JANUARY

NORWAY
Patients are free to choose a hospital for elective services but not for emergency care. Public hospitals are
financed through RHAs—for somatic services with a block grant (50%), and with an activity-based portion (50%,
based on diagnosis-related group, or DRG). The RHAs are free to decide how the hospitals are paid, but all four
have chosen the same funding mechanism for somatic services; 50 percent as block grant and 50 percent based
on DRG. All health personnel are salaried, including doctors, and all payments, public and private, include all
services.
Mental health: Mental health care is provided by GPs and by other providers (psychologists, psychiatric nurses,
social care workers) in municipalities. For specialized care, GPs refer patients to private psychologists or
psychiatrists, or to a low-threshold hospital (district psychiatric center). These hospitals are dispersed throughout
the country. They often include psychiatric outreach teams. More advanced specialized services are organized in
the inpatient psychiatric wards of general hospitals or in mental health hospitals. Hospital treatment is provided
free of charge, and outpatient services are subject to the same cost-sharing as described above. Hospitals and
district psychiatric centers are funded by government block grants through RHAs. The role of private mental
hospital care is very small, and includes services for eating disorders, nursing home care for older psychiatric
patients, and some psychiatrist and psychologist outpatient practices, mostly contracted by RHAs. The role of
private treatment centers for addiction (mainly drugs and alcohol) is more prominent, and funded mostly
through contracts with RHAs.
Long-term care: The municipalities are responsible for providing long-term care, and contract also to some
extent with private providers. Cost-sharing for institutionalized care is income-based, and is set at 75–85 percent
of patients’ income, depending on means tests. Home nursing is also provided, if needed. The levels of care
at home or in a nursing home are determined by the municipality. Only about 3 percent of nursing homes are
private, and for home nursing care, the proportion is even lower. There are a few private providers of home
nursing care and other services, which are purchased by patients most often as a supplement to services by
public home care. In some densely populated areas, patients can have a choice of home care provider or
nursing home, but rarely arrange for services themselves. Very few patients pay individually for full-time private
nursing home care. End-of-life care for terminal patients is often provided in particular wards within dedicated
nursing homes. There is a system in place for informal carers to apply for financial support from the municipalities.
What are the key entities for health system governance?
The Ministry of Health and Care Services is politically led by the Minister of Health, who ensures that political
decisions are translated into practice. This is done through legislation, economic measures, and documents
instructing the RHAs and the Directorate for Health and other underlying agencies regarding activities and
priorities. The political values conveyed by the annual national budget and the instructions in the annual
letter of allocation from the ministry are determinative, and specify provider fees, out-of-pocket payments,
and ceilings.
The Directorate for Health is an executive agency and authority subordinate to the ministry. It issues clinical
guidelines, maintains the National System for the Introduction of New Health Technologies, coordinates
18 patient ombudsmen, and provides public information on health and health care through the website
www.helsenorge.no. The Directorate for Health is not responsible for producing systematic reviews or health
technology assessments (HTAs) but rather applies them to decision-making pertaining to the system for new
technologies, to guidelines, and to policymaking. From 2014 to 2018, the directorate is also in charge of the
secretariat for the National Patient Safety Program. It is responsible overall for setting standards and leading
the development and application of health information technology in health care. The Directorate for Health
is responsible for fee-setting in the DRG system, and also for the five-year project on quality-based financing.
There is no single authority overseeing fee-setting for providers other than hospitals.
The Medicines Agency determines which medications to reimburse. For new drugs, the agency determines
whether a prescription drug should be covered (on the blue list) by evaluating its cost-effectiveness in
comparison with that of existing treatments; a “green” scheme encourages providers to prescribe lifestyle and
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The Commonwealth Fund