîðâåãèÿ, 2006 9 равление деятельностью на местах переходи ло к генеральному директору и исполнитель ному совету каждого предприятия. Предвари тельные результаты показывают, что боль ничная реформа, в частности, способствова ла сокращению очередей на госпитализацию и развитию навыков управления. В 2001 г. был принят новый закон, кото рый расширил возможности аптечной сети, способствовал вертикальной интеграции ап течных цепочек оптовых компаний и давал право аптекам предлагать больному аналог выписанного препарата (в том числе, джене рик). В результате этой реформы увеличилась доля рынка дженериков. Дальнейшим шагом в регулировании фармацевтического рынка стало введение в 2003 г. системы индексов предельной стоимости лекарств, что позволи ло продавцам розничной торговли повышать свою прибыль, если предпочтение отдавалось дешевым, а не дорогим препаратам. В 2005 г. эта система была заменена системой базовых цен, которая «срезает» компенсации за непа тентованные препараты. Закон о борьбе с курением 2004 г. запре тил (с 1 июня 2007 г.) курение в местах, где подают или продают напитки и еду. Основ ная цель закона – защита сотрудников таких заведений и их посетителей от пассивного ку рения. Соблюдение закона о запрете курения в ресторанах контролируют муниципальные власти. Çàêëþ÷åíèå Норвегия успешно проводит многочислен ные реформы в области первичной и специа лизированной помощи, финансирования, общественного здравоохранения и психиат рической помощи, обеспечения лекарствен ными средствами и других секторах. В числе предпосылок успешной реализа ции политики реформ можно выделить сле дующие. В Норвегии действует согласитель ный механизм принятий решений. В боль шинстве случаев решения принимаются по соглашению заинтересованных сторон и с ключевым участием Норвежской медицинс кой ассоциации. Можно сказать, что полити ческий курс характеризуют управление и кон троль со стороны центра (определение поли тических целей, мониторинг результатов и т.д.) и независимость местных властей в вы боре наиболее эффективных механизмов ре ализации (принцип «баланса власти и само стоятельности»). Процессы политической воли и исполнения разведены (принцип «быть у руля, а не на веслах», когда политики больше заняты решением стратегических за дач и в меньшей степени – вопросами воп лощения). Кроме того, одной из движущих сил государственной политики Норвегии было стремление придать вопросам здраво охранения статус наиболее приоритетных. Сохраняется ряд проблем, на которые не обходимо направить будущие усилия: • Интеграция служб здравоохранения и со циальной помощи. В 2003 г. были созда ны две государственные комиссии – по нормативноправовому регулированию медицинских и социальных услуг и орга низации различных уровней в системе здравоохранения. Цель их деятельности – определить пути улучшения координации действий между секторами и уровнями в рамках одной службы. Особенно это ак туально для ухода за престарелыми и ин валидами с отягощенными или хроничес кими заболеваниями, так как усиление интеграции медицинских и социальных служб повысит эффективность их услуг. • Дальнейшее развитие системы классифи кации больных на основе нормативов ста ционарного лечения и оплаты по резуль татам деятельности, что, кроме того, по может наладить сбор сопоставимых дан ных о госпитализации. • Проблема неравенства в секторе здраво охранения. Избавление от неравенства – это социальный приоритет. Между тем ре зультаты мероприятий, направленных на сокращение разных проявлений неравен ства, часто не подтверждены документаль но. Одна из серьезных будущих задач сис темы здравоохранения Норвегии – это выбор пути решения проблемы неравен ства в здравоохранении. • Выработка оптимальной системы взаимо действия муниципальных и региональных органов самоуправления. • Наконец, это мероприятия по снижению злоупотреблений алкоголем и наркотика ми, особенно среди молодежи Норвегии, проблемы старения населения (и их вли яние на структуру медикосанитарной по Ðåôåðàò îáçîðà: Íîðâåãèÿ, 2006 10 Àâòîð îáçîðà ñèñòåìû çäðàâîîõðàíåíèÿ Íîðâåãèè – ßí Ðîò Éîíñåí, ñîòðóäíèê Ãî- ñóäàðñòâåííîãî ñîâåòà ïî çäðàâîîõðàíåíèþ Íîðâåãèè. Ðåäàêòîð îáçîðà – Âàéäà Áàí- êàóñêàéòå.  ñîñòàâëåíèè îáçîðà ïðèíèìàëè ó÷àñòèå: Îää Àðèëä Õàóãåí, Õàðàëüä Ñèåì, Îëàâ Ìîëâåí, Oëaâ Ñëàòòåáðåêê, Äæîí Àðíå Ðîòòèíãåí, Òóðå Ãðîíëè, Ñèìåí Íåáè, Õàëäîð Áèðêåôëîò, Òåðè Õàãåí, Ñòåéíàð Ìàäñåí, Àéíà Øüîòö, Ñòåéí Õóñåáî, Äæîí Óèëüÿì Ãëýä, Êíóò Ýíãåäàë, Õàííå Ëóíäåìî è Êðèñòèíà Ôóðóõîëìåí (àâòîð íîðâåæñêîãî îáçîðà «Ñèñòåìû çäðàâîîõðàíåíèÿ: âðåìÿ ïåðåìåí» 2000 ã.). Åâðîïåéñêàÿ îáñåðâàòîðèÿ ïî ñèñòåìàì è ïîëèòèêå çäðàâîîõðàíåíèÿ áëàãîäàðèò Ãðåòå Áîòòåí (Óíèâåðñèòåò ã. Îñëî), Ãåéåð Ñâåððå Áðàóò (Ãîñóäàðñòâåííûé ñîâåò ïî çäðàâîîõðàíåíèþ) è Ìèíèñòåðñòâî çäðàâîîõðàíåíèÿ Íîðâåãèè çà ðåöåíçèþ îáçîðà. Êàæäûé îáçîð èç ñåðèè «Ñèñòåìû çäðàâîîõðàíåíèÿ: âðåìÿ ïåðåìåí» ñîäåðæèò âñå- ñòîðîííèé àíàëèç ñèñòåìû çäðàâîîõðàíåíèÿ òîé èëè èíîé ñòðàíû è åå ðåôîðì – ïðî- âîäèìûõ èëè ðàçðàáàòûâàåìûõ. Îáçîðû – îäíî èç îñíîâíûõ íàïðàâëåíèé äåÿòåëüíîñ- òè Åâðîïåéñêîé îáñåðâàòîðèè ïî ñèñòåìàì è ïîëèòèêå çäðàâîîõðàíåíèÿ. Îáñåðâàòîðèÿ – ýòî óíèêàëüíûé ìåõàíèçì ñîòðóäíè÷åñòâà, êîòîðûé îáúåäèíÿåò Åâðîïåéñêîå ðåãèîíàëüíîå áþðî ÂÎÇ, ïðàâèòåëüñòâà Áåëüãèè, Ãðåöèè, Èñïàíèè, Íîð- âåãèè, Ñëîâåíèè, Ôèíëÿíäèè, Øâåöèè, èòàëüÿíñêèé ðåãèîí Âåíåòî, Åâðîïåéñêèé èíâå- ñòèöèîííûé áàíê, Èíñòèòóò «Îòêðûòîå îáùåñòâî», Âñåìèðíûé áàíê, Ëîíäîíñêóþ øêîëó ýêîíîìè÷åñêèõ è ïîëèòè÷åñêèõ íàóê è Ëîíäîíñêóþ øêîëó ãèãèåíû è òðîïè÷åñêîé ìåäè- öèíû. Ýòî ñîòðóäíè÷åñòâî ñòàâèò öåëüþ ïîääåðæèâàòü è ðàçâèâàòü íàó÷íî-îáîñíîâàí- íûé ïîäõîä ê ðàçâèòèþ çäðàâîîõðàíåíèÿ íà îñíîâå ãëóáîêîãî è âñåñòîðîííåãî àíàëèçà îïûòà ðàçíûõ åâðîïåéñêèõ ñòðàí. мощи), проблема глобализации с точки зрения возможных для страны пандемий, и участие информационных технологий в секторе здравоохранения. В Норвегии здравоохранение является го сударственным приоритетом, а децентрали зация системы здравоохранения способству Åâðîïåéñêàÿ îáñåðâàòîðèÿ ïî ñèñòåìàì è ïîëèòèêå çäðàâîîõðàíåíèÿ Ñèñòåìû çäðàâîîõðàíåíèÿ: âðåìÿ ïåðåìåí Ðåôåðàò îáçîðà ет вовлечению потребителей услуг в процесс формирования государственной политики. Реформы здравоохранения, недавние и более ранние, свидетельствуют о высоком уровне поддержки со стороны властей. Развитие си стемы здравоохранения в Норвегии нагляд но демонстрирует возможности успешной ре ализации политических и социальных задач.

Vol. 8 No. 1 2006

Norway

on Health Systems and Policies

European

Jan Roth Johnsen

Editor: Vaida Bankauskaite

2006

The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, CRP-Santé Luxembourg, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.

Health Systems in Transition

Written by Jan Roth Johnsen

Edited by Vaida Bankauskaite

Norway

© World Health Organization 2006, on behalf of the European Observatory on Health Systems and Policies All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full.

Please address requests about this to:

Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark

Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the WHO/Europe web site at http://www.euro.who.int/PubRequest

The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners.

The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or any of its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.

The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the European Observatory on Health Systems and Policies in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.

The European Observatory on Health Systems and Policies does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use.

Keywords: DELIVERY OF HEALTH CARE

EVALUATION STUDIES

FINANCING, HEALTH

HEALTH CARE REFORM

HEALTH SYSTEM PLANS – organization and administration

NORWAY

ISSN 1817-6127 Vol. 8 No. 1

Suggested citation: Johnsen JR. Health Systems in Transition: Norway. Copenhagen, WHO Regional Office for Europe on behalf of the European Observatory on Health Systems and Policies, 2006.

Printed and bound in Great Britain by TJ International, Padstow, Cornwall.

