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The Norwegian Health Care System

by Anne Karin Lindahl, Norwegian Knowledge Centre for the Health Services

What is the role of government?

Government is responsible for providing health care to the population, in accordance with the stated goal of equal access to health care regardless of age, race, gender, income, or area of residence. Primary health and social care is the responsibility of the municipalities, with Norway’s ministry of health playing an indirect role through legislation and funding mechanisms. In specialist care, the ministry also plays a direct role through its ownership of hospitals and its provision of directives to the boards of regional health care authorities (RHAs).

Who is covered and how is insurance financed?

Publicly financed health care: Health expenditure represented 9.9 percent of GDP in 2015, slightly above the average of 8.9 percent for countries in the Organisation for Economic Co-operation and Development (OECD). Norway ranks among the highest in the OECD in terms of absolute expenditure per capita (NOK60 000, or USD6,122,1 in 2015). Public financing accounts for 85 percent of this spending.

Coverage is universal and automatic for all residents. It is financed through national and municipal taxes. Social security contributions finance public retirement funds, sick leave payment, and, for some patient groups, reimbursement of extra health care costs.

For acute hospitalization, there is no private alternative.

Through common agreements, European Union residents have the same access to health services as in their home country. Other visitors are charged in full. Undocumented adult immigrants have access only to emergency acute care, while undocumented children receive the same care as citizens.

Private health insurance: Private health insurance is provided by for-profit insurers and purchased for quicker access and greater choice of private providers. It covers less than 5 percent of elective services; it does not cover acute services. About 9 percent of the population, or nearly 15 percent of the workforce, has some kind of private insurance. About 91 percent of policies are paid for by an employer.2

What is covered?

Services: Parliament determines what is covered, although there is no defined benefit package other than for new and costly treatments and technologies (see below). In practice, national health care covers planned and acute primary, hospital, and ambulatory care, rehabilitation, and outpatient prescription drugs on the formulary (the “blue list”). It also covers dental care services for children up to 18 years of age and other prioritized groups, such as people with some chronic diseases, patients with chronic mental disabilities, and patients in nursing homes. Dental care for 19-to-20-year-olds and dental orthopedics (braces) for children are partially covered. Regular glasses and contact lenses are not covered unless the vision is very limited. Cosmetic surgery is not covered.

Primary, preventive, and nursing care are organized at the local level by municipalities. The municipality, often in cooperation with the county, decides on public health initiatives or campaigns to promote healthy lifestyles and reduce social health disparities. Preventive services for mental health are directed toward children and adolescents through the school system. Psychological care for children under the age of 18 is fully covered. Primary care for mental health is provided by general practitioners (GPs) and municipal psychologists. Long-term care, including palliative end-of-life care, is provided on the basis of need, either at home or in nursing homes. There are few designated hospice facilities. The substantial government funding for municipalities is generally not earmarked, and budgets are set locally, but provision of some services is statutory, particularly those related to pediatric and long-term care.

Cost-sharing and out-of-pocket spending: GP and specialist visits, including outpatient hospital care and same-day surgery, require copayments (NOK152 [USD15.5] and NOK345 [USD35] per visit in 2015, respectively), as do physiotherapy visits (in varying amounts), covered prescription drugs (up to NOK520 [USD53] per prescription), and radiology and laboratory tests (NOK245 [USD25] and NOK50 [USD5], respectively). Public providers cannot charge patients more than these amounts, other than for bandages and other supplies. Consultations for children under 16 years, for antenatal and postnatal follow-up of mother and child, for prevention and treatment of some transmittable diseases, and for treatment of sexually transmitted diseases are also exempt from copayments. Hospital admissions and inpatient treatment are free. Out-of-pocket payments finance about 14 percent of total expenditure.

Home-based care and institutional care for older or disabled people require means-tested, high cost-sharing of up to 85 percent of personal income.

Safety net: The major safety net mechanisms are annual caps, set by Parliament, for out-of-pocket expenditure, above which fees are waived. For 2016, the cost-sharing ceiling for most services is NOK2,185 (USD223). A second ceiling, for services such as physiotherapy and certain dental services, is set at NOK2,670 (USD272). Long-term care and prescription drugs outside the blue list do not apply toward these ceilings.

