Volume 14, Issue 1/2012 - Interview

Healthcare in Norway

Challenges, Plans and Solutions  

Norway faces the same dilemma of many western  European countries, as the standard of living  improves and people’s life expectancy increases,  there are new challenges with an ageing  population and a growing number of people  with chronic diseases. An ageing society will be  a challenge for the Norwegian healthcare system.  To make further progress in the health of  the population, it will be necessary to focus on  the challenges of health promotion and illness  prevention. From the end of the 1990s several  reforms have been launched, designed to  meet the main challenges that the Norwegian  healthcare system will face in the next century.  An overall challenge is to combine a decentralised  system with a regulatory environment  that ensures equal access.  


Health Services in Norway:  Organisation and Financing 

The system of healthcare provision in Norway  is based on a decentralised model. The state  is responsible for policy design and overall capacity  and quality of healthcare through budgeting  and legislation. The state is also responsible  for hospital services through state  ownership of regional health authorities. Within  the regional health authorities, somatic and  psychiatric hospitals and some hospital pharmacies  are organised as health trusts.  

The Norwegian healthcare system is taxbased  and is formed around the principles  of equal access to healthcare services, political  decentralisation to local governments,  and free choice of provider. Public expenditures  consist of more than 80 percent of  total health expenditure.  

Special reforms in the late 1980s and early  1990s have contributed to the expansion of  the range of services provided to meet the  specific needs of the elderly, the handicapped  and the mentally ill. In addition, an activitybased  system of hospital financing, based on  the DRG system, has been in place since 1997.  The system has the aim of decreasing waiting  lists through the expected expansion of capacity  and utilisation. For inpatient stays, hospitals  are paid by a combination of cost per  case and global budgets.  

Norway’s 430 municipalities have responsibility  for primary healthcare, including both  preventive and curative treatment.  

There are about 23,000 physicians in Norway.  There are currently 230 citizens per physician  under 67 years of age in Norway, or 4.34  physicians per 1,000 citizens, more than in the  other Nordic countries (source: Physicians in  the Nordic Countries 2008). Within the OECD,  only Greece has clearly more physicians per  head of population than Norway, while it is  about equally high in Belgium, Italy, Spain and  Switzerland (source: OECD Health Data 2010).  


The Coordination Reform  

The Government has introduced a Coordination  Reform to ensure sustainable, integrated  and coordinated health and care services that  are of high quality, maintain a high degree of  patient safety, and are tailored to the individual  user. Greater emphasis will be placed on measures  to promote health and prevent disease, on  habilitation and rehabilitation, on increased user  influence and on binding agreements between  municipalities and hospitals. The municipal health  and care services will be strengthened and the  specialist healthcare services will be expanded.  

Medical investigation and treatment of frequently  occurring diseases and conditions will  be decentralised when possible. Medical investigation  and treatment of less frequently occurring  diseases and conditions will be centralised  when this is necessary to ensure a high quality  of service and effective utilisation of resources.  

If the Coordination Reform is to succeed,  better balance and reciprocity between the  specialist and municipal healthcare services  must be achieved. The reform will be implemented  over a period from January 2012. To  achieve the reform’s objectives, a wide array  of instruments is required:  

- Legal instruments, including the entry into  force of the Act relating to public health efforts  (Public Health Act) and the Act relating  to municipal health and care services (Health  and Care Services Act). The Public Health Act  lays the foundation for long-term, systematic  public health activities at all administrative  levels: National, county and municipal.  The Health and Care Services Act is designed  to improve coordination within the municipalities  and between the specialist and municipal  health and care services. The municipalities’  overall responsibility for the services  offered is clarified, and the municipalities are  given greater freedom to organise the services  in accordance with local conditions and  needs. The municipalities and regional health  authorities/hospital trusts are required to enter  into agreements at the local level.

- Financial instruments A scheme for limited  municipal co-financing of somatic treatments  within specialist healthcare services has been  introduced. The ministry has stipulated that the  regional health authorities, in conjunction with  the municipalities, must chart the potential for  cost-effective, local collaborative projects. The  municipalities will be given financial responsibility  for patients released from hospital. The  municipalities must be able to provide 24 hour  in-patient care for patients who require immediate  assistance and monitoring from the health  and care services, when the municipality has  the capacity to investigate, treat or provide  care. The municipalities have been given the  opportunity to seek state investment funding  to develop services in cooperation with other  municipalities and hospital trusts.  - Profession-oriented instruments are designed  to bring about a change in the practices  used within the services, in keeping with the intentions  of the Coordination Reform. Instruction  material, guidelines and procedures and the  introduction of national quality indicators are  examples of profession-oriented instruments.  New requirements on expertise will be needed.  Education and training of personnel must be  adapted to the objectives of the Coordination  Reform. The municipalities must participate in  and create a viable foundation for research on  the municipal health and care services.  - Organisational instruments Appropriate arenas  must be established for cooperation between  various services and administrative levels.  One example of this is the organisation of  community medical centres as a collaborative  effort between the specialist healthcare services  and one or more municipalities. The services  offered at a community medical centre  may be designed on the basis of local needs,  and may include a daytime clinic and possibly  24-hour care. Ownership and responsibility for  the operation of such clinics should be regulated  through agreements at the local level.  


Patient Safety  
In Safe Hands: The Norwegian Patient  Safety Campaign 2011 – 2013  

The Norwegian health and care system holds  in general high standards. However, OECD and Commonwealth fund publications tell us that  this picture is nuanced:  

  • Variation in clinical practice;  
  • Waiting time is unacceptable;  
  • Variation in health personnel qualification;  
  • Variation in user involvement; and  
  • Adverse events.  


Financial Incentives  

Today, there are no financial incentives for quality  and patient safety. But in this context it is relevant  to discuss how pay for performance (P4P)  mechanisms can be considered as complementary  tools for creating further incentives  for achieving quality improvement and efficiency  gains in the Norwegian health sector.  

The Norwegian patient safety campaign, In  Safe Hands, was launched in January 2011 by  the Norwegian Ministry of Health. The threeyear  campaign aims to reduce patient harm  and involves both specialist and primary healthcare  services. The campaign aims to reduce  patient harm, build pervasive structures and  systems for patient safety and improve patient  safety culture in the health services. In Safe  Hands marks the beginning of lasting improvements  in patient safety in Norway.  

The campaign will introduce specific measures  in several focus areas.

As of now, three focus areas  are ready to be implemented nationwide: 
• Safe Surgery, with focus on post operative  infections;  

  • Medication Reconciliation; and  
  • Drug Review.  In addition, the following areas are under preparation:  
  • Stroke Treatment;  
  • Mental Health;  
  • Central Line Infection;  
  • Fall;  
  • Pressure Ulcer; and  
  • Urinary tract infection.

Further areas will be developed in the course  of the campaign. Measurements will be carried  out within each priority area.  

All focus areas are considered areas with  great potential for improvement. They have  been recommended by a special advisory  board and have been considered by expert  groups with expertise in the areas concerned.  Because patient safety is a management  responsibility, the campaign also  promotes relevant leadership interventions.  The interventions are piloted locally to ensure  that the measures work in practice. Two  of the five pilots concern leadership, such  as Leadership WalkRounds.  



In Safe Hands was commissioned by the Ministry  of Health. A steering group, led by the CEO of the  National Health Directorate, is responsible for all  key decisions in the campaign. The campaign  secretariat forms part of the National Unit for  Patient Safety, positioned in the National Knowledge  Centre for the Health Services.

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Challenges, Plans and Solutions  Norway faces the same dilemma of many western  European countries, as the standard of living  improves and

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