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Contents

Preface .................................................................................................... v Acknowledgements ...................................................................................... vii List of abbreviations...................................................................................... ix List of tables and figures ............................................................................... xi Executive summary ..................................................................................... xiii 1. Introduction ................................................................................................ 1 1.1. Overview of the health system ................................................... 1 1.2. Geography and sociodemography .............................................. 1 1.3. Economic context ....................................................................... 4 1.4. Political context ......................................................................... 6 1.5. Health status ............................................................................... 8 2. Organizational structure ........................................................................... 13 2.1. Historical background .............................................................. 13 2.2. Organizational overview .......................................................... 16 2.3. Decentralization and centralization .......................................... 21 2.4. Patient empowerment ............................................................... 22 3. Financing ................................................................................................. 31 3.1. Health expenditure ................................................................... 31 3.2. Population coverage and basis for entitlement ........................ 34 3.3. Revenue collection/sources of funds ........................................ 41 3.4. Pooling of funds ....................................................................... 47 3.5. Purchasing and purchaser–provider relations .......................... 49 3.6. Payment mechanisms ............................................................... 51 4. Planning and regulation ........................................................................... 57 4.1. Regulation ................................................................................ 58 4.2. Planning and health information management ........................ 62 5. Physical and human resources ................................................................. 69 5.1. Physical resources .................................................................... 69 5.2. Human resources ...................................................................... 77

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6. Provision of services ................................................................................ 89 6.1. Public health ............................................................................. 89 6.2. Patient pathways ....................................................................... 91 6.3. Primary/ambulatory care .......................................................... 92 6.4. Specialist ambulatory care/inpatient care ................................. 94 6.5. Emergency care ........................................................................ 99 6.6. Pharmaceutical care ................................................................ 102 6.7. Rehabilitation/intermediate care ............................................ 106 6.8. Long term care ....................................................................... 108 6.9. Services for informal carers ................................................... 111 6.10. Palliative care .......................................................................... 112 6.11. Mental health care .................................................................. 114 6.12. Dental health care ................................................................... 119 6.13. Alternative medicine/complementary medicine ..................... 120 6.14. Health care for specific populations ....................................... 122 7. Principal health care reforms ................................................................. 123 7.1. Analysis of recent reforms ..................................................... 124 7.2. Future developments .............................................................. 139 8. Assessment of the health system ............................................................ 143 8.1. The stated objectives of the health system ............................. 143 8.2. The distribution of the health system’s costs and benefits across the population .............................................................. 144 8.3. Efficiency of resource allocation in health care ..................... 148 8.4. Technical efficiency in the production of health care ............. 149 8.5. Accountability of payers and providers.................................. 151 8.6. The contribution of the health system to health improvement 153 9. Conclusions ............................................................................................ 155 10. Appendices ........................................................................................... 159 10.1 References .............................................................................. 159 10.2 Useful web sites ..................................................................... 165 10.3 A selected list of laws ............................................................. 167

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Preface

The Health Systems in Transition profiles are country-based reports that provide a detailed description of a health system and of reform and policy initiatives in progress or under development in a specific country. Each

profile is produced by country experts in collaboration with the Observatory’s research directors and staff. In order to facilitate comparisons between countries, the profiles are based on a template, which is revised periodically. The template provides detailed guidelines and specific questions, definitions and examples needed to compile a profile.

Health Systems in Transition profiles seek to provide relevant information to support policy-makers and analysts in the development of health systems in Europe. They are building blocks that can be used:

to learn in detail about different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems;

to describe the institutional framework, the process, content and implementation of health care reform programmes;

to highlight challenges and areas that require more in-depth analysis; and

to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in different countries.

Compiling the profiles poses a number of methodological problems. In many countries, there is relatively little information available on the health system and the impact of reforms. Due to the lack of a uniform data source, quantitative data on health services are based on a number of different sources, including the WHO Regional Office for Europe Health for All database, national

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statistical offices, Eurostat, the Organisation for Economic Co-operation and Development (OECD) health data, the International Monetary Fund (IMF), the World Bank, and any other relevant sources considered useful by the authors. Data collection methods and definitions sometimes vary, but typically are consistent within each separate series.

A standardized profile has certain disadvantages because the financing and delivery of health care differs across countries. However, it also offers advantages, because it raises similar issues and questions. The Health Systems in Transition profiles can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situation. They can also be used to inform comparative analysis of health systems. This series is an ongoing initiative and material is updated at regular intervals. Comments and suggestions for the further development and improvement of the Health Systems in Transition series are most welcome and can be sent to: info@obs.euro.who.int.

Health Systems in Transition profiles and Health Systems in Transition summaries are available on the Observatory’s web site at www.euro.who. int/observatory. A glossary of terms used in the profiles can be found at the following web page: www.euro.who.int/observatory/Glossary/Toppage.

The data used in this report reflect information available at 1 January 2006. However, for updated and specific statistics, readers should contact Statistics Norway (www.ssb.no).

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Acknowledgements

The Health Systems in Transition profile (HiT) on Norway was written by Jan Roth Johnsen at the Norwegian Directorate for Health and Social Affairs. The editor of the Norwegian HiT was Vaida Bankauskaite.

The following people contributed to some of the writing of the Norwegian HiT: Odd Arild Haugen, Harald Siem, Olav Molven, Olav Slåttebrekk, John Arne Røttingen, Tore Grønlie, Simen Neby, Haldor Byrkjeflot, Terje Hagen, Steinar Madsen, Aina Schiøtz, Stein Husebø, John William Glad, Knut Engedal, Hanne Lundemo and Christine Furuholmen (the author of the Norwegian HIT 2000).

The European Observatory on Health Systems and Policies is grateful to Grete Botten (University of Oslo) and Geir Sverre Braut (Norwegian Board of Health) and the Norwegian Ministry of Health and Care Services, for reviewing the report.

The current series of Health Systems in Transition profiles has been prepared by the research directors and staff of the European Observatory on Health Systems and Policies. The European Observatory on Health Systems and Policies is a partnership between the World Health Organization (WHO) Regional Office for Europe, the governments of Belgium, Finland, Greece, Norway, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, CRP-Santé Luxembourg, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.

The Observatory team working on the Health Systems in Transition profiles is led by Josep Figueras, Head of the Secretariat, and research directors Martin McKee, Elias Mossialos and Richard Saltman. Technical coordination is led by Susanne Grosse-Tebbe.

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Giovanna Ceroni managed the production and copy-editing, with help from Nicole Satterley and with the support of Shirley and Johannes Frederiksen (layout). Administrative support for preparing the Health System profile on Norway was undertaken by Caroline White.

Special thanks are extended to the European Health for All database (from which data on health services were extracted), to the Organisation for Economic Co-operation and Development (for the data on health services in Western Europe) and to the World Bank (for the data on health expenditure in central and eastern European countries). Thanks are also extended to the national statistical offices that provided data.

The data used in this report reflect information available at 1 January 2006. However, for updated and specific statistics, readers should contact Statistics Norway (www.ssb.no). Do not hesitate to contact the author regarding this HIT report.

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List of abbreviations

AIDS Acquired Immunodeficiency Syndrome

CAM Complementary and Alternative Medicine

CMHC Community Mental Health Centres

CT Computer tomography

DRG Diagnosis Related Group

EEA European Economic Area

EPR Electronic Patients’ records

EU European Union

GATS General Agreement on Trade in Services

GDP Gross Domestic Product

GNP Gross National Product

GP General Practitioner

HIV Human immunodeficiency virus

HTA Health Technology Assessment

HVPU Reform on downsizing institutions for people with disabilities

ICT Information and communication technology

KS Norwegian Association of Local and Regional Authorities

MMR Measles, mumps and rubella virus vaccine

MRI Magnetic Resonance Imaging

MSIS The Norwegian Surveillance System for Communicable Diseases

NATO North Atlantic Treaty Organization

NAVO State Negotiation Body

NGO Nongovernmental Organization

NIS National Insurance Scheme

NKr Norwegian Krone

NOU Royal Commission

NPR Norwegian Patient Register

OECD Organisation for Economic Co-operation and Development

PET Positron Emission Technology

UN United Nations

US United States

VAT Value Added Tax

WHO World Health Organization

WTO World Trade Organization

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List of tables and figures

Tables

Table 1.1. Population/demographic indicators, 1970–2004, selected years

Table 1.2. Macro-economic indicators, 1990–2004, selected years

Table 1.3. Mortality and health indicators, 1970–2004, selected years

Table 1.4. Main causes of death per 100 000, 1970–2003, selected years

Table 1.5. Factors affecting health status, 1980–2004, selected years

Table 1.6. Decayed, missing or filled teeth at age 12 years, 1975–2004, selected years

Table 3.1. Trends in health expenditure, 1980–2004 (selected years)

Table 3.2. Sources of revenue as a percentage of total expenditures on health 1980–2003, selected years

Table 3.3. User charges for health care services, 1 January 2006

Table 5.1. Acute care and psychiatric hospitals and long-term institutions, 1980–2004, selected years

Table 5.2. Total personnel in the health and social service industry. Education. 2004

Table 7.1. Major health care reforms and policy measures, 1984–2004

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Figures

Fig. 1.1. Overview chart on health system

Fig. 1.2. Map of Norway

Fig. 3.1. Total expenditure on health as a % of GDP in the WHO European Region, 2002, WHO estimates

Fig. 3.2. Trends in health expenditure as a share (%) of GDP in Norway and selected other countries, 1998–2002

Fig. 3.3. Health care expenditure in US$ PPP per capita in the WHO European Region, 2002, WHO estimates

Fig. 3.4. Financial flow chart, 2004

Fig. 3.5. Health expenditure by function, 2004

Fig. 3.6. Total health expenditure from different sources, 2003

Fig. 5.1. Hospital beds in acute hospitals per 1000 population in western Europe, 1990 and 2004 or latest available year (in parentheses)

Fig. 5.2. Beds in acute hospitals per 1000 population in Norway and selected countries, 1990–2004

Fig. 5.3. Number of physicians in Norway and selected countries per 1000 inhabitants, 1990–2004 or latest available year

Fig. 5.4. Number of nurses in Norway and selected countries per 1000 population in 1990–2004 or latest available year

Fig. 5.5. Number of physicians and nurses per 1000 population in western Europe, 2004 or latest available year (in parantheses)

Fig. 6.1. Regional health authorities

Fig. 6.2. Medicine sales, pharmacy retail price (PRP) (in NKr millions nominal currency)

Fig. 6.3. Flow of pharmaceuticals from manufacturers to end users and price regulation model

Fig. 8.1. The development in technical efficiency and cost-efficiency in hospitals from 1992 to 2004 (1992=100)

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Executive summary

Norway is a monarchy with a parliamentary form of government. There are three independent government levels – the national government, the county councils and the municipalities. The Norwegian population

reached 4.6 million in 2005. The life expectancy in Norway is among the highest in the world. Diseases of the circulatory system are the primary cause of mortality, with cancer being the second largest cause of death.

