Norwegian health care reforms

Norway has in the last decade seen two health care reforms, the first in primary care and the more recent one in the hospital sector. (Haug C 2004) These reforms have intended to control spending as well as securing patients’ rights to choose more freely health care provider and guarantee a certain level of quality defined as time spent before seeing a consultant and so forth. The changes have predominantly had an individual level approach to equity. (Bravemann P & Gruskin S 2003) The egalitarian ethos of the Norwegian health care system and public service in general has probably been seen as a guarantee enough for equal access to these services for any population group, weather it be socially, ethnically or geographically defined. And the recent health care reforms have paid little attention to the potential population health impact radical changes in health service infrastructure may have.

Norway has also at the end of the nineties seen more interest in the quality aspect of health services.(Sosial- og helsedirektoratet 2004) With increased consumer power in health care this has also meant giving out information on how good one provider is relative to others. Ranking of hospitals based on relative survival and so forth, is not yet part of the package of information patients can use to choose provider. But it is likely as a logical extension to the current practice, not least because this is already established in other countries. (Anderson P 1999) Opening up for competition between providers is already explicitly stated policy, and quality of the services is one possible vehicle for this competition. The future extent of this policy is at present uncertain. (Sosial- og helsedepartementet 2001)

But given the present emphasis on choice at the individual level based upon various aspects of quality of the provider, it is quite conceivable that the effect of this at population level would be an increase in health inequalities. As long as issues related to access by different population groups remain largely unresolved, this could easily mean different groups receive services of different quality which has repeatedly been shown in studies from other countries. (Carr D et al. 1999) In other words, the health policy appears to pay little attention to the population health impact of changes in health services and may even have the potential to increase health inequalities. This is a paradox because the overall intention of these services has been equal access to equally good services. What is remarkable is the lack of debate on this paradox both in the political and professional discourse.

The Norwegian experience in perspective

The creation of a market in health care by separating the commissioning of health services from their provision raises some challenges. People’s demands for health care are based on a desire to be healthy and not on the ability to benefit from health care which characterizes the definition of epidemiologically assessed need. (Stevens A & Raftery J 1997) The supply of health care previously determined by clinicians has been characterized by wide variation of health care services, such as referral rates, intervention rates etc. Various approaches to needs assessment has been developed as tools enabling purchasers in the UK to shift the balance of investment from areas of wasted resources to measurable benefits to population health. An important part of public health specialists’ job within the NHS in the UK is to carry out a comprehensive needs assessment for the District Health Authorities. The Department of Health gave specific responsibility to primary care trusts highlighting the role of public health practitioners in assessing the needs of health care in local communities. (Department of Health 2001)

This objective was formulated within the wider goals of improving the health of the nation by integrating the role of public services with other determinants of population health such as sanitation, education and housing. In this way, assessing health care needs could be seen as integrated with other tools for this purpose, such as health impact assessment. (NHS Health Development Agency 2004) The wide array of policy documents from the British department of health is clearly in contrast to the lack of similar formulations in the Norwegian policy context. The impact of health services for improving population health, and ways to assess this for different local areas and health problems, are hardly mentioned in documents being published after recent health care reforms were implemented in Norway. The white and green government reports on specialist services released after these reforms were implemented, hardly consider the population level health outcome of changes in health service infrastructure. (Helsedepartementet 2003a; Helsedepartementet 2003b) Their main target seems to be increased accountability.

The legacy of Thomas McKeown within health policy

The British epidemiologist and historical demographer Thomas McKeown has probably had a major importance in health policy, although his name may have been forgotten in clinical medicine compared to Archie Cochrane. His detailed accounts of trends in cause-specific mortality rates showed that only a negligible part of declining mortality rates in the 19th and 20th centuries could be ascribed to medical and specific public health interventions. (McKeown T 1976a; McKeown T 1976b) He rather thought nutritional improvements were the driving force. He never refused historical extrapolation to other periods or populations. Groups of historians, particularly in Cambridge, have come to different results than McKeown. (Wrigley EA & Schofield R 1981) And the present status of the evidence among historians is mixed in the sense that he was probably correct in the overall picture that general social conditions were probably of far more importance than medical or public health interventions. On the other hand, even in the period of higher mortality, some researchers point to the importance of targeted interventions having had an important role. (Szreter S 1988)

Furthermore, even if the precise nature of the mortality decline is still debated, the relevance of these historical data to improvement of today’s population health is questionable. After McKeown published his two much cited books, medical treatment of coronary heart disease has improved considerably and is probably partly responsible for the lower mortality of this disease in recent years. (Hunink MGM et al. 1997) As this is a disease more associated with older ages, it is plausible that medical treatment may have a large influence on population health with an ageing population. Evidence of predictions on population health, both from historical and current data, depends on specificity in plausible causal mechanisms. With the interest in the life course approach among researchers today, successive birth cohorts may have experienced different factors during their life time. (Blane D 2004) And this may differ for various disease outcomes, disfavouring historical extrapolation of evidence.

McKeown originally published his work in the 50s in demographic journals, but it was after the release of his two books in the 70s that his work became much cited. This rise of interest has been linked to political shifts in the Western hemisphere in the 80s and 90s. Several commentators have commented on the unintentional alliance between radical critics of medical care and liberal economic theory. (Colgrove J 2002) McKeown’s interpretation was taken as support that organized social interventions by medicine and the state had never played an important role in improving human health and that only strong economic growth was the principal guarantor of such improvement. (Knowles JH 1977)

What explains the lack of attention to population health in Norwegian health care policy discourse?

