Current Challenges in Norwegian Health Care Policies

Ambassador, Excellencies, ladies and gentlemen,

Good afternoon. It is very nice to be here in Japan again. I have visited your beautiful country in the past and always found it one of the most fascinating countries in Asia. I am delighted by the invitation from the Norwegian Embassy to talk about the current challenges for me as Minister of Health.

There are three main issues I would like to address today: First, what are the Norwegian health priorities on the international arena? Secondly, what are the main features of the Norwegian health system? Finally I will talk about the key challenges of the Coordination Reform. This is a major new health reform that will be launched in Norway in April.

I have one central aim as Minister of Health. I want to improve coordination and cooperation between the different health service providers. This is the reason for my visit to Japan this time. I hope that by studying systems developed in Japan, both by your health providers and enterprises, I will gain new ideas and valuable input for my work in Norway. In other words I am here to learn from you!

Learning from other countries is one of the best ways to assess and improve your own system. Of course, Japan and Norway are very different countries – not least in size of population. But we do have our similarities. For instance, our life expectancy rates are quite similar. So is the health expenditure as a percent of GDP.

1. International health issues

But first of all, what do we in Norway regard as the most important challenges at the international level?  Improving health conditions globally is a key political objective for the Norwegian Government. Our Prime Minister, Mr Jens Stoltenberg, is actively engaged in promoting the Millennium Development Goals. Especially goals 4 and 5: to reduce child mortality and to improve maternal health. For example, we are contributing to the vaccination of thousands of children in developing countries such as India every year.

The international awareness of the link between health issues and international politics is increasing. Issues relating to global health and health security are gaining political momentum. This is very encouraging. Bioterrorism, communicable diseases such as AIDS and pandemics are now regarded as threats to our security. Ladies and gentlemen, Better Health must be taken seriously as an independent objective in international politics.

The work of the WHO is vitally important for us all.  I would especially draw your attention to: 

Pandemic Influenza preparedness. It is an ongoing process in the WHO in which Norway is heavily involved. It is in my view of great importance to ensure a timely and systematic sharing of virus samples between countries. This must be respected by all countries and continued efforts and political pressure must be made to resolve this issue.

Another issue of increasing importance - also for the developing countries - is non-communicable diseases (NCDs). Communicable diseases have traditionally contributed heavily to the burden of disease in both developed and developing countries.  Risk factors such as alcohol, tobacco, obesity and lack of physical activity increasingly contribute to the global burden of disease. I am as Minister for Health committed to the work of reducing the NCDs, both at a national and international level. 

A central task for the WHO in the years to come will therefore be to guide Member States to develop effective tools and measures to reduce diseases caused by life style. Smoking is a good example. The Framework Convention on Tobacco Control has inspired effective policies in a large number of member states. In Norway we have already - or will soon - introduce additional measures such as a smoking ban in public places and off the counter sales of tobacco. Many of these tools are also introduced in the European Union.    

Another important global issue is Social determinants of health. Good health is unevenly distributed among social groups in the population. The most privileged people, in economic terms, have the best health. We must take steps to make the distribution more fair.

Another serious issue is the health personnel crisis faced by many developing countries. According to the WHO there is a global lack/shortage of more than 4 million health workers. With changing demographics more health workers will be needed also in my own country. We must work together to meet this challenge.

We cannot solve such problems alone. We have to share our experience. For example, in 1997 the Prime Ministers of Japan and the Nordic countries established a project on care policies for the elderly. It was the start of a successful history of cooperation between us on this question. Since 1997 seven Japanese- Nordic seminars have been conducted. The Japanese – Nordic cooperation has been a fruitful source for developing new thoughts, ideas and measures.

2. The Norwegian health system
Let me turn now to my second question: what are the main features of the Norwegian health system?

Public health services in Norway are financed by taxation. Our health service is designed to be equally accessible to all residents, regardless of social or economic status. With its 220 000 employees, the public health sector is one of the largest service providers in Norway. Our health care system is mainly organised as a two-tier system. The responsibility is clearly divided between the municipalities and the state:

The Municipalities are responsible for all primary health services. This includes the promotion of health and prevention of illness and injuries as well as diagnosis, treatment and rehabilitation. Nursing care within and outside institutions is the responsibility of the municipalities. So is the general practitioners scheme where all inhabitants in the municipality have the right to a general practitioner.