The Norwegian health care system is organized on three levels, i.e. national, regional and local levels. Overall responsibility for the health care sector rests at the national level, with the Ministry of Health and Care Services. The regional level is represented by five regional health authorities, which have responsibility for specialist health care; and the local level represented by 434 municipalities has responsibility for primary health care (including nursing care).

The parliament’s most important functions are: to pass new laws and amend or repeal the existing ones, to adopt the fiscal budget, i.e. to fix the annual revenues (taxes, charges, etc.) and the expenditures of the state, to authorize plans and guidelines for the activities of the state through the discussion of political issues of more general character, to take a stand on plans for reform, to approve major projects and so forth.

In 2003, Norwegian health care expenditure was 10,3% of GDP. Health care expenditure expressed in US$ PPP per capita was 3572 in 2003, which was much higher than the EU average of 2326 (i.e., among those countries that were members of the EU before May 2004). The Norwegian health care system is primarily funded through taxes. The municipalities have the right to levy proportional income taxes on their respective populations, while the regional health authorities must rely on transfers from the central government. Block grants provide the primary source of funding, but the financing of health care services is also supplemented by state grants, earmarked means and some

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user charges. The social insurance system, managed by the National Insurance Scheme (NIS), provides financial security in the case of sickness and disability. There is no exact definition of the “coverage package” in the Norwegian health care system.

The aim of primary care is to improve the general health of the population and to treat diseases and deal with health problems that do not require hospitalization. Each municipality has to decide how best to serve its population with primary care. Primary care is mainly publicly provided. Much of the spending in the municipalities is directed towards nursing, somatic1 health care and mental health care. Regular general practitioners (GPs) are in practice self-employed, but financed by the NIS, the municipalities and by the patient’s out-of-pocket payments.

The regional level provides the basis for specialist health care. The regional health authorities plan the development and organization of specialist health care according to the needs of the regional population and services are provided by the regional health authorities’ health enterprises. Their planning responsibility also includes health services supplied by other providers, such as private agencies. Tertiary-level specialized health care is delivered in accordance with regulations set out by central government.

With regard to the training of physicians, the number of medical students is limited, and every year approximately 500 students join medical training programmes in Norway. Further education and specialization of physicians is limited. Medical education is financed by the central government. The training of other health care personnel is normally regulated in the same way.

Resource allocation does not vary among the regional health authorities and the municipalities. The regional health authorities are financed by basic grants, earmarked means and activity-based funding (based on the DRG system and other fee-for-service for somatic care from the state). The municipalities’ health care services and nursing care are financed by basic grants, earmarked means, fee-for-service, and local taxes. The authorities have the freedom to set up their own financing arrangements (except for user charges, which are set by the central government), but in practice the same financing arrangements exist throughout the country. The majority of health care providers are publicly owned and, therefore, health care personnel are mainly salaried employees, with the exception of GPs.

The main purpose of the Municipalities Health Services Act (1982) was to improve the coordination of the health and social services at local level, to strengthen those services in relation to institutional care and preventive care, and

1 Somatic health care is used in this report to mean “general health care”.

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to pave the way for better allocation of health care personnel. The act provides the municipalities with a tool to deliver comprehensive health services in a coordinated way. In 1988 the Municipalities Health Services Act was further expanded and county nursing homes were transferred to the municipalities.

The Regular General Practitioners scheme implemented in 2001 is based on a registration system whereby patients can sign onto the list of the GP of their choice. Basic principles of the scheme include patients’ freedom to choose whether or not to participate in the scheme, the right to choose another physician as their GP (twice a year) and the right to a second opinion from another general practitioner. The aim of the reform was to improve the quality of the local medical services, to improve continuity of care and ensure a more personal patient–physician relationship. This reform also provided a new model for employing GPs, based on contracted physicians in private practice where capitation, fee-for-service and out-of-pocket payments form the income of GPs.

In 1997, Norway introduced activity-based funding (Innsatsstyrt finansiering, ISF) based on the DRG system for somatic inpatient activity. This measure was further expanded in 1999 to include day surgery. Introduction of activity-based funding has been followed by a substantial increase in the number of cases treated and a reduction in waiting times. The reimbursement of a DRG point is consistent throughout the country. But the regional health authorities are allowed to change these reimbursement rates to their health enterprises.

The hospital reform of 2002 aimed to increase efficiency and consisted of three main strategies: the ownership of the hospitals was transferred from the counties to the central government sector; hospitals were organized as enterprises; and the day-to-day running of the enterprises became the responsibility of the general manager and the executive board. Preliminary results, following these reforms, point to some positive outcomes, such as decreased waiting lists and improved management skills.

In 2001 a new law was passed allowing greater freedom in the establishment of pharmacies. This led to a vertical integration of pharmacy chains owned by wholesale companies and allowed pharmacists to substitute the physicians’ prescriptions with another (e.g. generic) brand.

Patients’ rights have been strengthened with the passing of the Patients’ Rights Act in 1999. Its main purpose was to ensure equality of access to good quality health care.

The Norwegian health care sector has undergone several important reforms during recent decades. Generally, national reforms that have had an impact on the health care system have focused on three broad areas: the responsibility for providing health care services, priorities and patients’ rights and cost

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containment. Future challenges include further cost containment, integration of care and health inequalities.

The health status of the Norwegian population is one of the best in the world. The key strengths of the Norwegian health care system include provision of health care services for all based on need (regardless of personal income), local and regional accountability, public commitment and political interest in improving the health care system.

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1 Introduction

1.1 Overview of the health system

The organizational structure of the Norwegian health care system is built on the principle of equal access to services: all inhabitants should have the same opportunities to access health services, regardless of social or

economic status and geographic location. To fulfil this aim, the organizational structure has three levels that mirror political tiers: the national/state level, the five health regions and the municipalities (Fig. �.�). While the role of the state is to determine national health policy, to prepare and oversee legislation and to allocate funds, the main responsibility for the provision of health care services lies with the five health regions for specialist health care and the 43� municipalities for primary health care (which includes nursing care), and dental care at the �9 counties. At the national level, the parliament (Stortinget) serves as the political decision-making body. Overall responsibility for the health care sector rests at the national level, with the Ministry of Health and Care Services.

1.2 Geography and sociodemography

Norway is located in northern Europe, bordering the North Sea and the North Atlantic Ocean, sharing physical borders with Sweden, Finland and Russia (Fig. �.2). Its 4.6 million inhabitants live in a total land area of 386 958 km2, which averages �5 persons per km2. This makes Norway one of the most sparsely populated countries in Europe. The terrain is mostly barren, with high plateaux and rugged mountains broken by fertile valleys, small, scattered

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Health systems in transition Norway

Fig. 1.1 Overview chart on health system

Norwegian Medicines Agency Directorate for Health and Social Affairs

The Norwegian System of Compensation to Patients Norwegian Board of Health

Norwegian Institute of Public Health Norwegian Radiation Protection Authority

Hospitals somatic/psychiatric Outpatient clinics

Hospital pharmacies

431 municipalities

Public dental care

Private agencies

Patients

Maximum gross margin set by

The Office of the Auditor General

Primary care emergency wards

Primary care providers

General practitioners

Pharmacies

Private hospitals/physicians

Private dentists

19 counties

35 health enterprises

Private providers

5 regional health authorities

National Insurance Administration

The Norwegian Knowledge Centre for Health Services

Ministry of Labour and Social Inclusion

Central Government

Ministry of Health and Care Services

Hierarchical relationship Financial/contractual relationship

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Fig. 1.2 Map of Norway

Sweden

Finland

Russian Federation

Estonia

Norwegian Sea

Barents Sea

Gulf of Finland

Gu lf

of Bo

th ni

a

North Sea Kristiansand

Ålesund

Trondheim

Bodø

Mo

Harstad

Tromsø

Hammerfest

Stavanger Drammen

Bergen

Florø

Narvik

Hamar

OSLO

Vardø 0 100 200 km 0 100 200 mi

Source: CIA World Fact Book.

plains, a coastline that is deeply indented by fjords, and arctic tundra to the north. When calculated against the proportion of arable land, Norway has 22 persons per km2 of land available for cultivation, compared with eight in both France and Denmark. The climate is temperate along the coast, modified by the North Atlantic current; it is colder towards the interior.

The population of Norway passed 4.6 million in 2005 – an increase of �.25 million since �950. In the immediate post-war years the annual growth in the population was approximately �%. The natural population growth rate, which had steadily decreased since the start of the �970s to less than 2 per �000 in the mid-�980s, turned upwards again, reaching an average of 3.4 per �000 in the

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Health systems in transition Norway

period �996–2000 – a figure well above average European Union (EU) levels. The population in Norway continued to grow throughout the �990s. The three reasons for this are immigration, rising birth rates and prolonged life expectancy. With a net immigration figure of 2.� per �000 population in 2002, Norway ranks highest among the Nordic countries, closely followed by Denmark.

At the beginning of 2004 the immigrant population in Norway was 349 000 and accounted for 7.6% of the total population. The majority originate from Asia (40%), followed by people from eastern Europe (�6%), the Nordic countries (�5%), Africa (�2%) and western Europe (�0%).

The old-age dependency ratio (those aged 65+/20–64) for Norway was 25.7 in 2000, and it is expected to increase to 42.9 by 2040. These figures are below the OECD average of 46 for the year 2040 and also below the other Nordic countries, with the exception of Iceland.

Norway is highly rated with respect to gender equality. Within education, the labour market and political life, Norway is among those countries in which women do very well compared to men. In two of the United Nations indices for gender equality, based on the Gender-related Development Index (GDI) and Gender Empowerment Measure (GEM), Norway was ranked as the most gender-equal nation in 200� (UNDP 200�; UNECE 2000).

In 200�, the proportion of the population with a university education, among the 30 to 39-year-olds, was 29% for men and 36% for women. In all, 57% of the population over the age of �6 had completed secondary education. In total, therefore, the enrolment level in secondary and tertiary education amounts to more than two-thirds of Norwegians over �6 years, which makes Norway one of the most highly educated countries in the world.

1.3 Economic context

The Norwegian economy is generally characterized as a mixed economy – a capitalist market economy with a clear component of state influence. As in the rest of Western Europe, private property rights and the private sector have largely governed the expansion of most industries. Nevertheless, some industrial activities are owned or even managed by the state. State ownership and the regulation of the private sector characterize Norway as a mixture of market and planned economy.

