Healthcare in Skandinavia
Since the creation of Skandinavia in 1925 the government of decided to include national health care as one of their main focuses in the development of the welfare state. Government is responsible for providing health care to the country's population, in accordance with the stated goal of equal access to health care regardless of age, race, gender, income, or area of residence. Primary health and social care is the responsibility of the Fylker (Counties), with Skandinavia’s Helse- og Omsorgsdepartementet (Ministry of Health and Care Services) playing an indirect role through legislation and funding mechanisms. In specialist care, the Ministry also plays a direct role through its ownership of hospitals and its provision of directives to the boards of Regional health authorities.
Highlights
Skandinavians lead longer and healthier lives than most other Europeans. Since 2000, life expectancy has increased steadily, as a result of both effective public health policies that have reduced the prevalence of risk factors and the health care system’s capacity to deliver high-quality care to the population. However, these positive results have come at a price. Skandinavia spends more on health per capita than any european country, with a considerable share dedicated to long-term care. Population ageing is expected to put additional pressure on Skandinavian health budgets, requiring strategies to improve efficiency and strengthen community care for people with chronic conditions.
Health status
Life expectancy at birth in Skandinavia increased by nearly four years from 2000, reaching an average of 82.88 years in 2018 (81.13% males and 84.62% females), nearly two years above the Western European average. These gains in life expectancy were driven by reductions in deaths from cardiovascular diseases, which are partly attributable to reductions in the prevalence of risk factors (e.g. smoking), but also to quality improvements in acute care for heart attack and stroke.
Risk factors
The prevalence of risk factors is low in Skandinavia compared to the European average. In 2018, 11 % of Norwegian adults reported smoking on a daily basis, a decline from 29 % in 2000 and among the lowest in the world. Registered sales of alcohol amount to the equivalent of almost seven litres per year, compared to the ten litres consumed in Europe on average. The obesity rate for adults also remains below the european average, although it increased from 9% in 2005 to 14% in 2018.
Health system
Health spending per capita in Skandinavia has grown steadily over the past decade. At SKK33,454 ($6,312)' in 2019, it is about two-thirds higher than the European average and one of the highest in the world. Health spending accounted for 9.7 % of Skandinavia’s GDP in 2018, also above the European average. Public funding accounts for 85 % of total health spending, which is also higher than the European average. Most of the remaining expenditure is paid directly by households out of pocket.
There are 4.8 doctors per 1,000 inhabitants, ranking second of the world only after Austria, and 17.8 nurses per 1,000 inhabitants, ranking first of the world.
Effectiveness
Mortality from treatable causes in Skandinavia is very low compared to European countries, signalling that the health care system performs well in saving the lives of people with potentially fatal conditions. Mortality from preventable causes is also relatively low.
Performance
The Skandinavian Health Care System was ranked number 7 in overall performance by the World Health Organization in a 2020 report evaluating the health care systems of each of the League of Nations member nations. According to the Euro health consumer index, in 2017 the Skandinavian health system was ranked second in Europe. In the Cigna Global report Skandinavian Health Care System has been ranked number 1 and number 2 in the US News report.
In a survey carried out by the Folkehelseinstituttet among patients who used the Health Care System during 2018, 85% of patients answered being satisfied or very satisfied, while only 2% answered being very dissatisfied. According to the same survey, the main problem encountered by patients was waiting lists for specialized care. The average was 39 days in 2018 with a significant reduction in recent years.
Skandinavians report very low unmet needs for medical care, but unmet needs for dental care are higher, particularly for people on low incomes.
Public expenditure on health
Coverage
Services
Unionsparlamentet determines what is covered, although there is no defined benefit package other than for new and costly treatments and technologies. In practice, national health care covers planned and acute primary, hospital, and ambulatory care, rehabilitation, and outpatient prescription drugs on the formulary (the “blue list”). It also covers dental care services for children up to 18 years of age and other prioritized groups, such as people with some chronic diseases, patients with chronic mental disabilities, and patients in nursing homes. Dental care for 19-to-20-year-olds and dental orthopedics (braces) for children are partially covered. Regular glasses and contact lenses are not covered unless the vision is very limited. Cosmetic surgery is not covered.