Residents eligible for the minimum retirement or disability pensions, which amount to about NOK162,000 (USD16,530) per year, receive free essential drugs and nursing care. Individuals with specified communicable diseases, including HIV/AIDS, and patients with work-related injuries receive free medical treatment and medication. Taxpayers with high expenses (above NOK9,180, or USD937) as a result of permanent illness receive a tax deduction. “Basic benefits” (NOK670–NOK3,346, or USD68–USD341 per month) may be provided, upon application, to patients who regularly incur additional expenses because of permanent illness, injury, or disability.

How is the delivery system organized and financed?

Primary care: The municipalities provide primary care in accordance with current legislation, government directives, and quality requirements set by the Directorate for Health.

The “regular GP scheme,” whereby people register with one general practitioner, covers 99.6 percent of the population. There was an average of 1,127 patients per GP in 2015.3 Patients may change their GP twice a year. GPs function as gatekeepers, as referral by a GP is required for coverage of specialist treatment.

There are 2.4 specialists in hospitals or ambulatory care for every practicing primary care physician.4 Financial incentives encourage physicians to certify as a specialized GP and to see many patients per day.

Municipalities contract with individual GPs, who receive a combination of capitation from the municipalities (35% of income), fee-for-service from the Norwegian Health Economics Administration (Helfo) (35%), and out-of-pocket payments from patients (30%). GP financing is determined nationally by negotiation between the Ministry of Health and the Norwegian Medical Association. In the fee-for-service scheme, there are fees provided for medication reconciliation, for taking part in coordination of care, and for coordinating the creation and follow-up of individual plans for patients with complex needs, but these are relatively low. Most GPs are self-employed; only 5 percent are salaried municipal employees.5 The average salary is estimated to be NOK750,000 (USD76,530), but can be substantially higher for full-time practitioners. GP practices typically comprise one to six physicians and employ nurses, lab technicians, and secretaries, but networks for shared resources are not common. Many municipalities have multidisciplinary mental health outreach teams.

Specialist care: The four RHAs, which are state-owned corporations that report to the Ministry of Health, are responsible for supervising specialist inpatient somatic and psychiatric care, as well as treatment for alcohol and substance abuse. The ministry provides the RHAs’ budgets and issues an annual document instructing the RHAs as to aims and priorities.

Outpatient specialist care is provided both by hospitals and by self-employed specialists. Hospital-based specialists are salaried. Privately practicing specialists contracted by an RHA are paid a combination of annual lump sums, based on the type of practice and number of patients on the list (35%); fee-for-service payments (35%); and patients’ copayments (30%). The annual lump sum and the out-of-pocket fees are set by government, and the fee-for-service payment scheme is negotiated between government and the Norwegian Medical Association. Specialists with an RHA contract can charge patients only the specified out-of-pocket fee. Those who do not receive public financing are neither regulated nor subject to the out-of-pocket expenditure caps.

In principle, patients have a choice of specialist, although in practice specialist availability varies by geographic location. In the more densely populated areas, clinics with multidisciplinary specialists have emerged during the last few years and seem to be increasing in number. Hospital-employed specialists cannot see private patients at the hospital, but may practice privately after hours, on their own time.

Patient out-of-pocket payments: Patients pay their out-of-pocket fee directly to the provider. If they reach the first safety net ceiling, it is automatically registered and copayments are made directly to the provider by Helfo. For the second ceiling, patients need to submit an application with proof of payment of the out-of-pocket costs.

After-hours care: After-hours emergency primary care services are the responsibility of the municipalities, whose contracts with GPs include after-hours emergency services on rotation. The municipalities provide offices, equipment, and assistance and pay the GPs a small fee. Other payments are provided by the national fee-for-service system and out-of-pocket payments from patients. The more densely populated municipalities have walk-in centers where nurses triage patients and answer calls, with several doctors seeing patients all through the day and night. In smaller municipalities, patients call an after-hours phone number and speak with a nurse, who calls the GP if the patient needs to be seen. There is a common national phone number for primary care after-hours services (legevakt), through which calls are directed to the caller’s local service. In larger cities, there are also a few privately owned and run after-hours clinics where patients pay in full.

There is variation as to whether information from emergency visits is shared with patients’ regular GPs. There is an emergency phone number that patients can call for urgent ambulance services, but no national medical advice line. Patient out-of-pocket fees are higher for after-hours emergency services (about NOK100 [USD10] higher per consultation).