In 2002 the gross domestic product (GDP) was more than NKr �500 billion (� e was equal to NKr 8.0073 in 2005). This comprised a total of 44% on household consumption expenditures, 22% on general government

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Table 1.1. Population/demographic indicators, 1970–2004, selected years

Indicators 1970 1980 1990 1995 2000 2001 2002 2003 2004 Population (mid-year, thousands) 3 877 4 086 4 241 4 359 4 470 4 514 4 538 4 565 4.591a

Population, female % of total 50.3 50.4 50.6 50.6 50.5 50.4 50.4 50.4 50.4a

% population <15 years 24.5 22.2 18.9 19.5 20.1 20.0 20.0 20.8 21.1a

% population 65+ years 12.9 14.8 16.3 15.9 15.2 15.0 14.9 14.7 14.8a

Population growth % – 0.32 0.34 0.52 0.18 0.98 0.54 0.62 0.55a

Urban population % 65.0 71.0 75.0 73.0 74.5 75.0 77.6 77.2 77.3a

Population density (population/ km2) – – 13.2 13.5 13.8 13.9 14.0 14.1 14.2a

Fertility rate – total births per woman – 1.7 1.8 1.9 1.9 1.8 1.8 1.8 1.8a

Crude death rate/ 1000 population 10.0 10.1 10.9 10.4 9.9 9.7 9.8 9.3 9.0a

Live births/ 1000 population 16.7 12.5 14.4 13.8 13.3 12.6 12.2 12.4 12.4a

Source: European Health for All database, January 2006; a Statistics Norway, January 2006.

consumption, with �9% being invested (Table �.2.). The remaining �5% represented the export surplus, indicating that the value of what is produced is higher than what Norway consumes and uses for investment.

GDP in �970 totalled NKr 23 500 per capita. In 2002, this figure had risen to NKr 337 400. GDP in �970 calculated at 2002 prices amounts to NKr �28 700. Thus the real growth was approximately �60%, i.e. an annual growth of 3%.

Norway has gradually become one of the richest countries in the world. In comparison with other European countries, its GDP is 43% above the average in the EU (allowing for price differences in the different countries). However, consumption expenditure for Norwegian households is around the average for the �5 countries that belonged to the EU before May 2004. Regarding personal consumption (which includes general government consumption expenditure on the individual, e.g. health and education services), Norway is somewhat above the average.

During the last 50 years, Norwegian businesses and industries have seen some dramatic structural changes. Generally speaking there has been a move from primary (agriculture) and secondary (manufacturing) industries towards tertiary (service) industries. The role of agriculture and manufacturing has diminished while that of services has increased. Primary industries now employ only 4% of the labour force and secondary industries around 22%, while the

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2 The Norwegian name as of � January 2006 is Statens pensjonsfond – Utlandet.

tertiary industries account for a total of 75%. The picture is slightly different if one looks at the significance of these industries in the light of their contribution to GDP. Primary industries contribute 2%, secondary industries close to 40% (with petroleum contributing far more in economic value than in employment) and the tertiary industries 59%.

The post-war era has been characterized as a period of rebuilding and reconstruction, with the result that imports exceeded exports for a considerable period of time. Only when oil exports began at the end of the �970s did Norway gradually build up an export surplus. Norway has had a surplus in external trade in commodities since then, apart from the years �986–�988. In 2002, the surplus was in the region of NKr 200 billion.

Approximately three-quarters of Norwegian exports are to European Union (EU) countries and two-thirds of the imports come from these countries. Twelve per cent of imports are from developing countries. As regards exports, oil (and increasingly gas) dominates, followed by metals (especially aluminium) and fish. For imports, motor vehicles (cars and buses) and other means of transport (aeroplanes and shipping vessels) are the most important.

In �990 the Norwegian Petroleum Fund2 was established, and from then on the surplus on the state budget from the oil industry was transferred to a fund outside the domestic economy. In 2005, the market value of the Petroleum Fund’s assets was more than NKr �000 billion.

1.4 Political context

Norway has been a constitutional state since �8�4, following approval of the first democratic constitution and the establishment of the Norwegian Parliament. Almost a century later, in �905, the country dissolved the union with Sweden and became a sovereign state.

Norway is governed by a three-tier parliamentary system, with each tier governed by a popularly elected body: the national parliament (Stortinget), the county councils and the municipal councils. The parliament has �69 members, and is elected by proportional representation for a four-year period. The King is formally the highest executive authority, although in practice the cabinet – comprising the prime minister (chosen by the King) and his/her cabinet members (selected by the prime minister) – has the executive power.

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Table 1.2 Macro-economic indicators, 1990–2004, selected years

Source: Statistics Norway and Ministry of Finance, 2005; a Statistics Norway, 2006.

Note: a billion = 1 000 million.

Indicators 1990 1995 1997 1999 2000 2001 2002 2003 2004

GDP in billiona NKr 727 937 1 111 1 233 1 469 1 527 1 521 1 562 1 717a

GDP growth rate (% ) 2.1 4.4 5.2 2.1 2.8 1.9 1.3 2.9 3.1a

GDP per capita in 1000 NKr 171.4 215.1 252.3 276.3 327.1 338.1 334.8 345.4 373.9a

GDP per capita US$ PPP 17 658 23 524 27 982 29 887 36 242 36 474 38 050 – 38 765a

GDP PPP Total billions US$ 74.9 102.5 123.3 133.4 162.8 164.6 – – 178.0a

GDP in billion NKr 705 925 1 100 1 218 1 455 1 515 1 523 1 590 1 724a

Value added agriculture and fishery (% of GDP) 3.4 3.0 2.4 2.4 2.1 2.0 1.8 1.5 1.5a

Value added industry (% of GDP) 33.9 34.1 37.1 34.6 41.8 39.5 37.2 37.4a 39.2a

Value added services (% of GDP) 62.7 62.9 60.5 63.1 56.1 58.5 61.0 61.1a 59.2a

Annual average rate of inflation in % 4.1 2.4 2.6 2.3 3.1 3.0 1.3 2.5 0.4a

Labour force 1000 2 142 – 2 287 2 333 2 350 2 361 2 378 2 375 2 382a

Unemployment, % total population 5.3 5.0 4.1 3.2 3.4 3.5 3.9 4.5 4.5a

Employment rate, % of active population 65.6 – 69.6 71.0 70.9 70.9 70.7 69.6a 69.3a

Real interest rate 10.6 5.2 3.4 5.3 5.8 5.7 7.4 2.2 –

Official exchange rate NKr/US$ 6.2544 6.3369 7.0788 7.8047 8.8058 8.9879 7.9702 7.0824 6.74a

Short-term debt outstanding current US$) 4 894 6 376 4 828 4 244 3 419 4 020 7 185 – –

Overall budget balance, including. grants (% GDP) 2.2 3.4 7.8 6.1 15.0 13.7 9.2 – –

Gini coefficient 0.228 n/a n/a 0.254 0.275 0.243 – – –

Parliamentary members must leave the parliament if they are chosen to serve in the government.

In 2003, there were �9 counties and 43� municipalities. The capital, and the largest city, Oslo, is formally both a municipality and a county. Population density varies widely throughout Norway, ranging from 2�8 to 500 000 inhabitants per municipality. There are some 20 municipalities with fewer than �000 inhabitants, and one-third have between 2000 and 5000 inhabitants.

The municipalities are responsible for health promotion, primary health care, care of the elderly, care of people with disabilities, including mental disabilities, kindergarten and primary school education, social work (child protection and social protection), water, local culture, local planning and infrastructure. The counties are responsible for dental care, secondary education, energy delivery and communication. The state level, delegated to five regional health authorities, is responsible for secondary care.

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Health systems in transition Norway

Politically, the country has been stable, with a Labour Party (Arbeiderpartiet) holding office between �945 and �965. From �965 to the time of writing, Norway has had a Labour government, alternating with periods of non-socialist coalition governments. From 200� to 2005, the country was ruled by a three- party coalition government (Christian Democratic Party (Kristelig Folkeparti), Liberal Party (Venstre) and Conservative Party (Høyre)). A new government coalition came to power following the 2005 election with the Labour Party for the first time ever in a government coalition, with the Socialist Left Party of Norway (Sosialistisk Venstreparti) and the Centre Party (Senterpartiet).

Traditionally, close cooperation with the other Nordic countries: Denmark, Sweden, Finland and Iceland, has been the norm, and there is a social security convention among the Nordic countries. In �972 and �994, a referendum was held on whether or not Norway should join the European Union. Both times this proposition was turned down. Norway has ratified several bilateral social security agreements with other Nordic countries, as well as the European Economic Area (EEA) Agreement, which came into force in �994.

Norway is a member of the United Nations, WTO, NATO, Council of Europe and Council of the British Isles. Norway has signed among others the following international treaties and documents: GATS, Convention on the Rights of the Child, European Convention on Human Rights, International Bill of Rights, the Barents Health Programme.

1.5 Health status

The health of Norwegians improved considerably during the twentieth century and especially during the last decades. In 2004, life expectancy at birth was 77.5 years for males and 82.3 years for females (Table �.3). This is a significant increase from the period �946–�950 when the average figures were 69.3 years for males and 72.7 years for females.

One of the major reasons for increased life expectancy in Norway since the �970s is attributed to decline in mortality from diseases of circulatory system (Table �.4). Such diseases still account for one third of all standard death rates (SDR) in Norway while malignant neoplasms are the second largest cause of mortality. SDR from malignant neoplasm has not changed during the last thirty years and in 2003 was �70.4 per �00 000 inhabitants. Mortality from trachea/ bronchial/lung cancer has doubled: from �5.5 per �00 000 inhabitants in �970 to 34.� per �00 000 inhabitants in 2003. Similar trends occur with regard to mortality from mental disorders and diseases of nervous system, where the mortality rate has increased twofold during the last 30 years.

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NorwayHealth systems in transition

As in all western countries, infectious diseases have been on the decline due to better hygiene, vaccinations and much-improved living standards. The HIV epidemic hit Norway in the �980s, but effective measures have been introduced, and the total number of persons infected each year is well under �00. In the period from �984 to 2005, 3263 persons were registered as HIV positive in Norway, whereas 833 were diagnosed with AIDS. In accordance with the Norwegian Communicable Disease Act, all counselling and treatment is free of charge for everybody who is infected.

