Norwegian gold
With a wealth of natural beauty, and natural resources providing great wealth, Norway has a lot going for it. But what of medical provision and access to care for the 4.4 million visitors who arrive in this Nordic country each year? Tatum Anderson finds out
First published in ITIJ 116, September 2010
With a wealth of natural beauty, and natural resources providing great wealth, Norway has a lot going for it. But what of medical provision and access to care for the 4.4 million visitors who arrive in this Nordic country each year? Tatum Anderson finds out
With fjords, the world’s third largest ice-cap, northern lights and the midnight sun, Norway has many natural wonders that draw visitors from all over the world. But it is also one of the world's richest countries as a result of being a major oil and gas producer. And as equality in access to healthcare and social services is a political priority in Norway (public social services have been running in the country since the 1700s), the country spends more on health per person than almost any other nation apart from the US. That’s around US$5,003 per person, more than the average amongst the Organisation of Economic Cooperation and Development (OECD), a grouping of rich countries, which average a spending of US$3,060.
There are no private skiing fracture clinics of the kind that are more common in the Alps
The density of doctors and other health professionals is one of the highest in Europe too. Norway had 4.0 practising physicians per 1,000 population in 2008, compared with an average of 3.2 in OECD countries; and 14 nurses per 1,000 population, compared to an OECD average of 9.0 practising nurses per 1,000 population. High investments in health services are reflected in health outcomes of its population. In 2008, life expectancy at birth for the whole population in Norway stood at 80.6 years.
So, visitors to Norway who experience health problems during their stay can expect a generally high-quality public healthcare system, especially around cities and larger conurbations.
A glowing example
Assistance companies say some of the best hospitals in the country include the National Hospital in Oslo, and six university hospitals in the largest cities of Norway including Oslo, Bergen, Trondheim, Tromsø, Stavanger and Akershus. Stavanger University Hospital, for instance, is Norway's fourth largest university hospital and in 2006 cared for 45,638 inpatients and 311,725 outpatients.
The healthcare system provides tax-based universal coverage through its Norwegian National Insurance Scheme (Folketrygden). Foreigners who live and work in Norway must contribute to the scheme too. They are able to choose a general practitioner (GP) from a list of those participating in the country’s so-called Regular GP Scheme (GPs other than those on the scheme can be used but they may cost more – see below).
Tourists are able to access services used by Norwegian communities. Most areas have a public medical clinic (helsesenter) staffed by GPs who can refer patients to hospitals. There are specialist tourist services too. Ski resorts provide dedicated healthcare services for tourists that are state-run and staffed with specialists including orthopedic surgeons. There are no private skiing fracture clinics of the kind that are more common in the Alps. If surgery is needed, patients can find a good standard of treatment at state hospitals.
Norway’s public health system is divided into five regional health authorities, which each operate several hospital trusts, groups of hospitals and specialist care facilities. The South-Eastern Norway Regional Health Authority, for instance, is responsible for 56 per cent of Norway’s population, and encompasses Oslo. It has the most hospital trusts – 11 in all plus five private non-commercial hospitals. The health trusts that operate under the Western Norway Regional Health Authority own around 50 public hospitals. They also have agreements with private hospitals and a number of specialists with private practices (some private companies are even being contracted by the public sector to build and run so-called patient hotels, or accommodation for patients).
Most medical doctors and nurses speak English, German and other European languages. This is partly because this small country has historically had less teaching capacity to train medical staff at home
Most medical doctors and nurses speak English, German and other European languages. This is partly because this small country has historically had less teaching capacity to train medical staff at home. “A large percentage of doctors in Norway have done their medical training abroad, especially in German-speaking countries. There are also a substantial number of immigrant doctors mainly from European countries,” says Dr Asgeir Kvam, medical director at SOS International Global Medical Support based in Norway.
