Country and population

Norway is located in northern Europe, bordering the North Sea and the North Atlantic Ocean, sharing physical borders with Sweden, Finland and Russia.

The climate is temperate along the coast, modified by the North Atlantic current; it is colder towards the interior. Its 4.8 million inhabitants live in a total land area of 386 958 km², which averages out at 15 people per km². This makes Norway one of the most sparsely populated countries in Europe.

Population growth in 2009 was 1.2%, and the fertility rate was 1.98 births per woman (Statistics Norway, 2010c). The tendency of people to move from the north and west to the more densely populated areas of the south-east is stable (Statistics Norway, 2010c). The average age of the population is 39 years; 25.5% of the population are below 20 years of age, 61.5% are between 20 and 66 years, and 13% are older than 66. Also in Norway there is an ageing population. In 2002 0.6 million people were over 67 years, in 2050 it is estimated there will be between 1.1 and 1.4 million people over 67 years old (Statistics Norway, 2010c).

Development and economy

Norway is a constitutional monarchy, in which a hereditary monarch is head of state and the Prime Minister head of government. The Parliament has 169 seats and general elections are held every four years.

In 2009 the GDP per capita in Norway was NOK 493 032 (€62 043), that is 78% above the average of the 27 EU countries. In the EU, only Luxembourg comes above Norway in this respect.

In 2009 43.3% of the population over 16 years of age have completed their secondary level education and 26.7% have education at tertiary level. Unemployment was 3.2% (Folkehelseinstituttet, 2010a).

Population health

Life expectancy for women is 83 years, and for men 78.5 (Statistics Norway, 2010c). The infant mortality rate is 3.7 per 1000 live births (2008). Leading causes of death in 2008 are circulatory disease 34%, cancer 25.5% and respiratory disease 9.6% (Statistics Norway, 2010c).

Characteristics of the health care system

Following hospital reform in 2001, the system in Norway changed from a decentralized to semi-centralized national health service model. Before 2001, the counties owned hospitals. In 2001 the state took over the hospitals but established the regional health authorities as enterprises that deliver specialized health services. The organization of the regional health authorities and health enterprises is unique to Norway. The regions have two roles, the authority role and the enterprise role. In their principal role regions have a “care role” in providing the population with specialized health care services; the other is as a supplier and producer of specialized health care, since regions own the health enterprises. During the last three decades Norway has developed enterprises that enjoy an element of freedom similar to that seen in the private sector, although the state has built-in directing/ steering and control mechanisms in the organization, in other words an “in between solution”. Consequently, the responsibility for primary care and secondary care has been divided between different governmental levels. The regional health authorities are responsible for specialized health care, while the municipalities are responsible for primary health care.

Health care expenditure as percentage of GDP is a little bit above the European average. Norway has half the number of hospital beds per 100 000 inhabitants. Despite this, the number of acute care admissions is comparable to the European average, but length of stay is shorter (see Table A21.1).

Table A21.1

Development of health care resources and utilization.

2.1. Primary care governance

The organizational structure of the Norwegian health care system is built on the principle of equal access to services, independent of social status, location and income. While the role of the state is to provide national health policy, to prepare and oversee legislation and to allocate funds, the main responsibility for the provision of health care services lies with the four health regional authorities and the 431 municipalities. The municipalities are responsible for primary care. The aim of primary care is to improve the general health of the population, and to treat diseases and deal with health problems that do not require hospitalization. This includes both preventive and curative treatment such as:

• promotion of health and prevention of illness and injuries, including organizing and running school health services, health centres, child health care provided by health visitors, midwives and physicians, pregnancy check-ups and vaccinations according to the recommended immunization programmes;
• diagnosis, treatment and rehabilitation, including responsibility for general medical treatment (including emergency services), physiotherapy and nursing;
• nursing care in and outside institutions. Municipalities are responsible for running nursing homes, home nursing services and home help services.

Contracts between municipalities and private providers are a very important tool in guaranteeing good quality for service users and also in securing good cooperation with other parts of the health system. The municipalities have a contractual relationship with GPs, who are part of the national regular GPs scheme. These contracts regulate the relationship between the GP and the municipality. For instance, the municipality has the right to order the GP to do municipality health care work (a maximum of 7.5 hours a week), if this is specified in the agreement. In 2006, 99% of the population is registered on the regular general practice scheme, a list system which aims to strengthen the patient–physician relationship by giving the patient the right to choose a regular GP.

GPs work as gatekeepers for specialized health services. That is, if such services are needed, the GP has to send a referral to a hospital, or a private practice specialist. Within the limits of legislation and available economic resources, the regional health authorities and municipalities are formally free to plan and run public health services as they like. However, in practice, their freedom to act independently is limited by available resources.