The post-war baby boom, which lasted until the mid-�960s, was followed by a decline in the birth rate, reaching its lowest point around �985. In 2005 the total fertility rate was �.84. Since the beginning of the �970s, the average childbearing age has increased by approximately four years, and the average age for first-time birth is 28.�. During the last three decades teenage pregnancy has declined significantly: in the �970s teenage births accounted for 20% of those giving birth for the first time, whereas in 2005 the figure was less than 5%.

Abortion rates rose sharply at the beginning of the �970s. Since the introduction of the Abortion Act in �978, numbers have stabilized at between �4 000 and �6 000 per year. In 2005, �3 989 abortions were carried out, a figure equivalent to some 25% of all live births. The number of abortions among teenagers in Norway in 2005 was about 2200, while in 200� it was 2600. The perinatal death rate is one of the lowest in the world and decreased from �4.2 per �000 births in �975 to 5.2 in 2004.

Absences from work due to sickness amount to almost 7% of the total number of working days. One per cent of those is short term and self-certified, whereas 6% are certified by a physician (women have a slightly higher percentage absence rate due to sickness than men, especially when it comes to physician- certified absences).

The percentage of regular daily smokers in Norway has decreased slightly, from 3�% in �980 to 26% in 2004 (Table �.5). The standardized mortality rate due to smoking-related causes has also been decreasing since the �990s. The proportion of overweight and obese members of the population was 35% and 8% respectively in 2004, while in �995 overweight and obese inhabitants totalled 27% and 5%, respectively.

Indicators show significant improvement in dental health in Norway during the last three decades, particularly among children. In 2004, the number of decayed, missing or filled teeth was �.3 among �2-year-olds in comparison with 8.4 in �975 (Table �.6).

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Table 1.3 Mortality and health indicators, 1970–2004, selected years

1970 1980 1990 1995 1997 2000 2001 2003 2004 Life expectancy at birth, female (years) 77.5 79.4 80.0 81.0 81.2 81.6 81.7 82.2 82.3a

Life expectancy at birth, male (years) 71.1 72.5 73.5 74.9 75.5 76.1 76.3 77.2 77.5a

Life expectancy at birth, total (years) 74.2 75.8 76.7 77.9 78.4 78.8 79.1 79.7 79.9a

Crude death rate per 1000 population, female 8.9 9.1 10.3 10.5 10.4 9.9 9.8 9.5 9.2a

Crude death rate per 1000 population, male 11.1 11.2 11.4 10.7 10.2 9.8 9.7 9.1 8.8a

Infant deaths per 1000 live births 12.8 8.05 7.02 4.13 4.2 3.8 4.1 3.5 3.2a

Source: European Health for All database, January 2006; a Statistics Norway, 2006.

Table 1.4 Main causes of death per 100 000, 1970–2003, selected years

1970 1980 1990 1995 1997 2000 2001 2003 SDR, all ages per 100 000

– all causes 925.6 820.9 774.1 712.8 684.4 652.2 642.2 608.2

– diseases of the circulatory system 460.9 388.03 344.8 295.5 275.5 245.5 237.5 214.5

– cerebrovascular diseases 143.1 97.7 84.4 69.8 67.5 57.9 54.7 50.2

– malignant neoplasms 171.4 174.1 179.1 180.1 184.3 175.2 174.3 170.4

– trachea/bronchial lung cancer 15.5 20.6 28.1 31.0 33.5 32.8 33.3 34.1

– diseases of the respiratory system 86.5 68.2 70.02 69.4 54.9 58.2 56.2 50.9

– diseases of the digestive system 21.3 24.3 22.8 19.99 21.3 21.2 19.5 19.1

– diabetes 7.26 8.23 8.27 8.13 11.12 9.46 10.33 9.9

– external causes 60.04 60.6 54.2 42.9 42.5 42.7 40.1 43.8

– suicide and self- inflicted injury 8.88 12.7 15.1 12.2 11.8 11.9 11.9 10.8

– mental disorder and disease of nervous system 14.9 18.2 29.0 30.8 33.99 36.4 39.96 35.1

– infectious and parasitic disease 7.44 6.36 5.31 6.34 6.78 7.71 7.31 8.21

– tuberculosis – – 1.23 1.05 0.98 0.71 0.77 0.65

Source: European Health for All database, January 2006.

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NorwayHealth systems in transition

Table 1.5 Factors affecting health status, 1980–2004, selected years

1980 1990 1995 2000 2001 2003 2004 % of regular daily smokers in the population, age 15+ 31 35 33 31 30 26 26a

SDR, selected smoking related causes of death, per 100 000 – 325.39 279.92 237.97 229.39 212.09 –

Pure alcohol consumed, litres per capita, age 15+ 4.84 4.39 4.20 4.74 4.68 4.82 6.22a

SDR, selected alcohol related causes of death, per 100 000 – 89.33 71.07 55.24 51.77 52.83 –

Overweight population % total pop. 25<BMI<30 b – – 27.3 – – 35.0a –

Obese population % total pop. BMI>30a – – 5.0 – – 8.0a –

Source: European Health for All database, January 2006; a Statistics Norway, 2006; b Organisation for Economic Co-operation and Development, 2004.

Table 1.6. Decayed, missing or filled teeth at age 12 years, 1975–2004, selected years.

1975 1980 1990 1995 2000 2001 2002 2003 2004 DMFT 8.4 8.4 2.7 1.9 1.5 1.0a 1.1a 1.3a 1.3a

Source: European HFA Database, a Statistics Norway, January 2006.

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2 Organizational structure

2.1 Historical background

The expansion and development of the Norwegian health care system must be viewed alongside the country’s general standard of living and economic growth.

The fact that the country remained poor and that the majority of the population lived in rural sparsely populated areas was reflected in the health care system well into the twentieth century. The first significant number of physicians established themselves during the second part of the eighteenth century; and it was not until the middle part of the nineteenth that the population–physician ratio passed 5000:�. At the same time the development of hospital-like institutions took place, but physicians and medical personnel were still rare in rural areas. In the early days of the health care system the municipalities and volunteer organizations played an important role as welfare and health care providers. In preventive public health, for example, the role of the state was to employ physicians as public ‘officers’, and from �836 and onwards, they were known as district medical officers. From about the middle of the nineteenth century, some municipalities also hired physicians who were responsible for the care of the sick poor.

The beginning of the twentieth century was marked by an increase in public responsibility for health matters at both state and municipal levels. Health care institutions were built to provide care and treatment for the sick and poor as well for the general population. As the population grew and industrialization increased, hospitals were built, especially in urban areas. These were owned and run either by voluntary organizations, municipalities or the state. Health care insurance schemes developed, based on individual applications. The Practitioners’ Act of �9�2 provided for everyone to have equal access to physicians’ services regardless of their income and settlement.

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3 Ministries in Norway regularly change name and tasks; currently, the Ministry of Health and Social Services and the Ministry of Labour and Social Inclusion are responsible for most of the tasks of the former Ministry of Social Affairs.

After the Second World War, the state governmental structure for health care changed significantly when the Directorate for Health (Helsedirektoratet) was established as part of the Ministry of Social Affairs3 (Sosialdepartementet). This directorate was a regulatory instrument of the medical profession, and gave physicians a unique role as policy and professional practitioners. Undoubtedly, the directorate’s work and the health policy were inspired by the United Kingdom Beveridge Report.

One important step towards universal coverage for welfare services and expenses was the introduction of the National Insurance Scheme (NIS) in �967. The NIS is a public universal insurance scheme that assures everybody a minimum of social security, regardless of income, and is administrated by the National Insurance Administration (Trygdeetaten).

After the Second World War the role of the hospitals widened, with increasing provision in specialized services. There was also a growth in ambulatory care services. The three-tier structure for hospitals was developed and consisted of central, regional and specialist hospitals, with the aim of providing a more efficient service. The Hospital Act of �969 (which came into effect in �970) introduced a unified system for all medical institutions, making counties responsible for planning, building and managing hospitals in order to meet the needs of their respective populations (the central government gained control of two tertiary level hospitals). Since the adoption of the act, each of Norway’s �9 counties assumed responsibility for the financing, planning and provision of specialist health care. An overall fundamental strategy of health services from the regional perspective was also developed during the �970s. However, the picture changed with the advent of the hospital reform in 2002, when central government took over responsibility for specialist health care. The country was divided in five regional health authorities, and the hospitals were part of the health enterprises.

One of the main difficulties with regard to primary health care was in achieving sufficient cover in physician services as required by the Practitioners Act of �9�2. The Municipalities Health Services Act of �982 (which came into effect in �984) made local municipalities responsible for all services under primary health care. This marked the end of the district medical officer system that had been established by central government in the middle of the �9th century. This, in turn, was followed by the abolition of the Directorate for Health. The municipalities’ responsibilities have been further expanded to

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include environmental health services, responsibility for nursing homes (which was shifted from the counties to the municipalities) and responsibility for care of people with mental disabilities (HVPU-reformen). In 200�, the regular general practitioners’ scheme was introduced, giving individuals the right to choose one regular GP.

The economic growth of the country was just below the OECD average until the �970s when Norway discovered vast amount of petroleum resources in the North Sea. Undoubtedly, the oil-propelled economy has carried the country to one of the richest in the world today.

The years following the Second World War can be described as a period of continuous reforms in many sectors, including the health sector, while seeking to achieve an optimum balance between the state and local government. The process of devolving power from central to local government has continued, with the aim of focusing as much as possible on the municipal level. The philosophy behind this is that decentralization is an expression of applied democracy. It brings decision-making closer to those who are affected and promotes public participation in local political affairs. Moreover, it is believed that delegation of authority usually leads to the simplification of administrative procedures. The central authorities are responsible for national policy, for drawing up general guidelines, for advising, and for ensuring that services offered comply with national goals. Maintaining the principle of equal access to public service plays a critical role of the central authorities in a decentralized system.

However, maintaining the principle of equal access to public services while, at the same time, passing responsibility to local/regional authorities is challenging for central government. There are contradictory elements at play. It can therefore be argued that although the central government delegates tasks, it clearly continues to control the health care services through guidelines, legislation, directives, instructions, budgeting, the financing system, supervision and auditing. For instance, while the responsibility for primary health care services including the regular GP scheme is delegated to the municipalities, all GPs’ source of incomes are, in fact, set by the central government and there are, therefore, no local differences. There are more examples, but this tension between central and local government is not unique to Norway.

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2.2 Organizational overview

The central governance of health

The Ministry of Health and Care Services (Helse- omsorgsdepartementet) outlines national health policy, prepares major reforms and proposals for legislation, monitors their implementation and assists the government in decision-making. The government decides on general national priorities and proposes bills to be discussed by parliament.

