Comparing the Health Systems of Other Countries: Scandinavia: Why is population health so “good” Free Essay

History and Reasons for a Successful Healthcare Model in Scandinavian Countries

 

Introduction

The development of the national health care system is one of the major challenges for any country. In actuality, only the most developed nations have a comprehensive and manageable health care system at the national level, while other countries are too poor to be able to construct a reliable, effective, and manageable health care system, which could have allowed them to provide health care services and cover the large part of the population or the entire population. Nevertheless, even among those countries that are capable to afford their national health care system, the effectiveness of the national health care systems vary considerably.

The difference in the effectiveness and the overall impact of the national health care system on the public health and the quality of health care services is likely to depend on the specific model used by the specific country.

At the same time, the national health care model is not the only factor that determines the effectiveness of the national health care, but there are also such factors as the economic development of countries, the different role the government plays in the economy and health care, cultural norms and traditions, which define the attitude of people to the national health care, and many other factors.

In actuality, Scandinavian countries have reached a considerable success in the development of their health care and many researchers (Jacobsen & Mekki, 2012) recognize that their health care model is one of the most effective and cost-efficient models in the world. Scandinavian countries, including Denmark, Norway and Sweden, have a similar but not absolutely homogenous health care system. They have their national specificities which meet their specific needs and determined by the difference in culture, historical and economic development of Scandinavian countries. Nevertheless, their health care systems are very similar and basically use the same model with the state playing the main part in the national health care system.

In spite of existing drawbacks and criticism of Scandinavian health care model, the model has proved to be effective and is still one of the best health care models in the world so far. Therefore, the experience of Scandinavian countries in the field of health care is worth studying because their experience may be useful for the improvement of national health care systems of other countries, such as the US, which attempt to reform and improve their health care system and its efficiency.

Controversies

The historical development of Scandinavian health care system involved the development of national health care systems of Scandinavian countries. In spite of certain differences in their development, they still had a lot of similarities and their strategic development was so similar that often researchers (Byrkjeflot & Neby, 2008) use the concept of Scandinavian model of health care to describe and study the experience of health care systems of Scandinavian countries. The Scandinavian health care model developed on the ground of the extensive involvement of the state into the delivery of health care services. The Scandinavian health care model comprises an integral part of the concept of the welfare state which has become the milestone of the development of Scandinavian countries. The concept of welfare state implies that the government takes care of citizens and helps to build up the wellbeing of the entire nation, where no one is left aside and the government takes the responsibility for redistributing of the national wealth to ensure that even the poorest part of the population has access to basic services, including education and health care, and is capable to live a decent life. The welfare state focuses on the enhancement of basic services, including health care, and their delivery to all citizens, regardless of their level of income or social status. Such focus on the wellbeing of citizens and the introduction of the concept of welfare state defined, to a significant extent, the development of national health care systems of Scandinavian countries. Therefore, the welfare state way of development of Scandinavian countries contributed to the emergence of similar trends in the development of their health care systems and predetermined similarities between their health care systems.

However, some researchers (Byrkjeflot & Neby, 2008) argue that national health care systems of Scandinavian countries are not as similar as they are traditionally believed to be. the idea of a decentralized Scandinavian model for hospital systems has had limited validity, constrained to the years 1970-2000 (Byrkjeflot & Neby, 2008). Historical trajectories and recent developments both indicate that the three systems are more different than commonly assumed, and that recently they seem to be moving in separate directions (Byrkjeflot & Neby, 2008). Nevertheless, such findings basically contradict to other studies which traditionally agree upon the similarity of national health care systems of Scandinavian countries rather than their differences. At this point, some researchers (Hofmann, 2013) argue that differences between national health care systems are not significant since only some details differ, but their strategic development is very similar. This is why researchers (Hofmann, 2013) view national health care systems as the common Scandinavian model. In this regard, Byrkjeflot and Neby (2008) argue that new trends in the development of national health care systems of Scandinavian countries differ, especially in terms of decentralization because some countries like Denmark and Norway still tend to maintain the strict centralized health care policies, while others, such as Sweden, tends to deeper decentralization of their health care policies and funding of health care system.

The analysis of national health care systems of Scandinavian countries still proves that they basically moved in the same direction toward the government support and funding of the national health care system through taxes and insurance. The development of health care priority setting has been partly homogeneous and appears to follow certain phases (Hofmann, 2013). To understand the common trends and possible controversy in the development of national health care systems of Scandinavian countries as a homogeneous model requires the study of the historical background and development of national health care systems of Scandinavian countries.