However, he adds, many hospitals and medical centres are often not very well-versed in handling private patients and payments processing. While some hospitals and medical centres are used to billing private patients, there can be problems in institutions that receive few foreign patients. According to Kvam, some are not used to putting together bills, and pricing policies may not be standardised at all. That said, larger hospitals have improved billing processes recently.Oslo University Hospital even has a dedicated office for foreign affairs, for instance.
All that glitters
The massive investments in healthcare can have a downside for some visitors, particularly those who are not covered by the various reciprocal healthcare agreements like the European Health Insurance Card. Healthcare can be very expensive and healthcare providers sometimes require payment at time of service, says the US State Department. Prescription medicine costs in Norway are very low, however.
Tourists from countries within the European Economic Area are treated on the same basis as Norwegian residents, for the length of their stay. So, many services – such as inpatient treatment, medication and emergency services – are free. Interestingly, however, not everything is free at the point of delivery for Norwegian residents. The country operates a system of co-payments. Tourists will have to pay for a consultation with a GP, both public and private, at a cost of approximately NKr 300 (around €40), and a consultation with a specialist in their office or an outpatient clinic costs about NKR 500 (€65). These co-payments are usually paid up front although some outpatient clinics, especially the public ones, may send the bill directly to the insurance company. The UK Department of Health advises tourists to consult doctors with a reimbursement arrangement with the Norwegian Employment and Organization (NAV), which administers the nation’s health insurance. Costs are non-refundable in Norway but visitors may be able to seek reimbursement when they return home. Dental services also are not free.
The private option
Norway’s private healthcare system is small – with over 84% per cent of all health spending coming from public sources in 2008 (compared to 72.8 per cent in the rest of OECD). The private sector tends to provide outpatient treatment and planned surgery. For example, Scanhealth Scandinavia comprises a private hospital, radiology centre and infertility centre in Haugesund, West Norway. It also specialises in occupational medicine, ear, nose, and throat disorders, orthopaedic and eye departments and boasts 2,500 surgical procedures per year.
Private service providers tend to be clustered around the largest cities only, are not open 24/7 and do not offer emergency services. For that reason, the private sector plays a minor role in health provision for tourists, according to SOS International. The few private hospitals with specialist care are either non-profit organisations or deliver services predominantly to the public healthcare system.
But private services are growing. An increasing number of private medical clinics or polyclinics are opening in cities, especially Oslo. They provide emergency walk-in services, and scheduled appointments for both specialists and GPs.
Despite the quality of the public healthcare system, private healthcare providers do provide some benefits, say experts. Waiting times are shorter (although assistance companies say a tourist will get an appointment in a similar amount of time in a state-run hospital) and there may be better customer service. Resultantly, however, public hospitals have said the new competition from private services has led to improvements in the public healthcare sector. It has already brought about a considerable reduction in waiting lists, said one hospital. Generally, though, healthcare quality in public and private hospitals is similar. “Most private hospitals are small or medium-sized and deliver service at the same level as comparable public hospitals,” says Kvam.
So, for non-emergency consultations, tourists do have a choice between governmental and private general practitioners and outpatient clinics. Indeed, some assistance companies have agreements with private clinics to take care of minor incidents.
Getting around
Norway’s unique landscape also presents a unique set of circumstances for assistance companies, especially in primary and emergency care. That’s because Norway is a huge country with a population of just 4.8 million people.There are areas withremote and sparse populations and the most popular tourist destinations are no exception – from islands in the Arctic Ocean to a major dependency on ferries to cross fjords in western Norway. Healthcare services are generally good, however, even in rural areas, according to SOS International. The emphasis on equality of access to healthcare means there are GPs in the smallest communities throughout the country. Even acute cardiac care and trauma care is performed at a high level of quality in Norway, despite the long distances. In some rural areas, local health centres are equipped with more advanced equipment – including x-rays – and can provide telemedicine services through links with other hospitals. For more serious cases, including trauma, primary care departments within small rural hospitals are able to admit patients before transfer to specialist trauma centres (because of the distances involved, planned visits to specialists can take several hours).
many hospitals and medical centres are often not very well-versed in handling private patients and payments processing.