Although municipalities are responsible for primary care services, the central government has five central public health institutions, which are professional and administrative bodies under the authority of the Ministry of Health and Care Services. First, there is the Norwegian Directorate for Health, which is a professional body within the field of health and social affairs and has legal authority within its field. The Directorate monitors trends in health and care services. The Directorate also contributes to the implementation of national policy within health and sets national standards of behaviour in certain areas (Ministry of Health and Care Services, 2011). Second, there is Board of Health, a national supervisory authority with responsibility for general supervision of health and social services. It ensures that services are run in accordance with professional standards. Third, there is National Institute for Public Health, which is a national centre for health monitoring and for expert knowledge of epidemiology, infectious disease control, environmental medicine, forensic toxicology and drug abuse. Therefore it can be argued that, although central government is passing governance to local authorities, it continues to control the health care services through instructions, directives, guidelines, legislation, budgeting and financial incentives imposed by different central government bodies.

2.2. Economic conditions of primary care

Municipalities’ gross expenditure on health services reached nearly NOK 10.5 billion (€1.18 billion) in 2009 – an increase of almost NOK 680 million (€76 million) from 2008, which is equivalent to an increase of almost 7%. The expenditure includes wage costs, per capita grants to private physicians and physiotherapists, expenditure on health centre services and preventive health care. The increase is equivalent to approximately NOK 2160 (€242) per inhabitant (Statistics Norway, 2010a).

In 2008, primary care takes up 5.8% of total health expenditure (Helsedirektoratet, 2010). The population is fully covered by public health insurance for general practice services. However, there are out-of-pocket expenses for most health services, but if annual expenses for any health services exceed a certain level, all services above this threshold will be covered by the national insurance. This expenditure ceiling does not depend on income.

In 2006, co-payment for general practice services was NOK 1.24 billion (€0.16 billion). This was 32.4% of total financing of GPs. The co-payment was covered by the national insurance for 40% of consultations. The proportion of GPs who are salaried with national or local authorities is 7% and 93% are self-employed with contracts with local health authorities (municipalities). They are paid a mix of capitation fees, fee-for-service payments and co-payments from the patient. A rough estimate of the average mid-career income of GPs is around €100 000 to €130 000. Other staff within primary care, like nurses, midwifes and physiotherapists are paid fixed salaries by the municipalities.

2.3. Primary care workforce development

Nurses and GPs are the core of primary care. The White Paper The collaboration reform (Norwegian Ministry of Health and Care Service, 2010) aims to strengthen primary care to handle more health care services: tasks which are within specialized health care today should be transferred to primary care. Besides, GPs should also have more focus on chronic care and illness prevention. Hence more and also other groups of health personnel will be needed, such as specially trained nurses, physiotherapists, social workers, health educationists (a proposed new work group whose focus is to empower patients to take better care and live with chronically diseases). It will require much more teamwork and collaboration than there is today.

In 2005, there were 45 GPs per 100 000 population, whereas the total number of physicians was 362 per 100 000. The supply of GPs increased from 43 per 100 000 in 2003, to 48 GPs per 100 000 inhabitants (see Fig. A21.1). The number of physicians and physiotherapists is also increasing. A total of 104 new physician man-years were added from 2008 to 2009, attaining coverage of physicians at 9.5 per 10 000 inhabitants. Sixty new physiotherapist man-years were added from 2008 to 2009, reaching a coverage of physiotherapists at 8.7 per 10 000 inhabitants, which is the same coverage as in 2008. The number of nurses increased from 14 103 in 2003 to 18 514 in 2008 (Statistics Norway, 2010a).

Fig. A21.1

The development in supply of primary care professionals per 100 000 inhabitants in the most recent available five-year period.

3.1. Access to primary care services

The regular GPs scheme from 2001 intended to improve quality and access to primary care. Patients have the right to choose a GP to strengthen the relationship between GP and patient. Patients can change their GP only twice a year. There is a registration system through which the patients sign up with a physician; 99% of the population is included in this system which gives each GP an average of 1219 persons on their list (2007), however this may vary a considerably. In 2006, 71% of the population visited their GP on average 2.5 times for curative purposes (see Fig. A21.2). When telephone contacts are included, the figure is 2.9 times. Statistics Norway (Brøyn, Kvalstad & Skretting Lunde, 2007) reports that there are 4.6 contacts with general practice per person per year overall, and 2.2 consultations (face to face) per person per year overall.

Fig. A21.2

Number of consultations (incl. home visits) in 2006 per habitant by age and sex (blue bars women, red bars men). Source: Nossen, 2007: Fig. 8.

The Act of Municipality Health Services requires GPs to have an emergency service to cover out-of-hours medical care. This is mostly arranged as one emergency service in each municipality and covered by the GPs in this municipality. In addition to the numbers above, there were 300 consultations per 1000 inhabitants in the emergency service, and 440 consultations by contracting specialists.

3.2. Continuity of primary care services

As stated above, the regular GP scheme intended to improve continuity of primary care, especially for elderly people and for the chronically ill. Patients seems to be satisfied with this arrangement as 94% state that they are satisfied with their relation with their primary care physician (Godager, Iversen & Lurås, 2007).