The Ministry of Health and Care Services is responsible for administering the following services: primary health care, specialized health care, public health, mental health, medical rehabilitation, dental services, pharmacies and pharmaceuticals, emergency planning and coordination, policies on molecular biology and biotechnology and nutrition and food safety. The Ministry of Education and Research is responsible for planning and partially subsidizing the education of health personnel. The Ministry of Health and Care Services has administrative responsibility for the following subordinate agencies: the Directorate for Health and Social Affairs, the Board of Health, the Institute of Public Health, the Medicines Agency, the Radiation Protection Authority, the Patient Register and the Biotechnology Advisory Board.

The Ministry of Labour and Social Inclusion (Arbeids- og inkluderings- departementet) is not directly involved in the health care system but has indirect involvement since its task involves labour and social affairs issues. Sometimes, these boundaries of responsibility are not clear cut. The ministry also has responsibility for the National Insurance Administration, which provides significant financing for the activities of the health system.

The Directorate for Health and Social Affairs (Sosial- og Helsedirektoratet) is a professional body within the field of health and social affairs and has legal authority within this field. The directorate also contributes to the implementation of national health and social policy (for instance, the escalation plan for mental health), and it serves as an advisory body to central authorities, municipalities, regional health authorities and voluntary organizations. An essential task for the directorate is to develop and strengthen preventive work and to widen the availability of services within the field of health and social affairs (for instance non-smoking campaigns). The Patients’ Ombudsmen, one in each county, report to the directorate. Formally, subordinate to the Ministry of Health and Care Services, the directorate also services the Ministry of Labour and Social Inclusion.

The Knowledge Centre for Health Services (Nasjonalt kunnskapssenter for helsetjenesten) is a relatively new public agency (set up on � January 2004) that

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is autonomous and independent, but subordinate to the Directorate for Health and Social Affairs with regard to the setting of overall goals and tasks. The main responsibilities of the centre are to provide decision-makers and health personnel with synthesized research evidence on the effects of health interventions and quality of the health services. The centre has neither the authority to develop, nor the responsibility to implement health policies.

The Norwegian Board of Health (Statens Helsetilsyn) is a national supervisory authority with responsibility for the general supervision of health and social services. The board oversees the population’s need for health and social services, and ensures that services are run in accordance with professional standards. The board also collaborates in preventing failures and mistakes within the health care system. Locally, supervision is carried out by the Governmental Regional Board (in the counties). With regard to health and social affairs, the regional boards report to the Board of Health.

The Norwegian Medicines Agency (Statens legemiddelverk) is a national, regulatory authority for new and existing medicines and the supply chain. The agency is responsible for supervising the production, trials and marketing of medicines. It approves medicines and monitors their use, ensures cost-efficient, effective and well-documented use of medicines, and regulates prices and trade conditions for pharmacies.

The Norwegian Radiation Protection Authority (Statens Strålevern) is the competent national authority agency in the area of radiation protection and nuclear safety in Norway. The agency is responsible for overseeing the use of radioactive substances and fissile material; coordinating contingency plans against nuclear accidents and radioactive fallout; monitoring natural and artificial radiation in the environment and in the workplace, and increasing knowledge about the occurrence, risk and effects of radiation. The Radiation Protection Authority is organized under the Ministry of Health and Care Services. It provides assistance to all ministries on matters dealing with radiation, radiation protection and nuclear safety.

The Norwegian Patient Register (Norsk pasientregister, NPR) was founded in �997. The Ministry of Health and Care Services owns the register. The NPR collects and verifies patient data from all public somatic hospitals and psychiatric institutions in Norway, as well as from some private hospitals. The register includes data on all hospitalizations at somatic hospitals (24-hour hospitalizations and outpatients).

The National Institute of Public Health (Nasjonalt folkehelseinstitutt) is a national centre for health monitoring and for expert knowledge of epidemiology, infectious disease control, environmental medicine, forensic toxicology and drug abuse. It is also a research institution with comprehensive national and

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Health systems in transition Norway

international cooperation. The Norwegian Institute of Public Health was established in 2002. The institute resulted from the merger of the National Institute of Public Health, National Health Screening Service, the Medical Birth Registry in Bergen and the Department of Drug Consumption Statistics and Methodology from the Norwegian Medicinal Depot. The staff have also been supplemented with employees from the Norwegian Board of Health and the Ministry of Social Affairs and Health.

The Norwegian System of Compensation to Patients (Norsk Pasient- skadeerstatning, NPE) has covered and handled patient injury compensation on behalf of hospital owners and municipal authorities since �988. The NPE has by definition a neutral role and, as a rule, only covers the expenses of the attorney when a case is presented to the Patients’ Injury Compensation Board. The decisions made by NPE are binding on the hospital authorities and municipalities, but a complainant can appeal to the Patients’ Injury Compensation Board. Formally, the NPE is subordinate to the Ministry of Health and Care Services.

The National Insurance Administration (Trygdeetaten) has the administrative responsibility for the NIS, a public insurance scheme that secures everybody a minimum level of social security. The benefits under the NIS cover life subsistence to benefits for specific expenses. The NIS provides benefits for illness, accidents, bodily defects, pregnancy, birth, unemployment, old age, disability, death, and loss of the breadwinner. In addition, the NIS gives benefits to single breadwinners. The NIS is formally responsible to the Ministry of Labour and Social Inclusion. Compulsorily insured under the National Insurance Scheme are all persons who are either resident or working as employees in Norway or on permanent or movable installations in the Norwegian Continental Shelf. The National Insurance Administration function has an administrative body for financing public health services, for instance partly financing GPs, specialists, pharmaceuticals, ambulatory care, dental care, physiotherapists, psychologists, midwives etc. For further reading, see section 3.2.

The Office of the Auditor General (Riksrevisjonen), established in �8�6, is the Norwegian supreme audit institution and the supervisory body of the Norwegian Parliament, and has independent agency status. The main task of the Office of the Auditor General is to monitor public assets and ensure that they are used and administered according to sound financial principles, in keeping with the decisions and intentions of parliament. Since July 2002, the Office of the Auditor General has established a department for health services, thereby widening its remit to include the health care sector, in addition to its original auditing role.

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NorwayHealth systems in transition

In past years, there have been major changes in organizations at the central level (see section 7.� for further reading).

Municipalities – primary care

The country’s 43� municipalities, whose sizes vary considerably, are responsible for the provision and funding of primary health care and social services. The Municipalities’ Health Care Act defines their responsibilities for primary health care services and patients’ rights. All citizens have the right of access to health care services in their community.

The municipalities are responsible for primary health care, including both preventive and curative treatment such as:

Promotion of health and prevention of illness and injuries, including organization and running school health services, health centres, child health care provided by health visitors, midwives and physicians. Health centres offer pregnancy check-ups and provide vaccinations according to the recommended immunization programmes.

Diagnosis, treatment and rehabilitation. This includes responsibility for general medical treatment (including emergency services), physiotherapy and nursing (including health visitors and midwives).

Nursing care within and outside institutions. Municipalities are responsible for running nursing homes and home nursing services. The health services outside institutions are, to a varying degree, organized jointly within the same municipal department for treatment and care.

The general practitioners There are approximately 4000 regular GPs in Norway. The GP acts as gatekeeper and agent for the patient with regard to the provision of health services. At present 99% of the population is registered on the regular GP scheme, a list system, which aims to strengthen the patient–physician relationship by giving the patient the right to choose a regular general practitioner.

The maternal and child centres/school health centres Public health and preventive measures are important features within the paediatric area. Preventive maternity care and childcare are usually provided at local health centres and municipality schools.

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Health systems in transition Norway

The counties

The hospital reform of 2002 took away the counties’ responsibility for specialist health care. At present (2006) their responsibilities include organizing public dental care in cooperation with the municipalities. The counties also have some responsibilities with regard to general public health. In principle, the county politicians have virtually no direct influence on the health care system.

Regional health authorities (de regionale helseforetakene) – specialized health care

Norway’s five regional health authorities are responsible for the provision of specialized care. This includes both somatic and mental health institutions, as well as other specialized medical services, such as laboratory, radiology and ambulatory services, special care for persons with drug and alcohol addictions. There are at present 32 health enterprises under the five regional health authorities. The names of each region, together with the number of inhabitants, are as follows:

Northern Norway Regional Health Authority (Helse-Nord), inhabitants: 462 000

Central Norway Regional Health Authority (Helse-Midt), inhabitants: 649 000

Western Norway Regional Health Authority (Helse-Vest), inhabitants: 956 000

Southern Norway Regional Health Authority (Helse-Sør), inhabitants: 899 000

Eastern Norway Regional Health Authority (Helse-Øst), inhabitants: � 67� 000.

Private health care sector

The Norwegian health care system includes both private not-for-profit and private profit-making agencies. Private sector services are in most cases fully embedded in the public system, with some exceptions.

Not-for-profit agencies typically include hospitals or institutions set up as trusts that, in principle, are financed and seen as an integrated part of the public health services, i.e. the diaconal trust owned by the Norwegian church.

Private profit-making agencies have a subordinate role within the Norwegian health care system and were established primarily to complement publicly- funded services, for example, plastic surgery. As an illustration of the private

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NorwayHealth systems in transition

sector’s subsidiary role in the health care system, it is worth mentioning that in 2004 there were only 284 private somatic hospital beds, while there were �3 000 hospital beds in the public sector.

In short, private health care providers are situated mainly in urban areas and there are only three areas where they are prominent in health care services provision: namely, substance abuse treatment, rehabilitation and dental care. With regard to nursing care, Statistics Norway revealed that in 2000 approximately 90% of the nursing homes were owned by the municipalities, whereas only 3% were commercially run. Some support services such as radiology and laboratory services, defined as specialist health care services, are dominated by private profit-making providers. Figures from 2003 show that GPs order 60% of the laboratory tests run by private agencies, and 80% of the referrals to private radiology centres. In addition, most of the pharmacy chains are privately owned, whereas around �0% - �5% (measured in volume of sales) of the pharmacies are owned by the public regional health authorities.

2.3 Decentralization and centralization

The health care systems in Scandinavian countries are often characterized as being run according to a decentralized NHS model: funding is raised by taxation and the main players are public (Rice and Smith 2002). In comparison with the centralized British NHS, local and county governments have an important role in allocating resources. It is hoped that through decentralization it will be possible to lessen bureaucracy, improve the management of care and enhance user information. Following hospital reform, the system in Norway changed from a decentralized to semi-centralized NHS model (Hagen and Kaarbøe, 2004). Consequently, the responsibility for primary care and secondary care has been divided between different governmental levels. The regional health authorities are responsible for specialized health care, while the municipalities are responsible for primary health care.

