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The Nordic countries are healthcare systems with tax-based financing and ambitions for universal access to comprehensive services. This implies that distribution of healthcare resources should be based on individual needs, not on the ability to pay. Despite this ideological orientation, significant expansion in voluntary private health insurance (VPHI) contracts has occurred in recent decades. The development and role of VPHIs are different across the Nordic countries. Complementary VPHI plays a significant role in Denmark and in Finland. Supplementary VPHI is prominent in Norway and Sweden. The aim of this paper is to explore drivers behind the developments of the VPHI markets in the Nordic countries. We analyze the developments in terms of the following aspects: the performance of the statutory system (real or perceived), lack of coverage in certain areas of healthcare, governmental interventions or inability to reform the system, policy trends and the general socio-cultural environment, and policy responses to voting behavior or lobbying by certain interest groups. It seems that the early developments in VPHI markets have been an answer to the gaps in the national health systems created by institutional contexts, political decisions, and cultural interpretations on the functioning of the system. However, once the market is created it introduces new dynamics that have less to do with gaps and inflexibilities and more with cultural factors., (Copyright © 2018. Published by Elsevier B.V.)

This article maps current approaches to public reporting on waiting times, patient experience and aggregate measures of quality and safety in 11 high-income countries (Australia, Canada, England, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland and the United States). Using a questionnaire-based survey of key national informants, we found that the data most commonly made available to the public are on waiting times for hospital treatment, being reported for major hospitals in seven countries. Information on patient experience at hospital level is also made available in many countries, but it is not generally available in respect of primary care services. Only one of the 11 countries (England) publishes composite measures of overall quality and safety of care that allow the ranking of providers of hospital care. Similarly, the publication of information on outcomes of individual physicians remains rare. We conclude that public reporting of aggregate measures of quality and safety, as well as of outcomes of individual physicians, remain relatively uncommon. This is likely to be due to both unresolved methodological and ethical problems and concerns that public reporting may lead to unintended consequences., (Copyright © 2016 The Authors. Published by Elsevier Ireland Ltd.. All rights reserved.)

This paper explores leadership and governance arrangements in seven developed health systems: Australia, England, Germany, the Netherlands, Norway, Sweden and Switzerland. It presents a cybernetic model of leadership and governance comprising three fundamental functions: priority setting, performance monitoring and accountability arrangements. The paper uses a structured survey to examine critically current arrangements in the seven countries. Approaches to leadership and governance vary substantially, and have to date been developed piecemeal and somewhat arbitrarily. Although there seems to be reasonable consensus on broad goals of the health system there is variation in approaches to setting priorities. Cost-effectiveness analysis is in widespread use as a basis for operational priority setting, but rarely plays a central role. Performance monitoring may be the domain where there is most convergence of thinking, although countries are at different stages of development. The third domain of accountability is where the greatest variation occurs, and where there is greatest uncertainty about the optimal approach. We conclude that a judicious mix of accountability mechanisms is likely to be appropriate in most settings, including market mechanisms, electoral processes, direct financial incentives, and professional oversight and control. The mechanisms should be aligned with the priority setting and monitoring processes., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Recent reforms in Swedish primary care have involved choice of provider for the population combined with freedom of establishment and privatisation of providers. This study focus to what extent individuals feel they have exercised a choice of provider, why they exercise choice and where they search for information, based on a population survey in three Swedish counties. The design of the study enabled for studying behaviour with respect to differences in time since introduction of the reform and differences in number of alternative providers and establishments of new providers in connection with the reform. About 60% of the population in the three counties felt that they had made a choice of provider in connection with or after the introduction of a reform focusing on choice and privatisation. Establishments of new providers and having enough information increased the likelihood whereas preferences for direct access to a specialist decreased the likelihood of making a choice. The data further suggests that individuals were rather passive in their search for information and tended to choose providers that they previously had been in contact with. This is in line with results from previous studies and poses challenges for county councils governance of reforms., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Objective: To examine which attributes are important when individuals choose between primary care models. In particular, we studied whether individuals that were given a choice preferred individual family physicians (GP) or a primary care team consisting of physicians and nurses (PCT)., Method: A questionnaire survey, designed as a discrete choice experiment, was sent to 1600 individuals in Sweden. In the questionnaire, different primary care models were constructed on the basis of five attributes: GP versus primary care team, waiting time for non-emergency visits, user charges, ability to choose provider, and degree of influence over the care received. Individual preferences and willingness to pay for attributes were regressed against such characteristics as age, gender, education, and health status (as measured by EQ-5D)., Results: The response rate was 58%. Waiting time, user charges, ability to choose provider, and degree of influence over the care received were each statistically significant discriminants (p<0.001). Willingness to pay per visit was 224 SEK for great compared to limited degree of influence over the care received, 164 SEK for ability to choose a provider and 111 SEK for each 1 day reduction in waiting time for non-emergency visits. Subgroup analysis showed that older individuals and individuals in poor health preferred the option to register with a GP whereas working individuals and individuals living at a greater distance from a hospital preferred the option to register with a primary care team.

In Sweden decentralised drug-budgets at health-care facility levels were introduced in 1997 in an attempt to contain increasing pharmaceutical expenditures. This paper reports the findings of a postal survey which investigates whether decentralised drug-budgets according to a so-called primary-care based model in Swedish health care have led to increased cost awareness and changed attitudes towards cost-minimisation and cost-effectiveness as decision-making criteria among physicians. In particular, it was investigated whether there were differences in this respect between general practitioners (GPs) and specialists. The postal survey was sent to 1,520 Swedish physicians from a stratified sample of Swedish county councils. A total of 738 physicians responded (response rate 49%). Statistical analysis was performed of logistic regression analysis and independent or paired samples t-tests. The results suggest that GPs have a higher degree of cost awareness than specialists. Physicians with experience of decentralised drug-budgets have a higher degree of cost awareness than other physicians. However, the rating of the top four decision-making criteria; therapeutic effects, side effects, compliance and cost-effectiveness, were not significantly different when comparing GPs against specialists, and physicians practising in county councils with decentralised drug-budgets against other physicians. The main barriers to considering costs to a greater extent were perceived difficulties in switching drugs and a fear among physicians of losing credibility among patients. In conclusion, decentralisation of drug-budgets according to the Swedish primary-care based model increases cost awareness, especially among GPs. Such responsibility, however, does not create strong incentives for physicians to reconsider the importance of cost-effectiveness in relation to other decision-making criteria when prescribing. Parallel interventions are needed to meet the objective of cost-effective prescribing.

The pharmacy market in many European countries is characterised by individually owned pharmacies that operate under tight government control regarding barriers to entry, scope of activities and profit margins. Many countries are, however, in the process of introducing pro-competitive policies, including possibilities to own several pharmacies and competition based on price. In Iceland and Norway, restrictions to ownership and competition were relaxed in 1996 and 2001, respectively. In both countries, the new policies quickly led to horizontal integration and concentration of the market, and in Norway the merging pharmacy groups integrated vertically with wholesalers. By 2004, two pharmacy groups in Iceland and three pharmacy groups in Norway controlled 85 and 97% of the markets, respectively. In combination with remaining barriers to entry, this market concentration may call for additional pro-competitive interventions to prevent unfavourable developments. Such policies will simultaneously make it more difficult to uphold traditional social objectives related to pharmacy services. Experiences in both Iceland and Norway highlight the complexity of managing reforms that fundamentally influence competitive behaviour.