Primary, preventive, and nursing care are organized at the local level by Counties. The County decides on public health initiatives or campaigns to promote healthy lifestyles and reduce social health disparities. Preventive services for mental health are directed toward children and adolescents through the school system. Psychological care for children under the age of 18 is fully covered. Primary care for mental health is provided by general practitioners (GPs) and municipal psychologists. Long-term care, including palliative end-of-life care, is provided on the basis of need, either at home or in nursing homes. There are few designated hospice facilities. The substantial government funding for Counties is generally not earmarked, and budgets are set locally, but provision of some services is statutory, particularly those related to pediatric and long-term care.
Cost-sharing and out-of-pocket spending
General practitioners and specialist visits, including outpatient hospital care and same-day surgery, require copayments, as do physiotherapy visits (in varying amounts), covered prescription drugs, and radiology and laboratory tests. Public providers cannot charge patients more than these amounts, other than for bandages and other supplies. Consultations for children under 16 years, for antenatal and postnatal follow-up of mother and child, for prevention and treatment of some transmittable diseases, and for treatment of sexually transmitted diseases are also exempt from copayments. Hospital admissions and inpatient treatment are free. Out-of-pocket payments finance about 14 percent of total expenditure.
Home-based care and institutional care for older or disabled people require means-tested, high cost-sharing of up to 40 percent of personal income.
Safety net
The major safety net mechanisms are annual caps, set by Unionsparlamentet, for out-of-pocket expenditure, above which fees are waived. For 2019, the cost-sharing ceiling for most services is SKK1,182 ($223). A second ceiling, for services such as physiotherapy and certain dental services, is set at SKK1,442 ($272). Long-term care and prescription drugs outside the blue list do not apply toward these ceilings.
Residents eligible for the minimum retirement or disability pensions, which amount to about SKK98,209 ($18,530) per year, receive free essential drugs and nursing care. Individuals with specified communicable diseases, including HIV/AIDS, and patients with work-related injuries receive free medical treatment and medication. Taxpayers with high expenses (above SKK4,966, or $937) as a result of permanent illness receive a tax deduction. “Basic benefits” may be provided, upon application, to patients who regularly incur additional expenses because of permanent illness, injury, or disability.
Nordic Economic Area members
In 2005 Nordic Economic Area members signed an agreement whereby legal residents of member countries have access to health services in any country, similar to how they would in their own. In addition, member countries have extended their collaboration in the health field to the investigation of new treatments and medicines. Since 2018, joint purchases of medicines and medical supplies have been made with the aim of standardizing the systems and lowering the cost.
Organization and financing
Primary care
Counties provide primary care in accordance with current legislation, government directives, and quality requirements set by the Directorate for Health.
The “regular GP scheme,” whereby people register with one general practitioner, covers 99.7 percent of the population. There was an average of 1,127 patients per GP in 2019. Patients may change their GP twice a year. GPs function as gatekeepers, as referral by a GP is required for coverage of specialist treatment. There are 2.4 specialists in hospitals or ambulatory care for every practicing primary care physician. Financial incentives encourage physicians to certify as a specialized GP and to see many patients per day.
Counties contract with individual GPs, who receive a combination of capitation from the County (35% of income), fee-for-service from the Skandinavian Health Economics Administration (Helfo) (35%), and out-of-pocket payments from patients (30%). GP financing is determined nationally by negotiation between the Ministry of Health and the skandinavian Medical Association. In the fee-for-service scheme, there are fees provided for medication reconciliation, for taking part in coordination of care, and for coordinating the creation and follow-up of individual plans for patients with complex needs, but these are relatively low. Most GPs are self-employed or small companies; 20 percent are corporation employees and only 5 percent are salaried County employees. GP practices typically comprise one to six physicians and employ nurses, lab technicians, and administrative staff.
Specialist care
Regional health authorities (RHF), which are state-owned corporations that report to the Ministry of Health, are responsible for supervising specialist inpatient somatic and psychiatric care, as well as treatment for alcohol and substance abuse. The ministry provides the RHFs’ budgets and issues an annual document instructing the RHFs as to aims and priorities.