Basically, the historical development of the contemporary Scandinavian health care model and national health care systems involved three distinct periods. These three distinct periods had differing characteristics: (1) The making of the decentralized model (before 1970). Political decentralization characterized all three countries (Byrkjeflot & Neby, 2008). In Sweden counties were the major public institutions; in Norway and Denmark, municipalities (Byrkjeflot & Neby, 2008). The state and the counties incrementally became involved with hospitals, and funding gradually became a matter of public sector economy. Administratively, decentralization marked all countries (Byrkjeflot & Neby, 2008). (2) The heyday of the decentralized model (1970-early 2000s) (Byrkjeflot & Neby, 2008). Large and numerous reform initiatives indicate a more politicized sector and a consolidation of hospitals as a public responsibility. In spite of similarities, the timing and sequencing of reforms differed (Byrkjeflot & Neby, 2008). Funding, political decision-making and administration were placed with the counties. (3) Challenging the decentralized model (after 2000). The three countries differ as new reforms are introduced – they no longer follow in one another’s footsteps (Byrkjeflot & Neby, 2008). Recent developments undermine the institutions that constituted decentralization; Norway and Denmark are arguably becoming more centralized (Byrkjeflot & Neby, 2008). However, this trend toward centralization is still arguable and needs further research to determine whether Norway and Denmark really enhance the centralization of their health care policies or they still tend toward decentralization while changes that occur are just a part of the dynamic process of the evolution of their national health care system which requires certain enhancement of centralization elements of their national health care system to achieve further strategic goals of the health care development.

The development of Scandinavian countries and their national health care system was quite different from other countries, such as the US, where the private insurance funding comprised the core of the national health care system. In contrast, Scandinavian countries tended to the enhancement of the role of state in the national health care system and the public control over health care. Due to raises in costs, elaborate public control of health care, and a significant technological development in health care, priority setting came on the public agenda comparatively early in the Scandinavian countries (Hofmann, 2013). Therefore, high costs of health care services urged Scandinavian countries to shift toward the public health care model widely supported by the state. This shift was the result of the unaffordable health care services neither in terms of out-of-pocket payments nor private insurance. As Scandinavians could not afford private insurance and growing health care costs, they turned toward the public health care system, where the government guarantees the coverage of health care costs and availability of health care services to all citizens. The government took the responsibility for funding and managing the national health care system, while citizens had to pay taxes and insurance to allow the government to raise funds to cover health care costs.

Scandinavian countries developed their national health care system within basically the same framework. Some general trends have been identified: from principles to procedures, from closed to open processes, and from experts to participation (Hofmann, 2013). Such similarities mirrored the similar strategy of the development of national health care systems of Scandinavian countries, where the government played the main part in the funding and managing the national health care system. Health care services became a part of the welfare state policy conducted by national governments of Scandinavian countries.

Similarities between Scandinavian health care systems are evident in the approaches used by national health care systems and governments. Five general approaches have been recognized: the moral principles and values based approach, the moral principles and economic assessment approach, the procedural approach, the expert based practice defining approach, and the participatory practice defining approach. There are pros and cons with all of these approaches (Hofmann, 2013), but still they contributed to the creation of the effective and reliable health care system.

The five principles of the Scandinavian health care model have both advantages and drawbacks. Moral principles and values based approach creates clear values for priority setting that is obviously an advantage of this principle. On the other hand, this principle leads to the lack of action guiding capacity, significant local variation (justice), and little practical impact. Such drawbacks make the health care system of Scandinavian countries quite rigid and bureaucratic that raises the problem of the low adaptation of the health care system to individual needs of each patient which makes the Scandinavian model from private insurance-based model, where the highly personalized approach is applied to each insured client.

Moral principles and economic assessment approach is also very effective and helpful, including efficiency issues which are felt important in practice. The health care system develops in compliance with existing moral norms and principles that allows health care professionals to meet ethical norms and standards and meet cultural needs of their clients. However, moral principles and economic assessment approach is still not action guiding, little practical impact. The lack of action makes the health care system rigid and difficult to change and adapt to individual needs of clients.

The procedural approach brings openness and transparency to the health care system. As a result, the fund use is transparent and clear that increases the confidence of people in the government and the national health care system. On the other hand, the procedural approach is rather theoretical model, not really implemented in practice. The application of this approach in Scandinavian countries still does not bring the full transparency and openness because of the technical difficulty of controlling the flow of funds and the development of health care policies.