Acute-care hospital services are the responsibility of RHAs. Patients need an acute-care referral to these services by a primary care physician or, in specific cases (accidents, suspected heart attack, stroke, etc.), can access them directly via ambulance.

Hospitals: Public hospital trusts are state-owned, formally registered legal entities with an executive board and are governed as publicly owned corporations. A few hospitals are privately owned, and those owned by nonprofit humanitarian organizations provide publicly funded services as part of RHAs’ plans for providing acute care. The for-profit hospital sector is small, providing less than 0.2 percent of somatic hospital stays and 7 percent of daytime stays, mostly outpatient surgery.6 For-profit hospitals do not provide a full range of services and do not offer acute care. Some of their services may be publicly funded, but the proportion varies, from almost none to 85 percent.

Patients are free to choose a hospital for elective services, but not for emergency care. Public hospitals are financed through RHAs. While mental health is funded 100 percent by block grants to the RHAs, somatic services are financed only 50 percent by block grants, with the rest activity-based (based on diagnosis-related groups, or DRGs). 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 DRGs. 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 and 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. Psychiatric services in the larger hospitals as well as in the district psychiatric centers are funded by government block grants through RHAs. Private mental hospitals account for about 12 percent of mental health care, including 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 (38%) and funded mostly through contracts with RHAs.7

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 set at 75 percent to 85 percent of patients’ income. 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. Patients may purchase home nursing care and other services from private providers as a supplement to services by public home care. In some densely populated areas, patients themselves have a choice of home care provider or nursing home. People under 67 with permanently reduced functioning who live at home have a right to a personal assistant who will aid them according to their preferences. Very few patients pay individually for full-time private nursing home care. End-of-life care for terminal patients is often provided in specific wards within dedicated nursing homes. There is a system in place for informal caregivers to apply for financial support from the municipalities.

diagram of health care system

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 translates political decisions into practice 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 an 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 is responsible for the national quality indicator system. From 2014 to 2018, the directorate is in charge of the secretariat for the National Patient Safety Program, and from 2016 also administers a reporting and learning system for adverse events in hospitals. The Directorate for Health is responsible for fee-setting in the DRG system and also for a five-year project on quality-based financing (see “Strategies to ensure quality of care,” below). There is no single authority overseeing fee-setting for providers other than hospitals.

The new Directorate of eHealth, established January 1, 2016, is responsible for the overall setting of standards and for leading the development and application of health information technology in health care. It provides public information on health and health care through the website www.helsenorge.no.

The Medicines Agency determines which medications to reimburse for outpatients. 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. The agency decides the maximum price of drugs.

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 and 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 registries, including the prescription registry. The institute also assists the prosecuting authorities and the judiciary regarding forensic medicine. As of the beginning of January 2016, the Norwegian Knowledge Centre for the Health Services merged with the Norwegian Institute of Public Health. It produces comparative-effectiveness studies, systematic reviews, and health technology assessments and performs comparative health services and systems analyses, including patient-experience surveys. Its health technology assessments are used by the Norwegian Council for Priority Setting in Health Care and the National System for the Introduction of New Health Technologies.

The National Board of Health Supervision audits the different areas of the health care system, either systematically on a national level or individually. An alert system ensures that hospitals inform the board of 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. Local audits are performed by the county governors.

Patient advocacy is ensured through statutory “user boards” at all hospital trusts and regional health authorities and also through the offices of the patient ombudsmen in all counties.

Public information on the performance of the health services is made available partly through the website www.helsenorge.no, where national quality indicators are published, along with information on patients’ rights, economic support, and ability to change their regular GP. There is secure entry via this website to patients’ core medical records, as well as to a separate website for all patients’ prescriptions.

For public and stakeholder engagement, there is a tradition of public hearing of white papers before their discussion and approval in Parliament, as was the case with the National Health and Hospital Plan (2016–2019).8

What are the major strategies to ensure quality of care?

The National Strategy for Quality Improvement in Health and Social Services (2005–2015) focused on efficacy, safety, efficiency, patient-centered care, care coordination, and continuity and equality in access to health care.9 National evidence-based guidelines are being developed for a number of diseases. For cancer, there is a disease management program introducing defined “packages” to be delivered to patients, and a project to implement similar service packages is under way for mental health and addiction treatment. A five-year (2014–2018) national program aims to improve patient safety, and there is a national reporting and learning system for adverse events in hospitals. A total of 54 national clinical registries have been established for specific diseases, in addition to 15 national health registries. There is no registry for technical devices.