Among the professionals involved in health care planning and practice, there have been few attempts to see medical care as an integral part of population health. Clinicians often distance themselves from public health as they are preoccupied with individual patients’ suffering in their daily work. Health care managers probably see themselves as primarily budget keepers of organizations that take care of individuals demanding health care. (Haug C 2004) Their position could be seen as influenced by the health economist’s assertion of infinite demand for health services. Although this assertion is said to be empirically weak, it appears to have strong support within policy and promotes an individual level approach to planning. (Frankel S, Ebrahim S, & Davey Smith G 2000) Public health physicians have in Norway largely been recruited among GPs linking public health work to the field of primary care rather than all aspects of health care. And as Colgrove suggests, they may also have been exposed to the broad generalizations from the «McKeown generation». (Colgrove J 2002)

This structure of professional stakeholders provides some clues to the population health void within health care policy discourse. But as Dahl emphasizes, there may also be cultural explanations to this.(Dahl E 2002) The egalitarian view of Norwegian society in the population makes it hard to see inequality. Even though health inequalities in Norway have been shown to be comparable to other countries, this has not been seen as an important policy topic. Policy on inequality is mainly perceived of in terms of disadvantaged, vulnerable, or marginalized groups and individuals. Specific health care for such groups have been set up. Research on health inequality has, however, demonstrated a gradient across all social groups suggesting health care must pay attention to the whole population if it shall reduce such inequalities. (Dahl E 2000)

What is the evidence on the impact of medical care on population health?

Estimating the relative importance of medical care to other determinants of population health poses difficulties in design and may not even be of interest. Within the current climate of evidence based knowledge, problems of getting randomized evidence on population measures such as social conditions will of course prevail. Number of empirical studies is still limited. Bunker was the first to seriously take on the effort to test the assertions made by McKeown for contemporary medicine. (Bunker JP 2001) Based on an optimistic approach of various curative and preventive measures, he ascribes 7, 5 years of increased life expectancy since 1950 to medical care. Mackenbach later examined Dutch data and found reductions in mortality from avoidable conditions between 1950/54 and 1980/84 could have added 2.96 and 3.95 years to life expectancy at birth of Dutch males and Dutch females respectively. (Mackenbach JP et al. 1988) In a review, Mackenbach concluded that variation and declines in such avoidable mortality may be ascribed to other factors than level of supply such as specific aspects of health care delivery, closely related to socioeconomic circumstances. (Mackenbach JP, Bouvier-Colle MH, & Jougla E 1990) More recently, Andreev et al. studied trends in such causes of death comparing Eastern Europe with the UK and found that if outcomes of health care seen in the UK were achieved in Russia, life expectancy at birth might improve by at least 1.5 years. (Andreev AE et al. 2003) And the results from EURO-CARE study which was recently published, found substantial differences in cancer survival between European countries partly seen as an end result of the performance of health care systems. (Micheli A et al. 2003)

But ultimately, the time has probably passed for simple opposition of medical care and other determinants of health, as medical care is not a unitary enterprise. As Frankel states: «The more interesting questions concern which components of medical care and which influences upon other determinants of health justify investment. However, the discourse in health policy has been dominated by the idiom of the health economist where choices are always ‘hard’ and costs represent opportunities forgone». (Frankel S 2001) That means in most European countries, population health would probably benefit from increased investment in both medical care and the wider determinants of health.

Bridging the gap between clinical studies and health services output

Most clinical studies recruit patients that do not resemble the population of patients that would benefit from health care. Due to low external validity of randomized studies, the effect of health care on the population it serves is largely unknown. (Britton A et al. 1999) Unlike these studies, patients are older, do not suffer from one single disease and are more socially deprived. Because of this, calls have been made for mega trials including larger population segments, to resemble the study population with the true population of patients. (Egger M, Ebrahim S, & Davey Smith G 2002) Nick Black has advocated more use of high-quality clinical databases as it may help us to understand the natural history and development of disease; to identify causes of disease; to evaluate health care interventions; to assess equity of care; to describe trends in health care utilisation; and to ensure the methodological rigour of research. (Black N & Payne M 2003)

Julian Tudor Hart’s seminal paper on the «inverse care law» originally put this in perspective when he asserted that those most likely to benefit from medical care generally were the ones who received least of it. (Hart JT 1971) The implication of this in the Norwegian setting is to extend the assessment of medical technology from relying solely on randomized evidence and evaluate the intricacies of potential benefit for the whole population on specific health services. It remains to be seen if the new government funded bureau for evaluating health services, «Nasjonalt kunnskapssenter for helsetjenesten», incorporates this as one of their tasks.

Where does this lead?

Comparing the Norwegian health system reforms with the ones in the UK indicates some kind of vulnerability to radical changes in public service infrastructures that may be particular to Norway. Number of stakeholders is far less in a country with 4,5 million inhabitants. That means chances of receiving balanced inputs in times of reforms are somewhat limited. During the recent hospital sector reform, an explicit goal was to put this reform through at high speed because otherwise the success of it would be hampered by all different kinds of vested interests. Largely, the medical profession approved of it and was disengaged in looking into possible side effects. Within the profession, public health has been marginalized and appears even to suffer from an «identity crises». (Braut GS 2000) There was hardly any initiative from public health physicians or physicians in general to compensate the reforms with population level arrangements making sure medical care was delivered according to need. Rather, the mental dichotomy between medical care and the wider influences as of population health mutually constructed among all professional stakeholders, probably made health care policy to be written in the idiom of individual demand of health care. Ironically, as policy becomes increasingly concerned with health care spending, those interested in health of the population may have a strong case in arguing for population level actions within health care if equity does not loose support in the public. Adding this population level to the «vested interests» in the medical profession should provide a fertile ground in times when health care priorities are questioned.