Iceland’s triple whammy
Despite financial constraints and recent woes, the land of volcanoes remains solidly committed to its state healthcare system. Roger St Pierre explains how it all works for locals and visitors
First published in ITIJ 121, February 2011
Despite financial constraints and recent woes, the land of volcanoes remains solidly committed to its state healthcare system. Roger St Pierre explains how it all works for locals and visitors
Socially, economically and ecologically, Icelanders have been enduring a rollercoaster ride of late. DNA testing produced the shock conclusion that most of Iceland’s 305,000 population is actually of Celtic rather than Viking stock as the island’s firmly Nordic culture had always seemed to indicate. Then, after an unprecedented period of boom, the banks collapsed and the country went bust – or would have done had it been possible for a country to shut up shop and actually go bankrupt. Adding to all this gloom, came the volcanic ash cloud that spewed from the eruption of Eyjafjallajökull – an awesome display of the power of nature that cast a pall across Northern Europe and brought an entire continent’s air traffic to a halt for days. Even the country’s iconic healthcare system has been feeling the tremors of late, with strong calls for cost reduction; though the Heilbrigdisráduneyti – that’s the Ministry of Health to you and I – seems determinedly committed to socialised medicine, while the private health sector remains in its infant stages and is at present only active around the periphery. That said, standards of care of an international standard, and facilities exist to treat almost any medical condition: even access to care is fairly good.
Competition calls
Despite all the massive pressures on public finance, the country’s per capita expenditure on healthcare has risen more than in the other OECD countries (exceeding that organisation’s benchmark by more than 40 per cent), and this growth has exceeded that of Iceland’s per capita income by an even higher margin. Predictions are that, because of the dual pressures of population ageing and rising medical costs, Iceland’s spending on public healthcare could well exceed 15 per cent of GDP by 2050. There is a worthwhile payback for all this investment though: At 83 years (at birth) for women and 79.6 for men, life expectancy is the highest in the world for men and among the highest for women. Perinatal and infant mortality rates – the latter is currently around 3.5 per 1,000 live births – are the lowest of any nation, and maternal mortality barely registers; while it is said that Icelanders can expect to be in good health for at least 90 per cent of what are, in any event, longer lives than those enjoyed in other countries, giving the average Icelander a longer useful life expectancy than exists in any other land. Furthermore, because of the high standards of care available to all, survival rates for illnesses and operations are outstandingly high.
Given a relatively small population – with a third of the people spread over often remote and difficult to access rural areas and a density of just three people per square kilometre – it is perhaps not surprising that the country has an above-average healthcare worker-to-patient ratio and boasts more doctors per capita than any other country in the world. But even after making such allowances, staffing ratios are very high when compared to those in other nations.
Despite its daunting financial woes, the government’s expressed aim today is not to reduce such care provision levels but to make major cost savings through efficiencies, including increasingly aggressive purchasing policies. As by far the biggest purchaser, the government can achieve much enhanced economies of scale by actively driving prices down or choosing less expensive but equally good services.
A concerted prioritisation of government healthcare spending, based on careful cost benefit analysis of different kinds of services, is now being widely called for by both politicians and healthcare professionals. “Working within a robust regulatory framework, output related prospective payment systems can encourage providers to minimise costs without hurting patient care, as long as associated prices are set correctly and quality is appropriately controlled,” comments one anonymous surgeon blogger in what is warming up to be a heated debate.
At present, private provision accounts for just a quarter of Iceland’s publicly financed health services, but there are now strong calls for this market to be opened more widely in order to generate a more competitive market that would help contain expenditure on equipment, drugs and other items.
Navigating the health system
Iceland’s Ministry of Health was established on 1 January 1970 by Act of Parliament 73/1969, with responsibility for the policymaking and administration of the country’s health and health insurance. It is headed by Gudbjartur Hannesson, a member of the Althingi (parliament) since 2007. The Health Services Act came into force in 1974. Under the constitution, all patients – including visitors from other countries – are entitled to the best possible health treatment and care, regardless of sex, religion, nationality, financial status, family relationship or any other consideration.
The main trauma centres are in Reykjavic's University Hospital and Akureyri Hospital, located in what is Iceland's fourth largest municipality
Foreigners who have been resident in Iceland for six months or more are entitled to the same free treatment benefits as locals – in the state system. It is, consequently, important for them to ensure that they are treated by a state healthcare provider as private healthcare costs are not recoverable unless they private medical insurance. And, though not a member of the European Union, Iceland has affiliation arrangements with the EHIC (European Health Insurance Card) system, giving reciprocal cover to visitors to the country who are EU citizens. Furthermore, those from the European Economic Area and Swiss nationals are also covered for emergency treatment when in Iceland. Foreign visitors not covered by these schemes are required to arrange payment in full before leaving the health centre or hospital, so adequate travel insurance or private health insurance cover is essential.
Eighty-five per cent of the financing for all this comes from central government, and the funds are raised by taxation (mostly from income tax, VAT and compulsory health insurance, which is deducted directly from wages). The remaining 15 per cent comes from across-the-board, variable contributory fees for services.
Iceland is currently divided into seven healthcare districts, each having primary healthcare centres that provide general treatment and care, examination and home nursing, as well as placing a strong emphasis on preventive measures. The Sjukratryggingar (Icelandic Health Insurance Service) administers the national healthcare programme. Health centres open from 8 am to 4 pm while, in the capital, evening and weekend treatment and GP consultations are available at the Laeknavatkin centre. A fee of IKR 1,000 (£5.51), or IKR 500 (£2.25) for state pensioners (free for under 18s), is payable for an initial consultation.
