The Norwegian Health care System

1
The Norwegian Health care System

• By
• Maggi Brigham
• SINTEF Health Research
• Dep. of Health Services Research
• Trondheim
• Norway

2
Facts about Norway

• 4.6 million inhabitants
• Population density 14.2 (population per km2)
• Urban population 77
• Population gt 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

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

4
The new social services and health care
administration
Social security The Ministry of Social
Affairs
The Ministry of Health Ownership
The Directorate for Health and Social Affairs
The Norwegian Board of Health
Health Enterprises
The National Insurance Administration
The Norwegian Institute of Public Health
Hospitals
The Norwegian Medicines Agency
County municipalities
The Norwegian Radiation Protection Authority
The municipalities
The Municipal Health Service Care - care and
rehabilitation Social Services
The general public
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

6
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

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

8
Organisation and financing of hospital services
(secondary care) in Norway
9
Organisation and financing of hospital 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

10
Organisation and financing of hospital 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

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 local HA consists of one or more hospitals.
  The RHA supplements its own production with
  purchases from private, for-profit, providers.

12
Financing of hospital services

• The major elements in the financing of the RHA
  are
• Activity-based financing
• In-patient and out-patiens payment schemes.
• Block grants (needs-equalization grants)
  distributed among the RHAs according to
  socio-demographic characteristics (e.g.
  age-composition) of the population.
• Different ear-marked grants.
• There is also out-of-pocket payment (user fees)
  for out-patient hospital services (but these
  finance less than 2 of total costs).
• No out-of-pocket payments for inpatient hospital
  services
• RHAs are free to choose their own system to
  finance their hospitals.
• Most RHAs have chosen to copy the national
  model combining population-based grants with
  activity-based financing

13
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.

14
The Management System of Primary Health Care in
Norway
15
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

16
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 if you dont choose.

17
1b) Care for elderly and disabled

• TASKS
• - nursing homes
• - home-based services
• Large and growing task.

18
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

19
The municipalities are ordered by national
authorities to provide these primary health
services to the inhabitants.
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

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 to be spent on primary health care

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 in cooperation 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

23
2) Who is paying for Primary Health Care?

• About 80-90 from local and central taxes
• 10-20 percent fee for services

24
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

25
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
  insurance administration (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)

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 rich
• Italy 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 (?)

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)

28
3c) Health Stations financed by

• Grant from municipality
• (No fee for service)

29
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
  (gt12 y)
• Consultations, procedures, medicines
• roof
• Secondary health care
• Inpatient totally free for everyone
• Outpatient small out-of-pocket payment

30
The Norwegian National Insurance Scheme with
Focus on Health Insurance
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

32
History
33
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 the
  parliament 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

34
These public health insurances were introduced
while Norway was a relatively poor country
(before we found oil)

• A political project of welfare distribution

35
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

36
Membership in public health insurance
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

38
Cost sharing of health insurance
39
Revenue collection

• First premiums paid like normal insurance
  premiums
• 1971 incorporated into NIS, Premiums replaced by
  tax (see below)

40
Today
41
Membership today

• All persons who are either residents or working
  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

42
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)

43
Members also entitled to

• Retirement pension
• Disability pensions
• Benefits for single parents
• Cash benefits in case of sickness, maternity and
  unemployment
• Medical benefits in case of sickness and
  maternity
• Funeral benefits

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

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 smaller proportion of total budget

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

47
The NIS is administered by

• National Insurance Administration
• Subordinate to Ministry of Labor and Social
  Inclusion
• Tax authorities
• premium collection
• Municipal welfare offices
• Pays claims to individuals, GPs, Outpatient
  services

48
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