The expert based practice defining approach has the high quality evidence for decision making. The decision making process focuses on the quality of decisions and their consequences.  On the other hand, this approach raises the problem of leading to politically/publicly unacceptable decisions driven by concerns about the enhancement of the quality, regardless of cultural effects and other issues which can make such decisions unacceptable. In case of health care, the quality of the decision making is particularly important but all decisions should comply with existing legal and ethical norms. Otherwise, controversies are inevitable and they will make the decision making process ineffective.

The participatory practice defining approach contributes to the broad acceptance of decision making process and result. The broad acceptances is pivotal for the public support of health care policies. This is why this approach is helpful to keep the public confidence in the health care policy high and facilitate the development of health care policies due to the extensive public support. On the other hand, this approach raises the problem of the hidden agendas, power based decision making processes, capacity problems with addressing all priority issues. These issues emerge as the government cannot address all the issues and the problem of issues in the health care policy may emerge.

The welfare state policy defines the development of health care systems of Scandinavian countries. The Scandinavian welfare states have public health care systems which have universal coverage and traditionally low influence of private insurance and private provision (Hofmann, 2013). The public funding of health care is a part of the welfare state policy which allows Scandinavian countries to accumulate financial resources at the national level and redistribute them to fund health care services. More important, the key part of the welfare state policy is the universal coverage of health care costs that means that all citizens of Scandinavian countries have access to health care services and can receive all health care services they need, regardless of their level of income. The universal coverage makes health care services a social good rather than a mere privilege as is the case of countries, where health care is not universal and health care services are funded by private insurance companies or other way.

Health care systems of Scandinavian countries have their specificities but they all provide the universal health care and make health care services available to all citizens. Even though details vary, in all three countries the system is almost exclusively publicly funded through taxation, and most (or all) hospitals are also publicly owned and managed (Holm, Liss, & Norheim, 1999). The public funding and management imposes the burden of funding of health care system on the government and taxpayers. The government redistributes funds from taxpayers to the health care system to cover health care costs and to meet needs of the population. Such policy makes the role of private insurance companies and private clinics irrelevant in the national health care system.

The countries also have a fairly strong primary care sector (even though it varies between the countries), with family physicians to various degrees acting as gatekeepers to specialist services (Holm, Liss, & Norheim, 1999). The primary care lays the foundation to the strong public health because people receive the primary care of the high quality and enjoy better health. The in-time delivery of primary care of the high quality prevents the development of chronic health issues and large scale public health problems. This is why the focus on the primary care turns out to be an important condition of the overall success of the Scandinavian health care model. On the other hand, the focus on primary care raises controversy between the primary care and the maintenance of the public health. The overall success of the public health turns out to be the result of the effective primary care, while the concept of welfare state and health care policies of Scandinavian countries aim at the affordable health care services and good public health rather than primary care as its priority number one. Nevertheless, the gap between declared and actual policies still does not prevent the successful delivery of primary care along with the maintenance of the high quality public health.

The Norwegian public welfare system includes a range of universal benefits, including not the least the right to free education, free health care, pension and economic support for unemployed (Jacobsen & Mekki, 2012). The system functions at four main levels: the state, the regions, the counties and the municipalities, of which the regions are of lesser importance, and the municipalities of growing significance (Jacobsen & Mekki, 2012). The main responsibility for the health care sector rests at the national level, with the Ministry of Health and Care Services (Jacobsen & Mekki, 2012). Therefore, the Ministry of Health Care and Services plays the main part in the development of health care policies and management of the health care system of Norway.

In Denmark most of the GP services are free. For the patient in Norway and Sweden there are out-of-pocket co-payments for GP consultations, with upper limits, but consultations for children are free (Holm, Liss, & Norheim, 1999). Hospital treatment is free in Denmark while the other countries use a system with out-of-pocket co-payment (Holm, Liss, & Norheim, 1999). Nevertheless, these differences are irrelevant to the general principle of the universal health care because the health care is affordable to patients and they can count on health care services they may need in the course of their life, regardless of their level of income. The universal health care covers health care services for all patients and they may refer to doctors, whenever they need their help, while out-of-pocket co-payments and other payments are affordable and comprise just a part of the total coverage of health care costs for patients in Scandinavian countries.

