{DABE09E5 DD86 45B5 891A 5607E1B2C1E1}_The Norwegian Health Care System

8/3/2019 {DABE09E5 DD86 45B5 891A 5607E1B2C1E1}_The Norwegian Health Care System

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Health Research 1

The Norwegian Health care

System

By

Maggi Brigham

SINTEF Health Research

Dep. of Health Services Research

Trondheim

Norway


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Health Research 2

Facts about Norway

4.6 million inhabitants

Population density 14.2 (population per km2)

Urban population 77 %

Population > 65 years old 15 %

Fertility rate 1.8 births per woman

Deaths per 1000 inhabitants/year 9.0

Infant deaths per 1000 live births 3.2

Life expectancy 82.3 years

GDP per capita 59 000 USD (PPP 39000) Gini coefficient of income 0.243

3rd largest oil exporter in the world


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Health Research 3

Total health care expenditure in Norway

Primary and secondary (2004)

26 billion USD

Primary 18.5 billion; 4000 USD per person

secondary 7.5 billion USD; 1700 per person 5700 USD per person, PPP 3907 USD per person

9.9 % of GDP Johnsen p. 32


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Health Research 4

Norway health care administration

Social security The Ministry ofSocial Affairs

The National

Insurance Administration

The Directorate for

Health and Social Affairs

Health Enterprises

Hospitals

The Norwegian

Board of Health

The Norwegian Institute

of Public Health

The Norwegian

Radiation ProtectionAuthority

The Norwegian

Medicines Agency

The Ministry of Health Ownership

The municipalities

The Municipal Health ServiceCare - care and rehabilitationSocial Services

County municipalities

The general public


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Health Research 5

Ministry of Health and Care Services role

and responsibility

Legislation (preparation) and overall planning regarding primary health care

specialized health care/hospitals

public health

mental health medical rehabilitation

dental services

pharmacies and pharmaceuticals

emergency planning and coordination

policies on molecular biology and biotechnology food safety


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The Directorate of Health and Social

affairs role

Is a professional body (not political) that the Ministry of

Health and Care has delegated authority and

responsibility for

the surveillance of health and social services

Administration of health and social legislation

Implementation of policy

Both primary and secondary health care


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Health Research 7

The Norwegian Medicines Agency

Is the national, regulatory authority for new and existing

medicines and the supply chain.

Is responsible for supervising the production, trials and

marketing of medicines.

It approves medicines and monitors their use, and

ensures cost-efficient, effective and well-documented use

of medicines.

Prevention of over use.

NOMA also regulate prices and trade conditions for

pharmacies


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Health Research 8

Organisation and financing of hospital

services (secondary care) in Norway


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Health Research 9


services (secondary care) in Norway

In Norway, the financing and provision of hospital services

is mainly the responsibility of the national government,

financed by income and wealth taxation.

But one can also find a growing private contribution in terms of

both financing and provision

The political responsibility and control of hospital services

lies with the Ministry of Health and Care Services, i .e.

which is responsible for the overall financing, planning and

prioritizing of health services in the country Delegated authority to the Directorate of Health and Social Affairs

for implementation and surveillance


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Health Research 10


services in Norway, contd.

The Counties used to own, run and finance hospitals

(secondary care)

Transferred to national ownership 2002

Coordination

Budget control

Equalize access


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Health Research 11

The Regional Health Authorities

The responsibility of providing hospital services is delegated to five

geographically based Regional Health Authorities (RHA), which are

organized as national governmentally-owned enterprises.

The RHA exercises state ownership and has the responsibility for

providing services to the population in the health region, within the

framework stated by the overall health political goals.

The responsibilities also cover specialized mental-health services and

hospital services to persons with drug-related health problems.

The production of hospital services is performed mainly by local

Health Authorities (HA) owned by the RHAs or with private, non-profit,

hospitals that have a provisional agreement with the RHA. The localHA consists of one or more hospitals. The RHA supplements its own

production with purchases from private, for-profit, providers.


