by Karsten Vrangbæk
Scandinavian policy studies have a long tradition of seeking inspiration from organizational theory. This has spurred an interest in concepts and solutions that become “fashionable” and travel across policy fields. They become “standard recipes” that policy makers and managers in health systems turn to, although the actual translation may differ across organizational settings. So what are some of the fashionable policy ideas in the Nordic regions?
First there has been an emphasis on integration of care for a number of years. This is based on the observation that many problems with patient reported quality arise from lack of coordination. At the same time, it is recognized that ageing populations will lead to more patients with multiple chronic care needs requiring coordination vertically in the health system and horizontally to other sectors, such as social care and elderly care.
Second there are ongoing discussions in all the Nordic countries about centralization of administration, decision power and hospital infrastructure. Denmark implemented a major structural reform in 2007, Norway had less encompassing reforms in 2002 and 2012. Finland and Sweden are both considering similar reforms. The aim is to achieve administrative benefits of scale and better use of resources. At the same time there is an increased emphasis on the role of local governments in delivering health and social care close the homes of the population.
A third major trend is the emphasis on digitalisation and “big data” to support health delivery. Digital solutions are applied at all levels in the health system to facilitate patient flows and enable sharing of information. Due to the highly integrated nature of Nordic patient registries there are also large opportunities for building intelligent “big data” driven systems to optimize health services.
A fourth important trend is to consider solutions that build more extensively on patient involvement. This is translated into policy solutions building on choice and patient involvement in decision making. The underlying idea is the recognition that the patient is a resource in co-producing health and pushing the delivery organizations and health professionals to deliver better quality.
These four fashionable policy ideas are found in all the Nordic countries. Yet as emphasized in the organizational policy theories there are significant variations in the translation of the concepts into different organizational settings. Local politics influence decision making, and the constellation of resources and stakeholders in each country creates different pathways for implementation. Fashions may then end up with rather different colours and appearances in different settings.
While the idea of fashion trends in health policy is useful for understanding the spread of ideas and the relative convergence at the level of policy rhetoric, it is also important to recognize that most fashion trends also correspond to real challenges and opportunities. As Jim March pointed out many years ago, a winter coat can be functional and fashionable at the same time. What then are some of the challenges that are mentioned in the Nordic health systems.
The first major challenge is the changing demographic profile and related developments in disease patterns. We are only starting to understand the implications of the ageing populations. The process is complicated as there is growing evidence of the limitations in simply extrapolating from the experiences from previous generations. Future elderly people will have led very different lives and they will have different health profiles and different needs. Some remain active and healthy for a long time. Others are less fortunate financially and health wise. Furthermore, there is a rapidly growing proportion of elderly with different ethnic backgrounds and specific health problems and general problems in their interaction with the health system. Health systems of the future must be able to handle all types, and must span across significant diversity in demands and needs.
Technological advances represent both opportunities and challenges. There has been a rapid development of information and communication technology in the health sector. The fusion of new ICT solutions with new health care technology such as nano-robots, new materials, powerful imaging modalities and genetic screening provides us with great opportunities, but also significant economic, organizational and ethical issues.
Although the Nordic region remains relatively wealthy all of the countries have suffered the consequences of the ongoing economic crisis in Europe. This experience of constrained resources is likely to continue far into the future, as demographics change, and some of the traditional revenue raising activities are challenged by global competition. The Nordic welfare states, as with many other European welfare states, are facing long term financing issues that make it necessary to be very clear on the justifications for investing in health care compared to other societal investments.
All of this makes it important that scientific journals like HEPL remain committed to publishing research that addresses challenges and potential solutions. Some of the specific focus areas for future HEPL contributions should aim at:
- Understanding the real impact of changing demographics and handling the increasing diversity of needs and demands – preparing the political system to make long term decisions.
- Developing better political and managerial processes for decision-making on new technologies and getting rid of technologies and processes that do not work.
- Understanding political processes of implementing and evaluating vertical and horizontal integration.
- Addressing the many issues in providing high quality mental health care. In spite of technological advances elsewhere, this part of health care is still based on weak diagnostic tools and treatment modalities with limited evidence. Furthermore, it appears the organization of mental health services has not undergone the same modernization as other areas.
- Analyzing the interaction effects of the simultaneous policy pressures and policy solutions in future health systems. What happens when aging, technology developments and new patient types interact? How does this relate to changing demands, increased diversity and continued economic pressures?
About the author
Karsten Vrangbæk is Professor at the Political Science and Public Health Department and Director of Center for Health Economics and Policy (CHEP) at the University of Copenhagen. He is also a member of the Editorial Board for the Health Economics, Policy and Law journal.