One of the main issues that evoke the controversy in the universal health care and the health care policy of Scandinavian countries is the question of the quality of health care services and meeting needs of individual patients. The basis for the present Swedish model harks back to a question that should be familiar, which is how to make a publicly-funded monopoly more service-minded and manageable (Holm, Liss, & Norheim, 1999). Similar questions emerge in Denmark and Norway, especially in light of their strong trend to centralization which alienates the health care system from the individual in a way. The centralized approach involves the elaboration of general policies and national standards which cannot always take into consideration regional and local specificities and needs of individual patients. Such alienation or disregard to individual needs contradicts to the concept of welfare state and universal care which imply the delivery of high quality health care services to all patients.

In response to the problem of the gap between universal care and individual needs of patients, Scandinavian countries introduce the principle of solidarity and equality, when all patients stand on the equal ground and all citizens contribute to the national health care system. Solidarity and equality derive from the ideological basis for the Scandinavian welfare state (Holm, Liss, & Norheim, 1999). These concepts are fundamental for the welfare state and Scandinavian countries extrapolate them onto their health care system. Solidarity also means devoting special consideration to the needs of those who have less chance than others of making their voices heard or exercising their rights (Holm, Liss, & Norheim, 1999). In such a way, Scandinavian countries pay a particular attention to the support of people in need, who have difficulties with the access to health care services and do their best to meet needs of those people to make them feel being equal. However, the principle of solidarity and equality cannot resolve the problem of the failure of the national health care system to address individual needs and specificities of each patient. Instead, solidarity and equality changes the attitude of patients to the health care and their expectations from the health care system. Patients expect the access to the standard set of health care services and they always count on the free access to health care services whatever happens to them, but they do not expect the highly personalized approach to meet their very specific needs. Instead, they come prepared to receive the treatment similar to the treatment of other patients like them.

Therefore, national health care systems of Scandinavian countries still experience certain controversies. In this regard, the process of decentralization is one of the main trends that evoke the controversy within the national health care systems of Scandinavian countries. All of them now tend to decentralization of their health care system but the problem is that Scandinavian countries, for example, Sweden, have the highly centralized government funding system and the national government plays the key part in the redistribution of financial resources, i.e. funding, and management of the national health care system. Reformers view the decentralization as an essential condition of the improvement of the quality of health care services and their better delivery to all citizens, especially those in need.

On the other hand, the decentralization implies the change of the vector in the development of the national health care system of Scandinavian countries, when the centralized system of funding and management of the national health care system has to give more authority and financial freedom to local officials and health care organizations at the local level. Decentralization is an opportunity to address individual needs and take into consideration local specificities better than in case of the centralized approach. However, at the moment, only Sweden tends to decentralization, whereas Denmark and Norway retain their centralized approach. Nevertheless, the centralized approach still allows meeting needs of the population although provides little opportunities for the personalized approach and meeting individual needs and specificities of patients to the full extent.

Another important issue Scandinavian countries confront is the considerable growth of the elderly population. To put it more precisely, Scandinavian countries confront the problem of the aging population which evokes another controversy because the growth of the share of the elderly population increases the pressure on the economically active population, i.e. people, who work or run their business and, thus, make their contribution to the national economy and wealth. The problem is that the large part of the population is not working and contributing to the national economy but consuming benefits of the national economy created by a contracting part of the population. As a result, economically active people become more and more concerned that they have to pay more to make the national health care system functional and actually to cover health care costs of the elderly people. The sense of injustice grows particularly stronger as working people have to pay more but consume less health care services, while the elderly population consumes the larger part of total health care services delivered to the public because elderly people have many chronic health problems and their health is worse compared to the younger and economically active population. The elderly care sector in Norway is extensive and mainly public, with only a small fraction being run by commercial firms or by voluntary organizations (Jacobsen & Mekki, 2012). Volutnary organizations help to close existing gaps and deliver health care services elderly patients need. They help the public health care sector to improve the quality of health care services and provide elderly people with care and attention they need.

At the same time, the problem of the aging population and the coverage of health care costs of elderly people reveals a deeper and more challenging controversy the Scandinavian health care system confronts. Scandinavian countries developed socially-oriented national health care system as a part of their concept of welfare state. This means they developed their national health care as a social good that should be available to all citizens, especially, those, who cannot afford or have difficulties with accessing health care services. In such a way, health care is not a privilege but a social good that has to be accessible to all citizens and the Scandinavian health care model promotes the concept of health care as a social good.

However, such approach is totally different from what the US or other health care systems oriented on the health care as a private matter use. The public health care as a social good puts the burden of the coverage of health care system and health care costs on working and economically active people, who can afford taxes and payment to contribute to the national health care system. This part of the population actually covers health care costs of the entire population that often evokes the dissatisfaction of those, who contribute to the national health care system. In such a situation, the controversy between the individual contribution and health care services available in terms of the public health care system emerges.