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Private supplement

In later years, the private supplement of hospital services

has become increasingly important.

The number of private, for-profit, providers has grown.

The range and scale of activities (out-patient and day surgery) has

increased.

The public providers are the major purchasers, but there is also

privately financed purchases and a private health-insurance

market is emerging.


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The Management System of

Primary Health Care in Norway


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1) What is primary health care in Norway

rough overview

a) General Practitioners (GPs)

b) Care for elderly and disabled

c) Health Stations

90 percent of patients are trea


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1 a) General Practitioners (GPs)

TASKS:

Diagnosis

Prescribe medication 90 % of patients treated here, 10 % referred to specialist/hospital

Referral to hospital = Gatekeepers

ORGANISATION

- private, financed by municipality through agreements

- Trondheim: 150000 inhabitants (175000 with students) 125 GPs.Average: 1.400 inhabitants per GP.

- Every inhabitant has one GP, by choice or given by authorities ifyou dont choose.


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1b) Care for elderly and disabled

TASKS:

- nursing homes

- home-based services

Large and growing task.


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1c) Health Stations

FOR WHOM:

- Children and youth age 0-20.

TASKS: - mother and child care/information

- vaccination programs

- sexual education for youth/ prevent pregnancies


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The municipalities are ordered by

national authorities to provide theseprimary health services to the

inhabitants.


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Health Research 20

Main laws and directives regarding

primary health care

The most important law regulating the provision of primary

health care is the Municipal Health Services Act of 1986

Defines responsibilities for primary health services and patient

rights

Also a Directive on Regular General Practitioners


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Health Research 21

The Municipalitys role and responsibility

Municipalities are responsible for

planning and developing primary health care services to meet the

needs of the residents

Planning primary health services provided by other providers

Agreements with regular General Practitioners (GPs) Framework agreement between Municipalities Central Association and

Medical Doctors association

Agreements with private nursing homes

Also responsible for emergency services

Municipalities decide the amount of local public funds tobe spent on primary health care


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Health Research 22

Municipalitys health care organization

The chief administrative officer of the municipality is

responsible for primary health services

Municipalities are self-governed by local politicians incooperation with local civil servants and free to set their

own local management models

Ombudsman and the County doctor are institutions

where patients can file complaints about health services


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Health Research 23

2) Who is paying for Primary Health Care?

About 80-90% from local and central taxes

10-20% percent fee for services


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2: About local and central taxes

All inhabitants must pay

Controlled by local tax-authorities through employers

Progressive system, high income - high taxes

Central taxes to the national health insurance system Local taxes to municipality government

Used for primary health among other things

Same access to services whether you pay low taxes or

high taxes Basic principle: Pay according to ability, receive care

according to need


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3a) GPs financed by:

i) Grant from local authorities depending on how many

inhabitants the GP serve (40-50%)

ii) Activity based fees from central health insuranceadministration (NIS). Based on number of consultations

and diagnostic tests. (30-40%)

iii) Out of pocket fee from inhabitants (10-20%)

- Children do not pay

- Upper limit for out of pocket payment (chronic diseases)


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Health Research 26

User charges in primary health care in Europe

General practitioner______________________________________________________________________________________________________

Austria Free (80% of the population)

Belgium 8% - 30%

Denmark Free

Finland 16,8 Euro

France 30%

Greece Free in NHS (not in private)

Ireland Free for the poor, 19 Euro for the richItaly Free

Netherlands Free (not for the rich?)

Norway 16 - 25 Euros (with roof)

Portugal 1,5 Euros

Spain Free

Great Britain Free

Sweden 8 - 17 Euro

Germany Free (?)


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Health Research 27

3b) Care for elderly and disabled

Nursing homes financed by:

- Grant from local authorities, negotiated every year (80-

90%)

- Out of pocket payment (10-20%)

Home based health services financed by:

- Grant from local authorities, negotiated every year.