The Directorate for Health is in charge of a national program for health care quality indicators. The program includes results from national patient experience surveys, as well as quality indicators for criteria such as survival rates, infection rates, and waiting times, and also indicators specific to the different medical areas. No information is gathered or disseminated regarding results or quality of individual health care professionals’ performance.

The Registration Authority for Health Personnel, in the Directorate for Health, licenses and authorizes all health care professionals and can grant full and permanent approval to those meeting educational and professional criteria. There is no system for reevaluation or reauthorization. The authority issues certificates of specialization to medical doctors, in accordance with specific and transparent requirements. Only the specialization of GPs requires recertification. The Norwegian Board of Health carries out audits of all levels of the health system, including the health care workforce.

RHAs, hospitals, municipal providers, and private practitioners are themselves responsible for ensuring the quality of their services. There is no requirement for accreditation or reaccreditation, although some hospitals or hospital departments are accredited.

A five-year developmental program (2013–2017) is under way for quality-based financing of RHAs, based on performance and improvement as measured by a set of indicators—29 indicators in 2014, 33 indicators in 2015, and 32 in 2016—with patient experiences constituting about 30 percent of the reporting. Quality-based financing amounts to only about 0.5 percent of the total of the RHAs’ budgets. An evaluation in 2015 did not identify particular downsides to this quality-based financing, but did identify improvement areas.10

The Norwegian Institute of Public Health uses the Norwegian Prescription Database to produce annual reports on prescribing trends, giving national health authorities a statistical base for planning and monitoring the prescription and use of drugs. Personal information held by the registry is anonymized.

What is being done to reduce disparities?

Eliminating socioeconomic inequalities in health is a priority of the Directorate for Health. A national strategy for addressing inequalities in health and health care includes various ways of increasing knowledge and awareness.11 There have been some initiatives for children, including vaccination programs and kindergarten- and school-based programs; initiatives for people with disabilities to be included in the workplace; price and tax policies; initiatives for care integration; general information campaigns regarding smoking cessation, alcohol, and diet; and specific programs for populations considered at risk.

There is increasing focus on immigrants’ health and their underutilization of health care. Research on pregnancy among immigrants has been informative, as there are significantly more complications for newborns and mothers among immigrants than among native Norwegians.12 There has been a resulting emphasis on the need for adequate information to be provided in immigrants’ native languages.

Health outcomes vary by geography, not only because of differences in the prevalence of diseases but also as a result of variations in the availability and quality of health care. Recruitment of health personnel, notably doctors and specialized nurses, is more difficult in rural areas.

What is being done to promote delivery system integration and care coordination?

The care coordination reform of 2012 put more emphasis on municipalities’ responsibility for 24-hour and post-discharge care, including individual treatment plans for patients with chronic diseases. Hospitals and municipalities must establish formal agreements on the care of patients with complex needs.13

For hospitals, incentives for care coordination are provided by mandatory agreements with municipalities. Financing remains poorly aligned between the hospitals, which are state-funded, and primary care, which is municipality-funded. The municipalities are fined per day for patients who stay in hospitals after they are ready for discharge.

What is the status of electronic health records?

A national strategy for health information technology (HIT) was initiated in 2016 and is the responsibility of the Directorate of eHealth. Every resident is allotted a unique personal identification number, which is used in primary care and for hospitals’ medical records. GPs use secure messaging to request prescriptions or to address patients’ questions. Some GP and specialist outpatient offices have electronic booking, while most hospitals do not. All patients have the right to see or get a copy of their complete record, including doctors’ notes, but there is as yet no electronic method for doing so. An ongoing project on patient access currently gives 3.1 million inhabitants access to their core medical record.

The National Health Network, a state enterprise, is charged with providing efficient and secure electronic exchange of patient information between all relevant parties within the health and social services sector. It provides secure telecommunication for GPs, hospitals, nursing homes, pharmacists, dentists, and others.

HIT in primary care is fragmented, and some areas of service lack resources and equipment for its implementation. Still, virtually all GPs use electronic patient records and transmit prescriptions electronically to pharmacies. HIT is also used for referrals, for communication with laboratories and radiology services, and for sick leave. Most GPs receive electronic discharge letters from hospitals. Where after-hours emergency care is organized within the same patient record network as primary care, patient histories remain available, and primary care providers are able to access information regarding emergency visits. All hospitals use electronic records.