Nevertheless, the Scandinavian health care model reveals the choice of the population of Scandinavian countries in favor of the public health care which involves the public or government funding of health care costs through taxes or insurance that citizens pay, while the government redistributes funds to cover health care costs needed by the population. The experience of Scandinavian models has proved the effectiveness and cost-efficiency of such model in terms of the coverage of the total population of the country and availability of high quality health care services to all people.

On the other hand, the problem of the Scandinavian model and its main controversy is a deep-rooted sense of injustice that people, who make their financial contribution to the national health care system, feel because they have to pay for health care services all people receive, regardless of whether they pay taxes or insurance or not.

Suggested policies

Public health care system based on Scandinavian model is effective and cost-efficient compared to the health care system based on the private insurance like the one used by the US. The public coverage of the health care system which is actually the coverage of health care costs performed by the government either through taxes or government-managed insurance is less expensive and more cost-efficient compared to the private insurance funding. Researchers (Holm, Liss, & Norheim, 1999) argue the more a country relies on private insurance the more it pays for health care, without any extra benefit.

The experience of Scandinavian countries and the application of their health care model proves that health care can be and, in case of those countries, is a social good and not a privilege. This statement refers rather to the ethical realm than economic or health care one. Nevertheless, the concept of health care as a social good is very important not only for the public health but also to the national wealth and wellbeing of the population. Health care as a social good is not only the matter of funding of the health care system but also the matter of certainty of people in their future and in their life. People living in Scandinavian countries are certain that whatever happens to them and their health, they may and will always count on the proper health care services that are affordable and always available to them, regardless of their level of income, social status, or whatsoever.

The decentralization of the health care system and its funding and management may help to increase the quality of health care services available to all citizens, especially those in need. The decentralization is the main trend in the development of the Scandinavian health care model now. This trend emerges as Scandinavian countries are looking for effective ways to improve the quality of health care services and to meet needs of patients better. In such a context, decentralization may be potentially helpful because authorities and health care organizations at the local level can determine specific community public health needs as well as individual needs of local patients better than officials at the national level.

People in need, who cannot afford health care services or have problems with the access to health care services, should get more support from the part of the national health care system to make health care services more available to them and to elevate their quality of living to grant them with equal rights and opportunities to lead a decent life as do other citizens, regardless of their health problems. The availability of health care services is important but people in need are in a more disadvantaged position compared to the rest of society because their financial and health problems often raise unsurpassable barriers for them to get access to heatlh care services they need. Therefore, such people need assistance, but in countries, where the private insurance funding of the health care system prevails, people in need are often left aside. In contrast, the Scandinavian model implies that such people need a particular attention from the part of health care workers and the health care system should elaborate effective strategies to reach those people and to provide them with high quality health care services they need.

Furthermore, the Scandinavian health care model also teaches a good lesson concerning the cost efficiency of the health care. The cost-efficiency means the low spending and high health care coverage which is an unachievable goal for many countries so far, especially those with the private insurance health care funding. The low spending means that people contributing to raising funds spent on health care system of Scandinavian countries either paying taxes or health insurance which is managed by the government mainly. As a result, the individual spending on health care is low, while all citizens have access to health care services they need. The situation is quite different in countries like the US, where the private insurance health care funding still plays the key part because the individual health care spending is still very high, while health care services people can afford are often limited, especially, if people rely on government-sponsored health care plans or Medicaid and the like programs.

At the same time, the cost efficiency of the Scandinavian health care is substantial not only at the individual but also national level. To put it more precisely, researchers (Hofmann, 2013) reveal the fact that Scandinavian countries spend about 9% of their GDP, whereas the US, where the private insurance funding of the health care system prevails spends about 18% of the US GDP. Therefore, the public health care funding allows Scandinavian countries to spend twice less than the US that uses the private insurance funding of the national health care system mainly. The cost efficiency of Scandinavian health care model is evident. The cost efficiency of the health care system of Scandinavian countries comes hand in hand with the high quality of health care services delivered to patients. The major concern of critics of the public health care funding is the quality of health care services, but the case of Scandinavian countries proves the effectiveness of the model since national health care systems of Scandinavian countries can afford funding of the national health care and deliver health care services of the high quality in the mean time. The public funding does not compromise the quality of health care services in Scandinavian countries.