The organization of the regional health authorities and the health enterprises is unique to Norway (Joint Committee Report 2004) (see sections 6.4 and 7.�). The regions have two roles, the authority role and the enterprise role. In their principal role regions have a “care role” (“sørge for rollen”) in providing the population with specialized health care services; the other is as a supplier and producer of specialized health care, since regions own the health enterprises. During the last three decades Norway has developed enterprises that enjoy an element of freedom similar to that seen in the private sector, although the state has built-in directing/steering and control mechanisms in the organization, in

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Health systems in transition Norway

4 This section is based on Molven (2002).

other words an “in between solution”. The Norwegian oil company, Statoil, was the forerunner for this model. Health enterprises do not compete in the same sort of market as Statoil and do not make a profit, but rely on funding transfers from central government. These enterprise models, a mix of private and public elements, are unique to Norway. It is difficult to locate this system in the organizational chart, but they can be seen as a delegation of power. This involves shifting the responsibility to local offices or organizations outside the structure of the central government such as quasi-public (nongovernmental) organizations, but with central government retaining (in)direct control in so- called state-owned companies (SOC). Principal health policy objectives and frameworks are determined by central government and form the basis for managing the enterprises. The day-to-day running of the enterprises is, however, clearly the responsibility of the general manager and the executive board. In this way the reform is also about decentralization of the management process.

The municipalities have a great deal of freedom in organizing health services, which is one of the many tasks for which they are responsible. There is no direct command and control line from central authorities down to the municipalities who are responsible for primary health care. The funding system was changed in �986 giving the municipalities a greater degree of autonomy in the global transfer from the state. The earmarked funding system from the state to the municipalities is considered to be an effective tool to increase resources in certain areas as well as improving quality standards.

Unlike the regional health authorities the municipalities have the right to levy taxes on the population in order to finance their activities. Even though the responsibility for the health services is delegated there is a large element of third-party payment involved (as illustrated in Chapter 3) and legislation is a useful control tool (as illustrated in Chapter 4).

2.4. Patient empowerment4

Patients’ rights

The rules relating to patients’ rights can be divided into three groups:

�. the right to be a patient (e.g. to obtain a diagnosis and to receive treatment)

2. rights as patients (e.g. to be informed, to be given a copy of one’s medical records)

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NorwayHealth systems in transition

3. procedural rights (e.g. to be given a second opinion on a matter, to bring a matter to court).

The right to be a patient Parliament has declared that the population should be provided with health services and health care workers who should provide help according to priorities. It has also stated that when specific criteria are met, people have the right to be patients, and the right to receive health care. Health care services must meet at least minimum standards, and in some cases it must be provided within specified time limits. Those who have the duty to provide health care services cannot refuse to do so on financial grounds or on the grounds of their own priorities. That the legislative authority is able to stipulate this, and has done so in specific terms, is due in no small part to the fact that the country generally has a sound economy, which makes this possible.

The following example illustrates what this means in practice for the municipalities. Section 2-� of the Municipal Health Services Act and section 2-� of the Patients’ Rights Act state that citizens have a right to “necessary health care”. An MS patient who, based on this provision, received 22 hours’ home nursing care and home help from the municipality, made a claim for more assistance. The municipality refused, partly for economic reasons, and contended that the municipality had the right to decide what constituted sufficient help. The patient brought the matter to the court. In �99� the Supreme Court concluded that the help she received in the home did not comply with legal requirements. In her condition the help given did not accord with the law that gave her a guarantee of “necessary health care”, and the court stated that she had a right to more help at home. The municipality could not refuse to provide the “necessary health care” because of economic reasons.

For many years now the debate has focused on the extent to which people have the right to receive health services. The claim for general health services from the municipalities has not been much disputed since �99� when the Supreme Court confirmed this right. However, the question now is whether people can claim the right to specialized health services from the state and if so, to what extent. The Act on Specialized Health Services is not quite clear about this issue.

Rights as patients People have many explicit rights as patients. These rights are based on the principle of patient autonomy: to a great extent patients are regarded as independent in their dealings with the public health services and health care workers. Patients have the right to: participate in the process of treatment, be

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Health systems in transition Norway

informed, make their own decisions, have access to what is written about them, and be allowed to be with their parents and others (this applies to patients who are children).

According to Molven (2002) objections have been raised about the fact that patients were given many rights, and that these rights are explicitly explained in the Acts. Health workers believe that this makes the patient–provider relationship more bureaucratic (Molven 2002). The patients have been given what we may call procedural rights to put the law into action if the providers themselves do not meet these demands.

Procedural rights It is regarded as a fundamental right that a patient is able to review decisions made by the public authorities, including public health authorities, especially if he or she believes that a decision has been made which contravenes their rights according to the law. There are two types of procedural rights:

�. the right to have decisions reviewed and reversed

2. the right to demand that health care workers and hospitals are corrected.

Patients who think that their rights to receive health care, or that their rights as patients, have not been met, can ask the supervisory authority to review the decision. This authority is usually the County Medical Officer, who is established in every county. Their main task is to supervise health services on behalf of the state in order to ensure that acts and regulations are followed. The County Medical Officer is independent of those who provide health services.

Patient choice

Patient choice is a complex issue that is frequently the subject of political debates. In practice, choice in the Norwegian health care system is determined by the fact that the NIS is public and monopolistic, to a large degree in public ownership and provides a service. Opting out of public arrangements involves considerable out-of-pocket payments. It is difficult to measure the degree of choice in the health care system, but the government has set up some mechanisms in order to increase that level of choice.

In relation to the regular GP scheme, the patient can request registration with a GP of his or her choice, which can include a GP in another municipality. A person who is registered with one GP has the right to change to another GP no more than twice a year, provided there is free capacity on the requested list. Upon referral from a GP the patient is entitled to a re-evaluation (second opinion) of his or her needs to receive specialist treatment.

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NorwayHealth systems in transition

5 Indigenous people of Sápmi, which encompasses parts of northern Sweden, Norway, Finland and the Kola Peninsula of the Russian Federation.

The Patients’ Rights Act stipulates the patient’s right to choose the hospital, but he or she cannot choose the type of treatment (i.e. how specialized that treatment should be in the hospital). In 2004 the Patients’ Rights Act was amended to extend the free choice of hospital to include those private hospitals that have entered into an agreement with the regional health authorities.

The patients’ entitlement to necessary health care also extends to the right to have that care fulfilled within a specific, individually determined time limit. Patients must be informed of the time limit, and have the right to treatment in a private or foreign hospital if the time limit is exceeded.

Information for patients

A free information service (Internet and telephone) exists to assist patients with their choice of hospitals. This service also offers patients information about the anticipated waiting time for the actual treatment at various institutions, and on the quality of treatment those institutions can offer (based on the national quality indicators). As part of the free hospital choice, there are also established quality measures to decrease the information asymmetry between patient and provider.

In addition, information is provided about the telephone and Internet sites in connection with public health: smoking information centres (røyketelefonen), poison information centres (giftinformasjonen), mental health information centres (mental helsetelefon), substance abuse centres (rustelefonen), etc.

However, regarding the ethnic minorities, it is outlined in NOU �995:6 that language barriers make it difficult for Sami5 people to obtain information on diagnosis, treatment and other health care issues. Similar concerns have been raised with regard to immigrants.

Complaints procedures (mediation, claims)

Norwegian patients’ rights are of such a nature that they can give rise to substantive claims from patients (Molven 2002). Patients can take matters to court and compel hospitals and physicians to comply with the law. For example, if a physician does not give a patient a copy of his or her medical records, the court can order the physician to do so.

The County Medical Officers have the authority to reverse decisions regarding health care and the rights of patients that violate the law, and can

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Health systems in transition Norway

compel those who provide health care, i.e. health workers and health authorities, to reverse such decisions. Those who provide health care must be prepared to follow the decisions made by the County Medical Officers and the central Norwegian Board of Health.

If patients believe that health care workers or the health services have failed to do their duty, this can also be taken up with the supervision authority, irrespective of whether or not the patient can achieve a result. For example, if the patient believes that he or she has received poor quality health care services, e.g. if they have been injured as a result of negligence, they can ask the supervising authority to investigate the case. The authority can check on the quality of the treatment that the patient has received and can check on the services more generally. There seems to be general agreement that such a control system, which has functioned for many years, contributes both to patients’ safety and legal safeguards, and to raising the quality of health services.

According to the Patients’ Rights Act, every county must have a Patients’ Ombudsman whose purpose is to safeguard patients’ rights, interests and legal rights in relation to specialist health care, and improve the quality of the health service. To a reasonable extent, the Patients’ Ombudsman can provide information to anyone who requests it, advice and guidance on matters that are included in the remit of his or her work as an ombudsman. The Patients’ Ombudsman alone determines whether or not a request provides adequate grounds for investigation. If the ombudsman decides not to handle the case, the person who made the request must be notified, and be given a brief explanation for this decision.

The act gives a patient the right to complain if the rights laid down are not fulfilled by the health service providers, or if the patient feels that he or she has not received the appropriate treatment. The complaint must be directed to the County Medical Board, which is the local representative of the Norwegian Board of Health.

The Mental Health Care Act regulates administrative control by supervising commissions and judicial control by court proceedings for patients under compulsory treatment. Mentally-ill patients receiving compulsory treatment have the right to be assisted by a lawyer when making a complaint to the supervising commission, or in case of court proceedings.

Patient safety and compensation

Compensation The NPE has covered and handled patient injury compensation on behalf of hospital owners since �988 and for and municipal authorities since �992.

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NorwayHealth systems in transition

The decisions made by the NPE are binding on the hospital authorities and municipalities, but can be appealed by a complainant to The Patients’ Injury Compensation Board. The Board’s decision can also be brought before the civil courts by the patient. The system, including the assessed compensations (by the NPE, the Board or the court), is financed with contributions from both hospital owners and municipal authorities. The disbursement varies from NKr 5000 to more than NKr 7 million. In 2003 the average disbursement was NKr 36� 000.