There are very few private hospitals, largely because in the public sector, specialised teaching, general hospitals and community hospitals are all of an exceptionally and consistently high standard and waiting lists for appointments and admissions are generally extremely short. Because Icelanders are entitled to expect the best possible medical services at all times via the state system, there is little demand for private medicine, which consists mainly of specialist outpatient care.
Reykjavik has around 700 beds available for surgical procedures. The main trauma centres are in Reykjavic’s University Hospital and Akureyri Hospital, located in what is Iceland’s fourth largest municipality and unofficial capital of the north, with a population of 17,304.
Operated by the Icelandic Red Cross, the country’s land ambulances – of which there are around 80 – are usually based at fire stations and are distributed across the country’s towns and villages. In Reykjavik and other larger towns, they have full-time salaried crews but elsewhere EMTs are often part-time or work on an on-call, from-home basis. They are centrally dispatched, though organised through the various health districts. Thus, paramedics are normally only found in the capital. They work alongside an on-site physician. Out of 400 certified EMS staff in the whole country there are currently only 20 trained paramedics. Since there is no paramedic training facility in Iceland at present, training takes place overseas at the Centre for Emergency Medicine in Pittsburg Pennsylvania, US, which also provides validation and certification.
For those needing an air ambulance, Iceland has an abundance of airstrips, a fact that explains why the air ambulance service – contracted out to Myflug Air since 2001 – relies on fixed-wing aircraft. There is just one dedicated aircraft – a Beechcraft Super King Air 200 – which is based at Akureyri, the location of Iceland’s second largest hospital.
Iceland has an abundance of airstrips, a fact that explains why the air ambulance service... relies on fixed-wing aircraft
A second, chartered, aircraft is usually also on call, supplemented by another chartered plane during the long, dark winter months. When fixed-wing is not the solution, the air ambulance system is able to call on Super Puma or Aerospatiale Dauphin helicopters operated by the Icelandic coastguard service, based at Reykjavik.
There are around 460 fixed-wing and 160 helicopter call-outs a year. Air ambulance costs are 85 per cent covered by the state but to deter frivolous emergency calls, charges may be levied for the balance.
Branching out
Given a long tradition of geo-thermal spas, entrepreneurs have sensed the island’s potential for the development of medical tourism. Now, a former hospital that has stood vacant since the US Military left the base in 2006 is the subject of a lavish ISK 1 billion (€6 million) refurbishment. Operated by Iceland Healthcare, a private sector company headed by Robert Wessman, this new venture will provide specialist services, including gastric bypass surgery, cardiac rehabilitation treatment and hip and other joint replacements to mainly British and Nordic clients. Says Wessman: “We will also operate an adjacent hotel for patients’ spouses. We are expecting an average two-week stay while the hospital and related services will create around 300 new jobs in an area of relatively high unemployment.”
Another private healthcare venture is the 50-room Jonina Ben detox centre, established by local entrepreneur Jonina Benediktsdottir, which opened for business in May 2009. A profile on Norwegian TV kick-started the centre, which is now also attracting health tourism patients from Sweden, Finland, the UK and the Czech Republic. The centre is located within the new Asbru health village, which is located on another former air base in the South West of the country, close to Keflavik Airport, which has a convenient wealth of air services to Continental Europe, the UK and North America. Other projects at Asbru involve Robert Wessman’s Salt Investments and Nordhus Medical, owned by Otto Nordhus, a prominent chest wall surgeon.
Asbru has been re-invented as a community of students, entrepreneurs and cutting-edge businesses. It is home to Iceland’s largest university campus and is one of the country’s biggest new business incubators, as well as featuring a green energy research centre. Nordhus already has contracts with both Norwegian and Swedish healthcare authorities and comments: “Long waiting lists in those countries work in our favour. With its low population density, modern facilities and green environment, Iceland is sure to become a major player in medical tourism. Asbru is just the beginning.”
Adds orthopaedic surgeon Leif Ryd, a member of Asbru’s professional advisory council: “Asbru’s facilties will include a health and fitness centre, as well as being home to innovative companies in the health and wellness sector. The vast majority of incoming tourists, as well as thousands of people in transit to North America, pass through Kevlavik Airport. A Reykjanes Health Association has been formed to market Iceland as a premier destination for health and relaxation.”
Numerous health spas also exist, especially around the famed Blue Lagoon, with its health promoting thermal waters, which are renowned for skin treatments and the alleviation of other ailments. Around 2,000 patients a year attend the NLFI Rehabilitation and Health Clinic, in Hveragerdi, which specialises in stress relief treatment and stress management, as well as dietary and obesity treatments, back troubles and cardiac problems.
Though anxious to maintain its role at the leading edge of medicine, Iceland has been resolute in its desire to preserve patient rights and when, back in 2003, the government sought to introduce a wide-ranging health sector database project that would put the medical and genealogical records of every Icelander, living or dead, into the hands of an American-owned, if Icelandic-based company, the courts adjudged the move to be unconstitutional. “We take health issues very seriously in this country,” comments health minister Guobjartur Hannesson, adding, “Our healthy lifestyle and diet and a first-rate health service leads to long and fulfilling lives.”
Because of the high levels of fluency in English across the nation, communication is often not a problem. In any event, under article five of the Patient’s Rights Act, patients are entitled to free use of an interpreter, arranged by the medical service provider concerned.