And perhaps surprisingly, in the north of Norway, from Trondheim northwards, there are quite a lot of hospitals, all of them open for emergency care and manned by specialists, say experts. Interestingly, the health authority covering this area, Health North, has a higher proportion of its population in urban settlements.
Travel to Spitsbergen, the main island of the Svalbard archipelago in the Arctic, and polar areas are subject to special regulations. For instance, tourists venturing beyond Longyearbyen, the main settlement on Spitsberge, must apply for a permis issued by the local police. But there is a small hospital and a rescue helicopter at Longyearbyen.
Remote areas pose several other challenges too. Researchers have noted that it’s harder to retain doctors in these areas although this situation is improving. In addition, primary care doctors are often in short supply during the holiday periods, so patients with non-urgent medical problems are sometimes forced to wait a few days for an appointment with a doctor.
The timing of ground ambulances varies greatly in such areas too. In cities and densely-populated areas, 90 per cent of the population is generally served within 12 minutes by ground ambulance. However, one study has shown that ambulances rarely reach all inhabitants within half an hour in half of Norway’s municipalities. In rural areas, response times can be as high as 45 minutes, although ambulance helicopters, boats and airplanes make access to healthcare services faster.
The national emergency care system is accessed by calling 113. Around 20 emergency medical dispatch centres (EMCC) are responsible for answering calls and responding with out-of-hospital emergency resources like ambulances services and on-call primary care doctors. The operators also speak English. The EMCCs have access to a range of ambulances from boats to helicopters (complete with anesthesiologists and nurses) and planes.
For cases that are urgent but not life-threatening, residents and visitors are expected to use an alternative service, the local physician’s emergency reception. Norway’s 430 municipalities are in charge of organising such services. Importantly for visitors, each municipality has its own telephone number for accessing local emergency medical services (Legevakt) 24 hours a day.
These emergency local services are usually managed by the GP surgeries during office hours and by the municipality during out-of-hours. Actually, out-of-hours services are usually provided by on-call GPs who are legally obliged to work on a rota system during evenings, nights and weekends. In addition, some private medical centres provide limited primary care services from Monday to Friday in Norway’s largest cities. In 2006, there were 262 out-of-hours services in Norway, run by single municipalities or group co-operatives.
Both the local emergency care system (LEMCC) and the EMCCs are staffed with nurses who use telephone triage to prioritise patient treatment. For local emergency services, the LEMCC agents work out what level of care is appropriate – whether a home visit by a GP or an ambulance to hospital by land, sea or air ambulance.
Out-of-hours service location and facilities vary. One study found that some districts provide out-of-hours services from hospitals, others in GP surgeries and some were even based entirely on doctors making home visits. Despite this, some tourists may find it difficult to get a doctor to visit them, say experts. “To get a visit and examination by the doctor in the traveller’s hotel room may be very difficult. Most medical centres will insist the patient comes to the doctor’s surgery. Only the critically ill patient will get an ambulance or doctor on-site,” says SOS International’s Kvam.
Air, road and boat ambulance services are public and free for Norwegian citizens and tourists with reciprocal healthcare agreements. This includes air ambulance services, which provide inter-hospital transfers within Norway and from Spitsbergen. They are integrated in the state health trusts, so the bill will be included in the hospital bill. Often, though, the ambulance team will require an insurance document to pass onto the hospital billing office.
Although the ambulance service is public, the government does contract private suppliers to provide air services. They are expected to compete for the tenders on five to ten-year contracts. The prices for ambulance services are not standardised, unfortunately. But ground ambulances are normally billed per kilometre. While rates are rather low in international terms, Kvam warns that distances to a hospital by road may be as long as 100km.
Healthcare can be very expensive and healthcare providers sometimes require payment at time of service
The cost of repatriation must be borne by the patient or their insurance company. Citizens from Nordic countries are exempt, however, and can be transported home free of charge under an agreement called the Nordic Convention.