Norway: Health system review

TitleNorway: Health system review
Publication TypeBook
Year of Publication2006
AuthorsRoth Johnsen J
Series TitleHealth Systems in Transition
Volume8 (1)
Number of Pages187 P.
PublisherWHO Regional Office for Europe
KeywordsDelivery of health Care; Evaluation Studies; Financing, Health; Health care Reform; Health System Plans; Norway
AbstractNorway 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 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 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 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.