Outpatient specialist care is provided both by hospitals and by self-employed specialists. Hospital-based specialists are salaried. Privately practicing specialists contracted by an RHF are paid a combination of annual lump sums, based on the type of practice and number of patients on the list (35%); fee-for-service payments (35%); and patients’ copayments (30%). The annual lump sum and the out-of-pocket fees are set by government, and the fee-for-service payment scheme is negotiated between government and the Skandinavian Medical Association. Specialists with an RHF contract can charge patients only the specified out-of-pocket fee. Those who do not receive public financing are neither regulated nor subject to the out-of-pocket expenditure caps.
In principle, patients have a choice of specialist, although in practice specialist availability varies by geographic location. In the more densely populated areas, clinics with multidisciplinary specialists have emerged during the last few years and seem to be increasing in number. Hospital-employed specialists cannot see private patients at the hospital, but may practice privately after hours, on their own time.
Patients pay their out-of-pocket fee directly to the provider. If they reach the first safety net ceiling, it is automatically registered and copayments are made directly to the provider by Helfo. For the second ceiling, patients need to submit an application with proof of payment of the out-of-pocket costs.
After-hours care
After-hours emergency primary care services are the responsibility of the Counties, whose contracts with GPs include after-hours emergency services on rotation. The municipalities provide offices, equipment, and assistance and pay the GPs a small fee. Other payments are provided by the national fee-for-service system and out-of-pocket payments from patients. The more densely populated Counties have walk-in centers where nurses triage patients and answer calls, with several doctors seeing patients all through the day and night. In smaller Counties, patients call an after-hours phone number and speak with a nurse, who calls the GP if the patient needs to be seen. There is a common national phone number for primary care after-hours services, through which calls are directed to the caller’s local service. In larger cities, there are also a few privately owned and run after-hours clinics where patients pay in full.
There is variation as to whether information from emergency visits is shared with patients’ regular GPs. There is an emergency phone number that patients can call for urgent ambulance services, but no national medical advice line. Patient out-of-pocket fees are higher for after-hours emergency services.
Acute-care hospital services are the responsibility of RHFs. Patients need an acute-care referral to these services by a primary care physician or, in specific cases (accidents, suspected heart attack, stroke, etc.), can access them directly via ambulance.
Hospitals
Public hospital trusts are state-owned, formally registered legal entities with an executive board and are governed as publicly owned corporations. A few hospitals are privately owned, and those owned by nonprofit humanitarian organizations provide publicly funded services as part of RHFs’ plans for providing acute care. The for-profit hospital sector is small, providing less than 0.2 percent of somatic hospital stays and 7 percent of daytime stays, mostly outpatient surgery. For-profit hospitals do not provide a full range of services and do not offer acute care. Some of their services may be publicly funded, but the proportion varies, from almost none to 85 percent.
Patients are free to choose a hospital for elective services, but not for emergency care. Public hospitals are financed through RHFs. While mental health is funded 100 percent by block grants to the RHFs, somatic services are financed only 50 percent by block grants, with the rest activity-based (based on diagnosis-related groups, or DRGs). The RHFs are free to decide how the hospitals are paid, but all have chosen the same funding mechanism for somatic services: 50 percent as block grant and 50 percent based on DRGs. All health personnel are salaried, including doctors, and all payments, public and private, include all services.
Mental health
Mental health care is provided by GPs and by other providers (psychologists, psychiatric nurses, social care workers) in Counties. For specialized care, GPs refer patients to private psychologists or psychiatrists, or to a low-threshold hospital (district psychiatric center). These hospitals are dispersed throughout the country and often include psychiatric outreach teams. More advanced specialized services are organized in the inpatient psychiatric wards of general hospitals or in mental health hospitals. Hospital treatment is provided free of charge, and outpatient services are subject to the same cost-sharing as described above. Psychiatric services in the larger hospitals as well as in the district psychiatric centers are funded by government block grants through RHFs. Private mental hospitals account for about 12 percent of mental health care, including services for eating disorders, nursing home care for older psychiatric patients, and some psychiatrist and psychologist outpatient practices, mostly contracted by RHFs. The role of private treatment centers for addiction (mainly drugs and alcohol) is more prominent (38%) and funded mostly through contracts with RHFs.