All physicians in primary care keep records of their patients; 98% have an electronic patient record. Due to Norwegian regulations, the record cannot be shared with other health personnel, even if GPs work in a group in shared premises, and stand in for one another. Also the nursing services keep their own records, which can lead to the patient having a different medication list with the physician and with the nursing service, for example. Obtaining the necessary information when needed is thus very challenging, and also some of the background for the White Paper “The collaboration reform”. The Norwegian Health ministry has put strong emphasis on developing electronic messaging (Sosial – og helsedepartementet, 1996).

3.3. Co-ordination of primary care services

Access to specialist services requires referral from a GP. The patient can also go to a contracted specialist directly, but then the patient has to pay for the whole consultation out of pocket; there will be no reimbursement from the national health insurance. The GP receives discharge letters from hospitals electronically and is in many cases responsible for follow-ups, but not from private practising specialists with contracts with the regional health enterprise. Municipality nursing services usually coordinate the services for patients’ home care. They contact the patient’s GP when there is a need for consultation or referral to specialist services. They also receive discharge letters from the hospitals.

There seem to be no institutionalized meetings between the different professionals within primary care.

3.4. Comprehensiveness of primary care services

Table A21.2 provides an overview of the GPs’ involvement in delivery of various primary care services. Pregnancy care is performed both by GPs and midwives. GPs should do some consultations during pregnancy, but midwives do most of them. Midwives also offer birth-preparing courses.

Table A21.2

GPs’ involvement in delivery of various primary care services.

Public nurses follow children from birth through the national programme of vaccination and regular health check-ups up to the age of 12. There are also public nursing services in schools, offering consultations for pupils. Much of their work is directed towards giving advice on smoking, alcohol and drug misuse prevention, and contraception issues. An important function is also being a conversation partner for youngsters finding their identity.

General nursing services are a right for all inhabitants in a municipality. Besides nursing homes, the nursing services comprise home care services for those in need.

GPs offer the first contact point for all adults and children when they are in need of health services. The practices are well equipped to perform diagnostic investigations, follow-up treatment and minor surgery. The most commonly used ICPC-2 code is on muscular/skeleton diseases, heart and circulatory diseases and airways/ pulmonary diseases, in this order. Together these account for 46% of consultations. In the emergency services, the most commonly used ICPC-2 code is airway/ pulmonary diseases (Nossen, 2007).

4.1. Quality of primary care

The average number of prescriptions annually provided by GPs per 1000 contacts is 695 (2009, see Table A21.3). Use of antimicrobials for systemic use expressed in DDD/1000 inh/day in ambulatory care: 14.65 (2007) (ESAC, 2010).

Table A21.3

Average number of prescriptions by GPs per 1000 contacts by age in 2009*.

Nearly 140 000 people use medicines for diabetes in Norway today. However, we do not know how many actual diabetes cases there are as some are undiagnosed or managed through exercise and diet control. Figures from the Norwegian Prescription Database show that the number of users of diabetes tablets increased from 79 000 in 2004 to 105 000 in 2008; the increase was largest among the elderly (Norwegian Institute of Public Health, 2010).

An increase in the number of users can be due to longer life expectancy and because more people are diagnosed with the disease. It appears that more people with type II diabetes are receiving medicinal treatment, and that they are receiving more intensive treatment than previously. The risk for diabetes also increases with age. Among 60 – and 75-year-olds approximately 5% and 10% respectively have diabetes (Norwegian Institute of Public Health, 2010).

There is no good data for inappropriate hospital admissions in Norway. In a study from 1999 24% of admissions to an internal medicine department for a six-week period were judged by an expert panel to be inappropriate (Eriksen et al., 1999). Fig. A21.3 shows relatively high hospital admission for patients with some chronic diseases (Statistics Norway, 2010b).

Fig. A21.3

Number of hospital admissions per 100 000 population with a primary care sensitive diagnosis in most recent year. Source: Statistics Norway, 2010b.

The immunization programme for children ensures that 92% of all infants are vaccinated against diphtheria, tetanus, pertussis, measles, mumps and rubella. For hepatitis B there is no data, as this is not part of a national vaccination programme. Only those in “high-risk groups” (health personnel, drug abusers, immigrants from parts of the world where this is considered a threat) are offered the vaccine.

4.2. Efficiency of primary care

In 2006 there were approximately 11.6 million consultations by GPs. Of these less than 100 000 were home visits, that is 0–1%. There is poor data on the length of consultations, but a standard consultation is estimated and planned in schedules as 20 minutes.

The number of GP consultations per capita per year is 2.2 in 2005 (and 4.6 contacts per person per year). Average number of patient consultations per week is 81 in 2005. Average percentage of working hours spent on direct patient care is 67 in 2005 (Faber, Voerman & Grol, 2009).