- (No fee for service)


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Summary Primary and Secondary

(hospital) care

Two separate management and financing systems in health care

Primary health: (Local) Municipality planning, implementation and

financing (+ NIS)

Secondary health:

(National) state responsibility and financing

Health enterprises planning and implementing

Primary health care: small out-of-pocket payment (>12 y)

Consultations, procedures, medicines

roof

Secondary health care:

Inpatient totally free for everyone

Outpatient: small out-of-pocket payment


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Health Research 30

The Norwegian National Insurance

Scheme with Focus on Health

Insurance


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Health Research 31

The Norwegian National Insurance

Scheme (NIS)

The NIS is a public universal insurance scheme that

assures everybody social security and health insurance,

regardless of income

Introduced in 1967


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History


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Chronology

Public accident insurance introduced in 1894

Public unemployment insurance introduced in 1906

After many failed attempts since 1884, the law on

public health insurance was adopted by theparliament in 1909.

Implemented in 1911

Public old-age pension scheme introduced in 1936

The National Insurance Scheme (NIS) established in 1967

First social security

Health insurance incorporated into the NIS in 1971


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These public health insurances wereintroduced while Norway was a

relatively poor country

(before we found oil)

A political project of welfare distribution


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Health insurance membership

1911: Compulsory membership for workers

361 000 members in 1912

Workers and their family

Universal in 1956

Workers (as before)

Self employed

Farmers

Fishermen

Tradesmen

Unemployed


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Health Research 36

Membership in public health insurance

% of workforce % of population

1915 38 15

1950 72 31

1970 178 72


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Health Research 37

Health Insurance Coverage

Sick pay, doctor consultations and hospital treatment Not dental health (still)

Not medicine (now partly)

Midwives and maternity light in 1912

Now more comprehensive


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Health Research 38

Cost sharing of health insurance

1911 1956 1972

Member 60 % 49.5 33.6 %

Employer 10 % 29.7 50.4 %

Local

Municipality

10% 10.9 9.1 %

National

Government

20 % 9.9 7.9 %

Total 100 % 100 % 100 %


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Revenue collection

First: premiums paid like normal insurance premiums

1971: incorporated into NIS, Premiums replaced by tax(see below)


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Today


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Membership today

All persons who are eitherresidents orworking as

employees in Norway MUST be insured under the

National Insurance Scheme.

Also certain categories of Norwegian citizens working abroad

Others can apply for voluntary membership


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Members of NIS are entitled to

Free stay and treatment in public hospitals

Partial coverage of treatments by

GPs

Out-patient specialists

Psychologist/psychiatrist

Certain drugs

Transportation to examination/treatment

Children under 12 are exempt from cost sharing (out of

pocket payments)


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Health Research 44

Health care expenditure by NIS

NIS gross budget: USD 35 700 million

7.800 USD per inhabitant

Health care expenditure by NIS USD 3 125 million

Health care expenditure almost 10 % of total NIS

spending


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Health Research 45

Financing of the NIS

Central income tax to the

Employees: rate varies, first 3.2 %, now 7.6 % of income

Employers

Self-employed people

Controlled by local tax-authorities through employers

Same access to services no matter how much tax you pay

Allocations from National Government Budget

In the beginning large proportion, as people got richer smallerproportion of total budget


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Health Research 46

NIS funds partly finance these aspects of

Health Care:

Regular general practitioners (GPs)

Emergency ward

Private specialists/outpatient hospital services

Pharmaceuticals from pharmacies

Johnson p. 37


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The NIS is administered by

National Insurance Administration

Subordinate to Ministry ofLabor and Social Inclusion

Tax authorities

premium collection

Municipal welfare offices

Pays claims to individuals, GPs, Outpatient services


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H lth R h

Summary

Norwegian Health care mainly publicly managed and

financed

Two separate management and financial systems for

primary care and hospitals

Primary care: municipality

Hospitals: national government

GPs gatekeepers to hospitals

National Insurance Scheme.

Tax from Employers, employees. Municipal and national govt grant

Basic principle: pay according to ability & receive care according to

need

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