- Nordic Health Care Systems: Recent Reforms and Current Policy Challenges
Few areas of public policy are more important, extensive, or expensive than health. Even in the United States, where government health care issues have been controversial for more than a century, public expenditures on health care account, directly or indirectly, for half of the ever-rising total (currently about one-sixth of the economy). Given that publicly financed health care in the Nordic countries accounts for 80-85 percent of the total (and about 9 percent of gross domestic product), the sector is a core segment of Nordic public policy. This study collects the research of twenty-three experts, and its fifteen chapters give the reader a detailed comparative review of health policies in Denmark, Finland, Norway, and Sweden with a single chapter devoted to Iceland. It is part of the ongoing research by the European Observatory on Health Systems and Policies of the World Health Organization. The book is available online. There are frequent references and comparisons to other western European countries and more occasionally to the USA.
This is definitely a book for students of health policy and politics, but even non-policy "wonks" can learn how these countries manage to provide excellent health care to their entire population at a total relative cost nearly 40 percent less than the US system. Total expenditures are even [End Page 106] more modest in Scandinavia than most other universal access systems in western Europe and Canada. Although international health statistics are quite good and less subjective than most social indicators, there are some challenging measurement issues. For example, health and medical education and training costs are usually excluded from health sector costs. American health professionals must finance a large portion of their expensive education and pay for it out of future earnings. Scandinavian medical education is mostly covered by the government and paid through taxes. This reduces the specific costs that the health care system must finance. This issue is not discussed by any of the authors, but fiscal and cost-benefit concerns are.
Although the basic Nordic health care systems have been in place for a generation or longer, the past twenty years have seen some significant changes in management, financing, and organization. The trend has been to "squeeze" greater efficiency (i.e. effective health care) without increasing the relative size of the health care sector. No clear pattern emerges, although all of the countries have tried to use "market forces" to allocate resources and provide service more efficiently. Traditionally health care delivery (hospitals, rehabilitation, and primary care) was the responsibility of the counties except in Finland and Iceland where it was a municipal task. In Denmark and Norway, health policy management has been combined into "regions" with the national government providing substantial financial grants. In practice central government control has increased as the guidelines and financing are still made in the national capital. Even in Sweden and Finland, where structures have not been significantly altered, regional cooperation among hospitals and other health institutions has become the norm. At issue is the fate of "local" care with small hospitals closed or specialized, but group medical practices encouraged. As a Norwegian health administrator put it, "today it's quality of treatment, not localness of care" (85).
Most of the chapters discuss the"clients'" (i.e. patients) perspectives, who have a huge stake in the system because fully private care is still limited. Most primary care is provided by private physicians (and other medical professionals like dentists and physical therapists) but mainly financed by the national health system. Sweden had the smallest "private" sector, but over the past twenty years it has allowed and even in cases like Stockholm encouraged private medical practice—again with the public sector providing most of the funds. Private supplementary health insurance has appeared primarily in Denmark and Norway as non-socialist governments have tried to encourage more competition and private funding. Combined with these innovations is a growing responsiveness to client demands...