5. Provision of services
- The overall responsibility for public health rests with the MOHCS, while the municipalities are responsible for implementing cross-sectoral public health interventions locally. Various governmental and nongovernmental actors are involved in public health activities. The Public Health Act (2012) improved horizontal and vertical coordination of public health work. In 2015 the government presented a white paper with a comprehensive overview of public health initiatives, including incorporation of mental health as an integral part of public health.
- Primary care is provided at the municipal level, mostly by self-employed physicians and as part of municipal services (in nursing homes and as part of home-based services). GPs act as gatekeepers, referring patients to more complex care. Inpatient specialized care is mainly provided by hospital trusts owned by the RHAs. Hospitals also provide outpatient specialist care in their outpatient departments. As in many other countries, there has been a marked shift from inpatient hospital care into outpatient and day surgery and care settings, as well as an expansion of home care. Delivery of primary care through multidisciplinary teams is currently being tested alongside new primary care financing models. Policy efforts have also aimed at improving coordination between municipal and specialist care.
- Emergency care services are largely the responsibility of municipalities at the primary care level, and are provided by GPs or local emergency centres, which are a first point of contact in case of medical emergency. Referral from a physician or the ambulance service is needed to attend hospital accident and emergency (A&E) departments.
- Access to pharmaceuticals, including innovative therapies, is generally good in Norway. Generic substitution, introduced in 2001, has led to substantial reductions in the cost of pharmaceuticals financed through the NIS. The share of generics in 2018 accounted for 52% of total sales volume – more than double what it was in 2001.
More than a quarter of spending on health in Norway is devoted to LTC. It is provided in three types of settings: patients’ homes, nursing homes or sheltered homes run by the municipalities. With the exception of home care, LTC in municipal settings requires substantial co-payments by users.
- Specialized mental health services are the responsibility of the RHAs and are provided in highly specialized mental health hospitals/departments, community mental health centres and in outpatient settings. Mental health centres play an increasing role in the decentralization of mental health services, as they provide acute mental health treatment and rehabilitation, and offer supervision and support for other providers in primary care.
5.1 Public health
The overall responsibility for public health rests with the MOHCS, while the municipalities are responsible for implementing cross-sectoral public health interventions locally and ensure that they are knowledge-based, systematic and long-term orientated. Various governmental and nongovernmental actors are involved in public health activities. The Directorate of Health, the NIPH and the Board of Health (see section 2.1) all play important roles in supporting the implementation and monitoring of public health policies at the national level.
The Public Health Act introduced on 1 January 2012 aimed to improve coordination of public health work horizontally, across various sectors and actors, and vertically, between authorities at the local, regional and national levels. The Public Health Act is based on five guiding principles for public health work: equity, Health in All Policies, sustainable development, precaution and participation, which were further elaborated in the White Paper “Public Health Report: Good health – a common responsibility” (Norwegian Ministry of Health and Care Services, 2013). The strategic goals included in the White Paper are to increase life expectancy, ensure more years of good health and well-being for the entire population, reduce social inequalities in health, and create a society that promotes good health throughout the entire population. These goals were also embraced by the next government in their White Paper entitled “Public Health Report – Accomplishments and possibilities” (Norwegian Ministry of Health and Care Services, 2015c). This updated public health strategy emphasizes promotion of mental health measures, especially targeted at young people, reducing work absenteeism, promoting healthy lifestyles, active ageing, and empowering children and young people, as well as improving cross-sectoral cooperation in public health. These goals are detailed and operationalized in a number of strategies and national action plans, including:
- #Youth Health – the Norwegian government’s strategy for youth health 2016–2021, which is the first national youth health strategy in Norway and emphasizes the impact social media has on body image;
- the National Action Plan for a Healthier Diet (2017–2021);
- the National Action Plan for Diabetes (2017–2021);
- the National Brain Health Strategy (2018–2024);
- Dementia Plan (2020);
- “A tobacco-free future” – the National Strategy for Tobacco Control (2013–2016);
- Action Plan for Prevention of Suicide and Self-harm (2014–2017); and
- More Years – More Opportunities (2016), which is a national strategy to make society more age-friendly, and to better harness the resources offered by older people in terms of participation and contribution to society.
Public health is an integrated part of the Strategy for Good Mental Health (2017–2022) and the Action Plan for Mental Health in Children and Adolescents (2019–2024). In addition, the Action Plan for Prevention of Suicide and Self-Harm (2014–2017) is envisaged to be followed by a new action plan for prevention of suicide in the general population as well as in the health services in 2020.
An assessment of the effectiveness of public health interventions is provided in Box5.1.
While counties play an important coordinating role (see section 2.2), public health activities are mainly carried out at the municipal level. Counties are expected to have an overview of the health status in their territory, including risk factors as well as factors that influence health positively. Municipalities are expected to monitor the health status of their population and factors that may influence this; such information provides the basis for planning their local public health strategies. Municipal public health activities include promotion of the population’s health and well-being; prevention of mental and somatic illnesses, disorders and injuries; and ensuring good social and environmental conditions. The actual provision of services is carried out by GPs, the Municipal Medical Officers (one in each municipality), at municipal health care centres/clinics, in school health services and nursing homes, etc. The municipalities are also responsible for facilitating cooperation with the voluntary sector (Public Health Care Act 2012 4).