A provisional scheme regulates claims against public hospitals, municipal health services, first-aid stations and public general practitioners. In January 2003 the Patient Injury Act came into force. This act regulates claims against the whole health care system, but actively regulates only claims against the public health system. Compensation for injury is assessed according to the terms of the act, and mostly covers financial loss. The principal element of the new law is to assess a certain degree of liability regardless of fault. However, it is not necessary for patient to prove that the provider has caused actual harm. The NPE plays an active part in the handling of the case and in establishing possible grounds for liability. In cases of harm due to vaccination, the burden of proof is shifted, and lies in all respects with the NPE.

The Patient Injury Act is, at present, active only in claims against the public health system and private health care is not yet included in the Norwegian System of Compensation to Patients. According to the Health Care Personnel Act, health personnel who are authorized or licensed to run a private practice must take out insurance to cover any financial liability to patients that may arise in connection with the delivery of services. Compensation for harm caused within the private health care sector is organized and handled by private liability insurance, and patients still have to prove that harm has been caused by neglect on the part of the provider.

Of the patient complaints considered by the NPE in 2003, most of the claims for compensations were from patients with orthopaedic injuries (40%), followed by oncology (�4%), where most patients claimed for compensations because of delayed diagnosis and treatment, the last two groups were related to diseases of digestive and cardiovascular systems (both contributed to 8% of the claims). In 2003, the NPE considered 22�6 claims for compensations of which 34.3% were approved. In most of the cases (53.3%) that were upheld, the claims related to the treatment received: either that the treatment failed, or that the final result was not acceptable or faulty etc. Some 23.�% of the cases were about infections contracted after the treatment, and in a third category, �8.5% claims of late or wrong diagnosis (NPE 2004).

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Health systems in transition Norway

Patient safety The Specialist Health Care Act states that every hospital must have a quality assurance commission as part of its mandated system of internal control. A similar requirement is not defined for primary health care. The function of this commission varies from hospital to hospital. In addition, some institutions have quality subcommittees for each department. Usually, this kind of commission initiates and promotes quality standards at the hospital. However, commissions are not themselves responsible for quality, and the sole responsibility rests with the line management organization, from the physician and nurse meeting the patient through the chief of department up to the hospital director. The Specialist Health Care Act states that there should only be one responsible leader at each level of the organization.

Health institutions and/or the authorized or licensed health personnel must notify the public authorities as soon as possible, in writing, of severe injury to a patient caused by the delivery of health care, or where injury inflicted on one patient by another.

According to the Medicine Act, physicians and dentists must report adverse drug reactions to the Norwegian Medicines Agency. Furthermore, all marketing authorization holders in Norway are obliged to report such reactions in accordance with EU regulations. As of 3� January 2003 all reports of adverse drug reactions involving medicinal products for human use should be transmitted electronically according to the guidelines set out by the EMEA� and ICH2 regulations. Consumer-targeted advertising is permitted for over-the-counter (OTC) drugs and medical devices. Prescription drugs may be advertised to physicians and other health personnel, but advertising on television is not permitted under any circumstances.

The Norwegian Directorate for Health and Social Affairs has developed a national strategy called “…and it’s going to get better” (…og bedre skal det bli!) for quality improvement in health and social services, commissioned by the former Ministry of Social Affairs and the Ministry of Health in cooperation with the Norwegian Board of Health, an external group, and several other players in the field of health and social services. The strategy aims to ensure that users of health and social services receive services that are of high quality. The strategy also aims to ensure that the authorities’ policy for high quality is implemented, and that quality improvement work initiated in different areas within health and social services is coordinated and strengthened. The strategy has been inspired by similar strategies in other countries, by the work of the Committee on Quality of Health Care in America, the Institute of Health Care Improvement, and by the World Health Organization.

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Patients’ participation/involvement

Health care may only be given with the patients’ consent unless legal authority or other legal grounds exist for permitting health care to be delivered without consent. In order for the consent to be valid, the patient must have received the necessary information regarding his or her medical condition and what the prescribed health care entails.

The Patients’ Rights Act stipulates patients’ rights to receive information about their medical status and the prescribed medical treatment. The patient should also be informed of any possible risks or side-effects which might result from the treatment. The information offered should be tailored to the individual and their ability to understand what is being presented, taking into account, for example, their age, maturity and experience as well as their cultural and lingual background. Health care personnel should, as far as is possible, ensure that the patient understands the meaning and content of the information given.

The patient is, furthermore, entitled to participate in the process of his medical treatment. This includes the right to choose among available and medically sound methods of examination and treatment. If an injury occurs or serious complications arise, the patient must be informed. The patient should at the same time be made aware of the right to apply for compensation through the Norwegian system of patient injury compensation.

According to the WHO survey carried out in 2002 in Norway, there was a high degree of satisfaction among the users of health care services with regard to respect, privacy and communication between the patient and health care provider. There was less satisfaction with indicators on personal autonomy in choice of health care provider, and involvement in decisions regarding the type of treatments. On the question about the way that health care is managed in Norway, the interviewees were asked to rate the system care according to their level of satisfaction. About 60% expressed satisfaction, while �4% expressed dissatisfaction with the way the health care is run on the basis of this very general question.

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NorwayHealth systems in transition

3 Financing

Total expenditure on health in Norway amounted to NKr �68 billion in 2004, or NKr 36 000 per capita. Public sector spending on health accounted for about 84% of the total. Central government, local

government and the NIS are the public sources, while the private sources mainly consist of household out-of-pocket payments. The two functions outpatient dental care and pharmaceuticals are the main components of private spending. For the public sector, inpatient and day cases of curative care are the largest expenditure group.

3.1 Health expenditure

According to OECD data, the percentage of GDP taken up by total health expenditure in Norway in 2004 reached around �0% (Table 3.�). Comparing total health expenditures as a percentage of GDP, Norway ranked fourth in 2002 among the OECD countries, (Fig. 3.�). It is important to take into consideration the fact that Norway has a much higher GDP per capita than neighbouring countries. In 200�, GDP per capita was more than 23% higher than in Denmark and Iceland, and more than 37% higher than in Sweden and Finland, according to Statistics Norway. According to OECD Health Data 2003, Norway had the highest real annual per capita growth rates in health spending in the period �990–200� with 3.5%, followed by Iceland (2.8%), Sweden (2.�%), Denmark (�.9%) and Finland (0.5%). The reason for this high growth may be that Norway was less significantly affected by the economic downturn in the beginning of the �990s, and that it has a political commitment to spend more money on health. GDP growth in the same period was 2.8% (�990–200�) (see Fig. 3.2).

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Health systems in transition Norway

Table 3.1 Trends in health expenditure, 1980–2004 (selected years)

1980 1985 1990 1992 1995 1998 2000 2001 2002 2003 2004 Total health expenditure at 1995 GDP price level (in NKr billions) 42.6 47.4 60.2 67.8 74.3 95.9 112.6 135.3 150.0 160.8 167.9a

Total health expenditure per capita PPP 659 943 1 385 1 643 1 897 2 314 2 784 3 287 3 616 3 807 –

Total health expenditure as % of GDP 6.9 6.6 7.7 8.2 7.9 8.5 7.7 8.9 9.9 10.3 9.9a

Public expenditure on health as % of total expenditure on health 85.1 85.8 82.8 84.8 84.2 84.7 85.0 85.5 85.3 85.5 –

Private expenditure on health as % of total expenditure on health 14.9 14.2 17.2 15.2 15.8 15.3 15.0 14.5 14.7 14.5 –

Source: OECD Health Data 2005; a Statistics Norway, 2006.

According to the European Health for All database, Norway had the highest health care expenditure per capita among Nordic countries (Fig. 3.3) measured in purchasing power, followed by Iceland, Denmark, Sweden and Finland in 2003. In �980, the ranking was Sweden, followed by Denmark, Norway, Iceland and Finland using the same indicator. Norway was also ranked third followed by Sweden and Denmark with regard to total health expenditures as a percentage of GDP in �980.

A number of problems arise when making international comparisons between health care expenditures. When comparisons are made in relation to GDP, differences in both GDP and in health care expenditure must be taken into account, as well as fluctuations in the exchange rates. Finally, there are structural differences between the health services in individual countries, which, among other things, affect what is actually included as health expenditure.

According to OECD data, total health expenditure has been increasing in Norway from 6.9% of GDP in �980 to 9.9% of GDP in 2004 (Table 3.�).

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Fig. 3.1 Total expenditure on health as a % of GDP in the WHO European Region, 2002, WHO estimates

% of GDP

Western Europe Switzerland

Monaco Germany

Iceland Malta

France Norway Greece

Portugal Sweden

Israel Belgium

Netherlands Denmark

Italy United Kingdom

SanMarino Austria Spain

Ireland Finland

Cyprus Turkey

Andorra Luxembourg

CIS Republic of Moldova

Belarus Russian Federation

Armenia Uzbekistan

Ukraine Turkmenistan

Kyrgyzstan Georgia

Azerbaijan Kazakhstan

Tajikistan

Source: European Health for All database, January 2006. Note: CIS: Commonwealth of independent states; EU: European Union.

5.5 5.8

5.1 5.1

5.9 5.9 6.1 6.1 6.3

7.0 7.3 7.4 7.8 8.1 8.3

9.2

6.2 6.5 6.5

7.0 7.3 7.3

7.7 7.7

8.5 8.8 8.8 9.1 9.1 9.2 9.3 9.5 9.6 9.7 9.7 9.9

10.9 11.0 11.2

7.0 6.4 6.2

4.7 4.3 4.3

3.8 3.7

3.5 3.3

8.6 9.0

6.5 5.5

7.6

6.8

7.7

0 3 6 9 12

Central and south-eastern Europe Bosnia and Herzegovina

Slovenia Serbia and Montenegro

Hungary Bulgaria Croatia

Czech Republic The former Yugoslav Republic of Macedonia

Romania Poland Albania

Slovakia Lithuania

Latvia Estonia

Averages EU average

EU Member States before 1 May 2004 EU Member States joining 1 May 2004

CIS average

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Health systems in transition Norway

Fig. 3.2 Trends in health expenditure as a share (%) of GDP in Norway and selected

countries, 1998–2002

6

6.5

7

7.5

8

8.5

9

9.5

10

1998 1999 2000 2001 2002

Denmark Finland Norway

Sweden EU

Source: European Health for All database, January 2006.

The growth in health expenditure in Norway is similar to that in other western countries and can be explained by several reasons, such as the increasing number of elderly people, higher expectations, growth in the real GDP and increasing implementation of new technology in the health sector.

The Norwegian health care system is funded primarily from taxes and transfers from c