Norwegian health care reforms of the 2000’s

Name, title of the presentation

Norwegian health care reforms of the 2000’s

Jon Magnussen Norwegian University of Science and

Technology Helsinki 3/10 - 2013


1: Background


The challenge

Providing high quality health care in an efficient manner within a limited budget, distributing those services equitable across the population


A Nordic health care model • Tax funding • Decentralized public governance • Elected local governments • Public ownership (or control) of delivery structure • Equity driven, with focus on geographical and

social equity • Public participation.


Nordic model - similarities

• Common goals and aspirations – Equity ? – Public participation

• Common structural features – Tax based funding – Decentralization – the role of regions, counties and

municipalities – (Local) Political governance


But: Differences in health policy

• Governance

• Financing and contracting

• Choice

• There is a common model but we differ in how we approach important issues


2: Norway


The questions

• Centralized or decentralized governance? – Administrative or political?

• Centralized or decentralized delivery structure? – “A few large – or many small?”

• Payment systems and resource allocation – Efficiency vs. equity

• Coordination of care – Or coordination of providers of care?


The reforms

• Hospital ownership reform 2002 – The big one!

• List patient reform – GPs 2001 – The uncontroversial one!

• Coordination reform – 2012 – The fuzzy one!


Norway – year 2000 (i)

• Specialist health care – Responsibility of 19 counties – Mix of activity based payment and global budgets – Counties financed through tax income and

matching state grants – Limited choice of hospital


Norway – year 2000 (ii)

• Primary health care – Responsibility of 430 municipalities – Salaried GPs – Municipalities financed through tax income and

matching state grants – Free choice of GP


3: Specialist health care

Hospital reform


Hospital ownership reform (i)

• Why? Large county variations in per capita spending on health

• Central funding – local provision – Tension (blame games) – Soft budgeting

• Structural issues – Duplication of services (inefficiency) – Quality concerns (low volume)


Hospital ownership reform (ii)

• State takeover of ownership • Administrative delegation to four Regional

Health Authorities • Regional needs-adjusted distribution of funds • RHAs responsible for investments


Hospital reform (iii)

• Structural efficiency

• Cost containment

• Geographical equity

• Professional management


Lessons (i)

• Soft budgeting is difficult to avoid • Deconcentration (administrative decentralization) is

more difficult than devolution (political decentralization) – But may be more effective

• What should be the role of locally elected politicians?


Lessons (ii)

• Health policy goals and tools need to be internally consistent – ”No growth in activity” – 60 % activity based financing – Free choice of hospitals – Individual treatment guarantee

• Mixed signals creates escape routes and makes governance more difficult


New government – what now?


4. Primary health care

List patient reform Coordination reform


List patient reform – (i)

• Why? Access • What? Everybody joins a GP list – limited

possibility to change GP

• GPs financed 30 % capitation, 70 % FFS • GPs are private contractors with local public

authorities • Number of available “positions” are limited


List patient reform – (ii)

• Overall the reform has been positively received

• Patients; satisfied – better access to GPs • GPs; (mainly) satisfied – defined patient

population – stable working conditions – higher income

• Municipalities; satisfied – better coordination and planning


Coordination reform (i)

• Why? To coordinate care between different delivery systems – in particular primary and specialist care

• Why? To ensure that patients are treated at the “lowest efficient” level – i.e. shifting care from specialist to primary health care


Coordination reform (ii)

• Municipalities paying for hospital care (20 %) • Municipalities paying for patients remaining in

hospitals due to lack of municipal capacity (more than 100%)

• Providing acute care in municipalities • Increased role in prevention


Coordination reform (iii)

• Number of “discharge ready” patients remaining in hospitals have been drastically reduced

• Increased focus on primary care, but resource implications are still not clear

• Attempts to regulate GPs in more detail have been fiercely opposed


4: Current policy issues


Norway – year 2013 (i)

• Specialist health care – Responsibility of state through four regional health

authorities (RHA) – Mix of activity based payment an global budgets – Ear marked financing of RHAs through block

grants and some activity based financing – 20 % municipal co-financing

– Free choice of hospital – including private hospitals


Norway – year 2013 (ii)

• Primary health care – Responsibility of 430 municipalities – List patient system with GPs financed through

capitation (30%) and activity (70 %) – Municipalities financed through tax income and

matching state grants – Limited choice of GP


Structure / ownership

• Location of hospitals

• Division of tasks between hospitals

• Small vs large hospitals

• Private vs public hospitals


Decision making power

• Political vs. administrative decision making

• Local vs. central politicians

• Medicine vs. administrative


Challenges (i)

• Fiscal sustainability – Tax levels – Share of GDP to health

• Health care as a pure welfare good – Two tier system with a ”public benefit package”

and private services • Priority setting as a logical consequence of

limited resources – At what level and on what grounds?


Challenges (ii)

• Models of production – Private, public firms, trusts,

• Individual choice vs. public planning

– Equity, ”consumerism”


Finally – a personal observation

• It is difficult to see differences in underlying values between different political fractions

• Thus, differences are in how (and which) policy tools are used – and even these are often marginal

• Result: Health policy debate is reduced to “simple” rhetoric

• And reforms seems motivated by a need to signal “action” rather than the need to solve a problem..


Thank you!

Norwegian health care reforms of the 2000’s

Health & Medicine

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