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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 136 The Commonwealth Fund
NORWAY nutrition programs as a first alternative to more expensive preventive medicine. The agency also decides on the maximum price of specific drugs. The Norwegian Knowledge Center for Health Services, financed by government, produces comparative effectiveness studies (systematic reviews and HTAs) and works with quality and patient safety, quality indicators, and national patient experience surveys. Its HTAs are used by the Norwegian Council for Priority Setting in Health Care and the National System for the Introduction of New Health Technologies. The center also runs the national Reporting and Learning System for adverse events in hospitals. The Board of Health Supervision is a national public institution organized under the Ministry of Health. The board audits the different areas of the health care system, either systematically on a national basis or individually. An alert system ensures that hospitals alert the board to serious adverse events, and the board may then decide to investigate particular incidents. The board can issue fines to institutions and warnings to health personnel, and can revoke authorization for health care personnel who engage in misconduct. The Norwegian Institute of Public Health is a center for research on and surveillance of the health status of the population. It provides the Ministry of Health with advice on public health. It is the main authority regarding infection control and infectious disease surveillance. It provides community health profiles regarding prevalence of disease and holds several of the large health registers, including the prescription registry. The institute also assists the prosecuting authorities and the judiciary regarding forensic medicine. Organization of the Health System in Norway Parliament The Government The Ministry of Health and Care Services The municipalities County Board of Health Supervision The Institute of Public Health Primary health care Care services and rehabilitation Social services Dental care Public health The Medicines Agency The Radiation Protection Agency System of Patient Injury Compensation Biotechnology Advisory Board Directorate for Health Regional Health Authorities Hospital Trust SAK: Norwegian registration authority for health personnel NOKC: Norwegian Knowledge Centre for the Health Services POBO: Health and care services ombudsmen SAK NOKC POBO Hospitals Source: A. K. Lindahl, Norwegian Knowledge Centre for Health Services, 2015. International Profiles of Health Care Systems, 2015 137
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JANUARY 2016 2015 International Pro
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2015 International Profiles of Heal
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Table 1. Health Care System Financi
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Table 3. Selected Health System Per
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The Australian Health Care System,
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AUSTRALIA low-income adults, childr
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AUSTRALIA In 2013, the federal gove
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What is being done to reduce dispar
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References AUSTRALIA Australian Bur
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CANADA What is covered? Services: T
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CANADA funding to 145 not-for-profi
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CANADA Organization of the Health S
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CANADA provides recommendations to
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CANADA Health Council of Canada (20
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CHINA Private health insurance: Com
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CHINA is not substantially more exp
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CHINA Organization of the Health Sy
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CHINA References Chen, X. (2014).
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DENMARK In addition, nearly 1.5 mil
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DENMARK Social psychiatry and care
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DENMARK Quality data for a number o
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DENMARK portion is small, it makes
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48
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ENGLAND immunization, and vaccinati
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ENGLAND Hospitals: Publicly owned h
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ENGLAND Organization of the Health
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ENGLAND How are costs contained? Ra
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ENGLAND Organisation for Economic C
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FRANCE VHI finances 13.8 percent of
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FRANCE The average income of primar
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FRANCE What are the key entities fo
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FRANCE inequities in prevention rel
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FRANCE Nolte, E., C. Knai, and M. M
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GERMANY There were 42 substitutive
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GERMANY The 16 state governments de
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GERMANY management system, by the s
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GERMANY What major innovations and
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INDIA Private health insurance: The
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INDIA provide after-hour care, reim
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INDIA are provided by other ministr
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INDIA How are costs contained? Ther
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Page 88 and 89: ISRAEL Together, these two types of
Page 90 and 91: ISRAEL Primary care physicians are
Page 92 and 93: ISRAEL Organization of the Health S
Page 94 and 95: ISRAEL • Using electronic health
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Page 98 and 99: ITALY during hospitalization (Thoms
Page 100 and 101: ITALY Some regions are promoting ca
Page 102 and 103: ITALY Organization of the Health Sy
Page 104 and 105: ITALY although the degree of evolut
Page 106 and 107: ITALY The author would like to ackn
Page 108 and 109: JAPAN What is covered? Services: Al
Page 110 and 111: JAPAN incentives for providers to c
Page 112 and 113: JAPAN Organization of the Health Sy
Page 114 and 115: JAPAN The author would like to ackn
Page 116 and 117: THE NETHERLANDS receive faster acce
Page 118 and 119: THE NETHERLANDS Hospital payment ra
Page 120 and 121: THE NETHERLANDS Organization of the
Page 122 and 123: THE NETHERLANDS References Organisa
Page 124 and 125: NEW ZEALAND provided in GP clinics.
Page 126 and 127: NEW ZEALAND management (e.g., clean
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Page 134 and 135: NORWAY Primary, preventive, and nur
Page 138 and 139: NORWAY What are the major strategie
Page 140 and 141: NORWAY The National System for the
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Page 144 and 145: SINGAPORE Medifund is the governmen
Page 146 and 147: SINGAPORE Public hospital funding i
Page 148 and 149: SINGAPORE Public consultation: The
Page 150 and 151: SINGAPORE To keep demand for servic
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Page 154 and 155: SWEDEN What is covered? Services: T
Page 156 and 157: SWEDEN Hospitals: There are seven u
Page 158 and 159: SWEDEN Care, which promotes use of
Page 160 and 161: SWEDEN What major innovations and r
Page 162 and 163: SWITZERLAND Insurers offer premiums
Page 164 and 165: SWITZERLAND Hospitals: About 70 per
Page 166 and 167: SWITZERLAND Organization of the Hea
Page 168 and 169: SWITZERLAND To control pharmaceutic
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Page 172 and 173: UNITED STATES What is covered? Serv
Page 174 and 175: UNITED STATES Administrative mechan
Page 176 and 177: UNITED STATES The Institute of Medi
Page 178 and 179: UNITED STATES adopted at least a ba
Page 180: The COMMONWEALTH FUND Affordable, q
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