The lack of standardized, structured electronic records in primary and secondary care precludes automatic data extraction, hence there is still insufficient data for quality improvement at local and national levels.

How are costs contained?

Central government sets an overall health budget annually, and municipalities and RHAs are responsible for maintaining their budgets. The drug pricing scheme aims to encourage the use of generic drugs. Cost-effectiveness is a criterion for getting on the blue list of drugs eligible for reimbursement, and there is a defined maximum price for drugs, linked to reference prices set at the average of the three lowest market prices for the drug in a defined group of Scandinavian and Western European countries. The Drug Procurement Cooperation has been effective in negotiating drug purchases and delivery jointly for the four RHAs.

GP gatekeeping for specialized services helps contain costs. There is very little competition regarding pricing within the health services. A small proportion of specialized care is privately provided by RHAs and contracted through tenders, for which price is one of several criteria.

The National System for the Introduction of New Health Technologies, established in 2014, makes decisions on whether to approve new, costly drugs or treatments, mainly on the basis of health technology assessments that address cost-effectiveness.

Norway’s number of hospital beds—four per 1,000 inhabitants in 2012—is low by comparison with the OECD-Europe mean of five.14 The low number can be attributed to policy: efforts to drive services toward outpatient and daycare settings and to make municipalities accountable for reducing the need for specialized hospital care. There is an ongoing debate about overdiagnosing and the use of procedures that are not evidence-based. Clinical guidelines and a published atlas of variation in frequency of some daytime surgical procedures (www.helseatlas.no) are the only measures taken to date to reduce “low-value” care. Although the Council on Priorities in Health Care has debated, for instance, about levels of end-of-life care and the use of intensive-care beds, no focused initiatives have resulted from the debates.

What major innovations and reforms have been introduced?

Municipality cofinancing of hospital care was abolished in 2015, as it was concluded that it did not have the intended effect of keeping patients out of the hospital.

The new Agency for Hospital Construction (Sykehusbygg HF) was established in November 2014. Owned by the RHAs, it will serve as a national center of competence for hospital planning and construction for all hospital trusts. There is no plan for evaluation.

The restructuring of the governmental health bureaucracy in 2016, with the integration of smaller agencies into the Institute for Public Health and the Directorate for Health, as well as the development of the new Directorate of eHealth, will continue in 2017 with the establishing of common information technology services for the governmental health bureaucracy through the National Health Network.

Acknowledgements

The author would like to acknowledge David Squires and Ånen Ringard as contributing authors to earlier versions of this profile.

References

1Please note that, throughout this profile, all figures in USD were converted from NOK at a rate of about NOK9.8 per USD, the purchasing power parity conversion rate for GDP in 2015 reported by OECD (2016) for Norway.

2“Norske kunder kjøper helseforsikring for 300 millioner mer enn I 2013,” Dagens medisin, Feb. 24, 2016.

3Helsedirektoratet, Fastlegestatistikken, 2016.

4Den norske legeforening, Legestatistikk, 2015; accessed Nov. 19, 2015.

5Helsedirektoratet, Fastlegestatistikken, 2016.

6Helsedirektoratet, Private aktører I spesialisthelsetjenesten, 2016.

7Helsedirektoratet, Private aktører I spesialisthelsetjenesten, 2016.

8Stortingsmelding 11 (2015–2016); Nasjonal helse-og sykehusplan (2016–2019).

9“Og bedre skal det bli—Nasjonal strategi for kvalitetsforbedring i sosial-og helsetjenesten 2005–2015.

10Sirona Health Solutions, Evaluering av kvalitetsbasert finansiering (KBF), 2015.

11Ministry of Health and Care Services, National Strategy to Reduce Social Inequalities in Health, Report No. 20 (Ministry of Health and Care Services, 2007).

12N. Ahlberg and S. Vangen, “Pregnancy and Birth in Multicultural Norway,” Tidskr Nor Legefor 125(5):586–88.

13Ministry of Health and Care Services, The Coordination Reform: Proper Treatment at the Right Place and Time, Report No. 47 (Ministry of Health and Care Services, 2009); Ministry of Health and Care Services, Helse-og omsorgstjenesteloven (New Law for Health and Care Services), 2011.

14

Organisation for Economic Co-operation and Development, Health at a Glance Europe 2014; accessed Nov. 19, 2015.