The cost efficiency of Scandinavian model at the individual and national level makes the model worth implementing in other countries, such as the US. The reduction of spending on the national health care can boost the accessibility of health care and its affordability for Americans. At the moment, sky rocketing health care costs make health care services unaffordable for many Americans and they have already become the major burden for the US economy and taxpayers. In such a context, the experience of Scandinavian countries is worth considering conducting the reform of the US health care system to make it less costly and more affordable. The shift toward the reduction of spending can help to make health care services more affordable and economically efficient. Hence, it is possible to recommend using Scandinavian experience to reduce health care costs and spend less while retaining the high quality of health care services.

Future evidence

One of the most important issues the future evidence should prove is the quality of health care and whether the public health care system or privately covered health care system are more efficient in terms of the development of high quality health care services. The study of the Scandinavian health care model reveals the fact that patients often suffer from the lack of the personalized approach and meeting their very specific individual needs, when the universal health care approach is applied, while patients, whose health care is covered by the private insurance, may count on the personalized and highly individualistic approach to the health care services that meet very specific needs of the patient. In this regard, future evidence may show which of the approaches is more effective, but one should also take into consideration the fact that the universal health care involves the full coverage of the entire population that means that all citizens have access to health care services.

At the same time, the future evidence should also reveal the overall impact of the availability of health care services to all citizens and its impact on the overall public health. The question that begs is whether the Scandinavian model is better in terms of the overall quality of the public health compared to other models, for example, the one used by the US. The Scandinavian health care model is universal that means that health care services are available and affordable for all citizens. In contrast, the health care system based on the private insurance is effective in terms of the development of high quality services but this system faces the problem of the lack of access to health care services for a large part of the population as is the case of the US, for example. Therefore, the future evidence could reveal the effectiveness of the public health in case of the implementation of the Scandinavian model and other models which may be better in terms of the enhancement of the public health, although the Scandinavian model has proved its effectiveness so far in terms of the improvement of the public health which is the priority of the Scandinavian health care model.

At this point, the aging of the population may have a considerable impact on the quality of public health but also raises another issue which needs the future evidence. To put it more precisely, the aging population means the reduction of the basis for raising funds to cover health care costs and the expansion of the population that needs more health care services. The future evidence should show whether the Scandinavian model is viable and whether the model will be able to cover increased health care costs on the condition of the reduction of the fund raising basis. In face of such a challenge, governments of Scandinavian countries will either increase taxes or insurance payments for economically active citizens or change the health care model they use at the moment, for example, by introducing wider private insurance for health care. At the moment, private insurance is either absent or plays a minor part in health care systems of Scandinavian countries, but, in the future, their governments may need to increase the role of private health insurance to ease the pressure on the national budget and taxpayers.

Conclusion

Thus, the Scandinavian health care model is effective although have its controversies since, on the one hand, Scandinavians countries have made their health care universal that means health care services are available to all citizens, but, on the other hand, the universal health care also means the universal contribution to the national health care, when citizens have to pay taxes or insurance to cover health care services not only for them but also for those, who do not pay taxes or cannot afford insurance, such as children or elderly patients. Nevertheless, the experience of the Scandinavian model is useful and worth implementing in other countries like the US. Advantages of the Scandinavian health care model are evident. Scandinavian countries provide universal health care services available and affordable for to all citizens. Health care services are delivered on the equal ground and social status or the level of income of individuals does not matter. Health care services are still of a high quality and they are cost-efficient as Scandinavian countries spent twice less of their share of GDP on health care than does the US, for example.

References:

Byrkjeflot, H., & Neby, S. (2008). The end of the decentralised model of healthcare governance? Journal of Health Organization and Management, 22(4), 331-349. doi:http://dx.doi.org.molloy.idm.oclc.org/10.1108/14777260810893944

Hofmann, B. (2013). Priority setting in health care: Trends and models from scandinavian experiences. Medicine, Health Care, and Philosophy, 16(3), 349-56. doi:http://dx.doi.org.molloy.idm.oclc.org/10.1007/s11019-012-9414-8

Holm, S., Liss, P., & Norheim, O. F. (1999). Access to health care in the scandinavian countries: Ethical aspects. Health Care Analysis : HCA, 7(4), 321-30. doi:http://dx.doi.org.molloy.idm.oclc.org/10.1023/A:1009460010196

Jacobsen, F. F., & Mekki, T. E. (2012). Health and the changing welfare state in norway: A focus on municipal health care for elderly sick. Ageing International, 37(2), 125-142. doi:http://dx.doi.org.molloy.idm.oclc.org/10.1007/s12126-010-9099-3

 

 

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