The state is responsible for the running of all specialist health services, including the somatic and psychiatric hospitals. The state has organised the specialised health service in four regions. Each region has an enterprise owned fully by the state. The regional health enterprises own the hospitals. They are responsible for providing specialised health care to the inhabitants in the region. The organisation into enterprises means that we use organisational tools from the private sector and add elements from traditional public governance to operate our welfare policy.
 
Patients in Norway have a legal right to health care. The Patients’ Rights Act guarantees the patient’s right to care and regulates the relationship between the patient and the health service. Patients are entitled to information, a second opinion and free choice of hospitals. There is a system for complaints and there is a Patients’ Ombudsman in each county. When patients suffer economic loss as a consequence of medical errors a public system ensures that they are awarded compensation. 

3. The Coordination Reform

In a global context Norway may appear then to have a very good health system. But it is far from perfect. That is why I have started the work with a new reform.

So; what is the problem?

We are among the countries spending the most on health and social services in the world. One fourth of our national budget is spent on health. Our hospital budget has doubled over the last 7 years. However, we do not get enough health care in return. The analysis is simple; how do we get more health for the money we spend?

In my view there is a serious lack of coordination between hospitals and primary health care. There is a lack of coordination in all segments of the health care services. There is insufficient contact between municipalities and the hospitals; between the municipalities; within the municipalities; and within the hospitals. This needs to be addressed. The reform aims to address three challenges:
Firstly; what financial measures may be taken to facilitate coordination between the hospitals and the municipalities?
 Secondly; what legal measures may be taken?
 Thirdly: How can technology improve the coordination?

Most importantly, it is the patients who lose out. What changes are needed to get good coordination that will benefit the patient? They do not get the services they need. The lack of coordination results in long waiting times. Patients are shunted about in the system. They do not receive the necessary rehabilitation. This leads to sicker patients and slower recovery. As a result the patients require even more health care.  

Our population is getting older. In the year 2040 the percentage of people over 80 will double. I am sure you are facing the same challenge in Japan. And please don’t misunderstand me, it is positive that we are living longer. High life expectancy implies that we have good health and a well-functioning welfare system. Still, an aging population will require more health services.

The burden of disease is changing. The number of patients with chronic diseases is rapidly increasing. More people have mental problems. Obesity is increasing. The number of diabetes patients has increased. For example; the number of patients receiving dialysis has increased by 7 per cent from 2006 to 2007.

If you look at this slide you find an overview of the course and costs related to diabetes type 2. The slide shows that the highest amount of resources have to be spent at an early stage. As you see more efforts need to be done to prevent diabetes. Also guidance to patients diagnosed with diabetes is key to reducing the costs. Not only does this benefit the patient, it also reduces costs and beds. In order to achieve this I believe we have to strengthen the primary health care sector. Incentives for better prevention are needed.  

Let me give you another example of what can be done: As I said earlier it is the patients who lose out. They are not getting the necessary treatment at the right level. Too many are hospitalised because they do not get treatment at local level. This is expensive and does not benefit the patients.

In a small place in Norway called Søbstad, there is established a “health-house”. When patients are discharged from hospital they receive after-treatment at the “health-house”. These patients are still in need of medical assistance. But, they do not need to be hospitalised. After a couple of weeks at Søbstad the patients may go home. An evaluation shows that compared with traditional hospitalisation that;
Firstly, fewer patients admitted to Søbstad needed readmission/further treament
Secondly, after being discharged most of them managed at home without assistance
Third, the mortality rate after 6 and 12 months decreased
Fourth, the treatment was cost-effective.

The task I have undertaken is not easy. But I believe we will succeed. I will present my proposal for reform in April this year.

I look forward to learning from your experiences. As I like to say: the best knowledge is shared knowledge. Thank you all for listening. I now look forward to hearing your thoughts and questions.

Thank you.