Immunizations and other preventive services
Municipalities are responsible for delivering vaccines included in the Norwegian Childhood Immunization Programme. The Programme began in 1952 and currently offers free childhood vaccinations against 13 different diseases: measles, mumps and rubella (MMR), diphtheria, tetanus, whooping cough, Haemophilus influenzae type B (Hib), pneumococcal disease, poliomyelitis, rotavirus, hepatitis B, and human papillomavirus (HPV). Some children are also offered vaccination against tuberculosis. Children usually receive their first vaccinations at 3 months and follow the programme until they are 15 or 16 years old. Booster doses of vaccines are administered once school age is reached. Vaccination is not compulsory, but coverage is well above 90% for most of the vaccines included in the programme (Norwegian Institute of Public Health, 2017b). The rubella vaccine for adults is offered free of charge to women of childbearing age who do not have immunity against rubella. Influenza and pneumococcal vaccines are recommended to risk groups, including pregnant women and people over 65 years old. Vaccines are mainly provided by GPs and are subject to co-payment.
Municipalities are also responsible for providing family planning and antenatal services. The services are provided either by a midwife at the local Maternity and Child Health Care Centre (helsestasjon) or by the regular GP. This normally includes eight antenatal appointments, including one ultrasound screening during pregnancy. The consultations are free of charge, and working women who are pregnant have the right to paid time off work for attending antenatal appointments.
Since 1996 Healthy Life Centres (HLCs) have been established in the municipalities offering interdisciplinary primary care services such as exercise groups and counselling for people who need support in changing their health behaviour or coping with health problems and chronic diseases. While there is no statutory obligation for a municipality to establish HLCs, the Directorate of Health recommends that all municipalities create one in order to manage the preventive health services they provide (Saunes, 2016a). In 2018, 64% of the municipalities had an HLC (Statistics Norway, 2019a).
Norway has three national cancer screening programmes. Two of them, for breast cancer for women aged 50–59 and for cervical cancer for women aged 25–69, have been in place since 1995, while the third one, for colorectal cancer, is currently being piloted for men and women aged 50–74. From the autumn of 2019 men and women turning 55 years of age will be invited to participate in the screening programme and national coverage is expected to be reached in 2024. The screening programmes are all administered by the Cancer Registry of Norway.
Surveillance of communicable diseases
The NIPH runs the Norwegian Surveillance System for Communicable Diseases (Meldingssystem for smittsomme sykdommer, MSIS) and contributes to international surveillance in collaboration with the European Centre for Disease Prevention and Control and the World Health Organization. The MSIS distinguishes between three groups of diseases. Reports on group A diseases (e.g. cholera, hepatitis) from medical microbiological laboratories and doctors are sent to the NIPH immediately after detection with full patient identity. Copies of the notifications are also sent to the Municipality Medical Officer in the patient’s municipality of residence. For group B diseases (gonorrhoea, HIV and syphilis), reports are also sent immediately to the NIPH by doctors and medical microbiological laboratories, but the patient’s identity is not disclosed. Copies of the notifications are also sent to the Municipality Medical Officer in the patient’s municipality of residence. For group C diseases (genital chlamydia and clostridium difficile) reports also do not disclose the patient’s identity but they are not sent immediately. Early warning notification (i.e. immediate notification outside the regular written notification system) is required in isolated cases of selected group A diseases, such as rabies and rubella. The warning must be delivered to the local Municipality Medical Officer, who will then immediately notify the NIPH and the County Physician. This applies both within and outside the hospital settings. If there is a suspicion or confirmation of an infectious disease that can be transmitted in food or water, the Municipality Medical Officer must also notify the local Food Safety Agency.
Occupational health services
According to the Working Environment Act 2005, which regulates occupational health, employers are responsible for ensuring that health and safety standards are met in workplaces and must have written objectives for health, environment and safety activities. Implementation of this Act is monitored by the Norwegian Labour Inspection Authority under the Ministry of Labour and Social Affairs. The Labour Authority has seven regional offices and 16 local offices around the country. The latter guide and supervise individual employers in local communities and oversee that they comply with the legal requirements (Norwegian Labour Inspection Authority, 2018).
Norway has the highest rate of work absences of full-time employees among OECD countries (see section 1.4). A series of inclusive workplace agreements between employers, employees and the NAV have been in place since the early 2000s in order to reduce work absenteeism due to sickness; to increase the employment rate among employees with functional impairment; and to increase the actual retirement age. The current agreement covers the period from 1 January 2019 to 31 December 2022. Employees of companies that have signed the agreement have the right to take sick leave without a physician’s certificate for up to eight calendar days per single absence, up to a total of 24 days per calendar year. Occupational health services provided by the workplace to help bring employees on prolonged sick leave back to work and get them off disability benefits may be refunded at a special rate under the NIS. The employment rate among employees with a functional impairment was 44% in 2018 compared to 70.4% for the population between 15 and 66 years of age (Statistics Norway, 2019a). A report documenting goal attainment for the inclusive workplace agreement from 2012 to 2018 documented rather stable levels of sickness absenteeism and employment rate of people with functional impairment, while there has been an increase in the actual retirement age (Telle et al., 2018).