Local Healthcare Provision in Norway –
An Expression of Applied Democracy
Eberhard ‘Paddy’ Bort looks at how Norway organises its healthcare and some possible lessons for Scotland
Extracted from an original journal and re-produced here because of the inability to link directly to it..
Original article included here.. http://www.shascotland.org/healthier%20scotland%20journal%20mar12.pdf
The Scottish Local Government elections loom, but are we, apart from the big cities, actually electing any ‘local’ governments? Highland council has the size of Belgium, but the population of Belfast. Distances are huge. ‘Local’ may actually contravene against the trade description act. And yet, we are talking about further centralisation. Why 32 councils? Would not 15 suffice? Or even fewer? All in the name of efficiency and cost-cutting.
But there are other ways to organise local democracy. We only have to look beyond our borders. Let’s take Norway – roughly the same population as Scotland – but with 434 municipalities. The average Scottish council serves 162,500 people; the average Norwegian municipality has 12,500 (Riddoch, 2010). Elected for a period of four years, are the foundation of Norwegian democracy.
For decades, the devolution of central powers to local governments aimed to focus as much as possible on the municipal level. The philosophy behind this was that decentralisation is an expression of applied democracy, that it brings decision-making closer to those who are affected and promotes popular participation in local political affairs. Moreover, it was believed that delegation of authority usually leads to simplification of administrative procedures (WHO, 2000).
Take health – the Ministry of Health and Care in Oslo (the national level) has overall responsibility for the health and wellbeing of Norway’s citizens. Among the reserved matters are university education and research, for health and other registries, and for institutions like the National Institute of Public Health and the National Board of Health. Healthier Scotland – The Journal: March 2012 Page 13
The hospital reform in 2002 meant a state takeover of ownership of hospitals – formerly owned, run and financed by the regional councils, which are still responsible for specialised outpatient care, and pharmacies – and the establishment of local and regional healthcare enterprises (Hagen and Kaarbøe, 2004). The stated purpose of the reform was to transfer power to govern the daily affairs of hospitals from local politicians to local managers and professional boards, while at the same time strengthening the capacities of the central government to establish principles for hospital governance in its capacities as owner of hospitals (Byrkjeflot, 2005).
The Norwegian public health service is mainly financed through contributions to the Norwegian National Insurance Scheme (NIS), generated through taxation and supported by state grants and some user charges. The funds allocated to the 19 regions of Norway are administered by regional councils; the municipalities have the ability to raise additional funds for primary healthcare by way of local taxes. They also collect a small amount of finance by way of user charges.
Initially, counties and municipalities received earmarked block grants for each type of service. From 1986 onwards, however, under the block grant scheme, municipalities were allowed to prioritise different types of services. By giving local authorities both the autonomy to set the level of service provision and the economic means to provide the services, the aim was that this decentralised model would provide a more efficient service provision and serve local needs better than a centralised model. That is why the Norwegian law leaves a large mandate for local health care services to take part in shaping the local social structure (WHO, 2000).
The Local Authority Health Care Act defines the responsibilities of the primary health care services and patient rights. All citizens have the right to satisfactory health care, accessible in their local community. At the regional level, there are five regional health authorities, responsible for universal and equal healthcare standards as set by the Ministry, and implemented by the regional councils.
The responsibility for primary healthcare is devolved to the municipalities. These cover health promotion, primary health care, care of the elderly, care of the handicapped and mentally handicapped, kindergarten and primary school education, social work (child protection and social protection), water, local culture, local planning, and local infrastructure.
Generally speaking, each municipality has three administrative departments: for medical care; nursing and home care; and social welfare. Many of the medical services are located in health centres, often including physicians in joint practice. The welfare service responsibilities of local authorities are so huge that some scholars suggest we should use the expression ‘welfare municipality’ rather than ‘welfare state’ (Overbye et al, 2006). Local authorities account for the lion’s share of public expenditure and public employment in Norway’s ‘local welfare state’ (Rose and Stålberg, 2005). This still holds true, despite some moves in recent years away from welfare localism to direct state involvement in governance of healthcare institutions (Overbye et al, 2006).
So, let’s look beyond the local elections of May 2012 and, if needs be, beyond our borders, if we’re short of inspiration. Scotland’s ‘local’ government is anything but local. Decisions are taken far away from the citizens affected by them, and democratic participation is severely limited.
In the last local elections in Norway in September 2011, 10,7812 councillors and 787 county councillors were elected – Scotland has 1241. In Norway one out of 800 citizens is an elected member of local or regional government – in Scotland the ratio is 1 : 4,000. Norwegian local councils raise 40% of their revenue, Scottish councils 20% – and they are further curtailed in their power by the ongoing council tax freeze. Turnout in Norway was 63.6% – will we get more than 30% in May? Healthier Scotland – The Journal: March 2012 Page 14
Empowered and truly local government would mean seeing citizens not as mere customers, but as actively shaping – and sharing ownership in – their local communities and local services. Let’s be guided by the late Campbell Christie’s demand that “reforms must aim to empower individuals and communities receiving public services by involving them in the design and delivery of the services they use.”
Eberhard ‘Paddy’ Bort is the Academic Coordinator of the Institute of Governance and a Lecturer in Politics at the University of Edinburgh.
Haldor Byrkjeflot, The Rise of a Healthcare State? Recent Healthcare Reforms in Norway, (Working Paper 15), Bergen: Stein Rokkan Centre For Social Studies, University of Bergen, 2005.
Campbell Christie, ‘Foreword’, Report on the Future Delivery of Public Services by the Commission chaired by Dr Campbell Christie, Edinburgh, 2011, http://www.scotland.gov.uk/Publications/2011/06/27154527/1
Terje P. Hagen and Oddvar M. Kaarbøe, The Norwegian Hospital Reform of 2002: Central government takes over ownership of public hospitals, Department of Health Management and Health Economics and Health Organization Research Norway (HORN), University of Oslo, 2004.
Einar Overbye, Signy Vabo and Knut Wedde, Rescaling Social Welfare Policies in Norway, Oslo University College, 2006.
Lesley Riddoch, ‘Mini-councils will energise Scotland’s communities’, The Scotsman, 26 June 2010.
Lawrence E Rose and Krister Stâhlberg, ‘The Nordic Countries: still the “promised land”?’, in Bas Denters and Larence E Rose (eds), Comparing Local Governance: Trends and Developments, Palgrave Macmillan, 2005, pp.83-99.
WHO Europe/European Observatory on Health Care Systems, Health Care Systems in Transition: Norway, 2000, http://www.euro.who.int/__data/assets/pdf_file/0010/95149/E68950.pdf