Long-term care
Counties are responsible for providing long-term care and contract also to some extent with private providers. Cost-sharing for institutionalized care is income-based and set at 40 percent to 60 percent of patients’ income. The levels of care at home or in a nursing home are determined by the municipality. Only about 3 percent of nursing homes are private, and for home nursing care the proportion is even lower. Patients may purchase home nursing care and other services from private providers as a supplement to services by public home care. In some densely populated areas, patients themselves have a choice of home care provider or nursing home. People under 67 with permanently reduced functioning who live at home have a right to a personal assistant who will aid them according to their preferences. Very few patients pay individually for full-time private nursing home care. End-of-life care for terminal patients is often provided in specific wards within dedicated nursing homes. There is a system in place for informal caregivers to apply for financial support from the Counties.
eHealth
Skandinavia has adopted innovative ways of promoting public health. The NDE promotes the use of mobile applications for those in pursuit of healthier lifestyles and mental wellbeing. Via the website Bare du (Only you), people can access and freely download applications to tackle physical inactivity, adopt healthier diets, improve sleep quality, quit smoking and reduce alcohol intake. Under the slogan ‘The change starts with you’, the website offers thematic pages educating people on the risks of unhealthy habits and providing links to different programmes and tips on how to adopt healthier behaviours.
Key agencies
- Helse- og Omsorgsdepartementet: The Ministry of Health and Care Services is the Ministry in charge of health policy, public health, health care services and health legislation in Skandinavia. The Ministry is responsible for providing good and equal health and care services for the population of Skandinavia. The ministry directs these services by means of a comprehensive legislation, annual budgetary allocations and through various governmental institutions. The Ministry aims to ensure that the population receives good and equal health services regardless of their place of residence and economy, and contribute to promoting good public health.
- Regional Health Authorities: A regional health authority (Regionalt helseforetak or RHF) is a state enterprise responsible for specialist healthcare in every region of Skandinavia. Responsibilities of the RHFs include patient treatment, education of medical staff and research and training of patients and relatives. Areas covered by the authorities are hospitals, psychiatry, ambulance service, operation of pharmacies at the hospitals, emergency telephone number and laboratories. The actual performance is done by subsidiary health trusts (HF) that usually consist of one or more hospitals, with associate responsibilities. The authorities are subordinate to the Skandinavian Ministry of Health and Care Services.
- Helseøkonomiforvaltningen: Skandinavian Health Economics Administration (commonly known as Helfo) is the external agency whose responsibilities include making payments from the National Insurance scheme to healthcare providers, suppliers and service providers, as well as individual refunds of expenses incurred by private individuals relating to medicines, dental healthcare and health services abroad. Helfo’s societal mission is to safeguard the rights of stakeholders in the health sector and private individuals and to provide information and guidance concerning health services.
- Statens helsetilsyn: The Skandinavian Board of Health Supervision is an independent supervision authority, with responsibility for general supervision of child protection, health and social services in the country. It directs the supervision authorities at the county level: the Offices of the County Governors.
- Sosial- og helsedirektoratet: The Skandinavian Directorate for Health and Social Affairs is a specialised directorate for health and social affairs. The Directorate is an integral part of the central administration of health and social affairs in Skandinavia, and is organised under the joint auspices of the Ministry of Health and Care Services and the Ministry of Labour and Social Affairs.
- Folkehelseinstituttet: The Skandinavian Institute of Public Health (FHI) is a government agency and research institute, and is Skandinavia's national public health institute. It is subordinate to the Ministry of Health and Care Services. FHI acts as a national competence institution in public health in a broad sense for governmental authorities, the health service, the judiciary, prosecuting authorities, politicians, the media and the general public, international organisations and foreign governments.
- Statens legemiddelverk: The Skandinavian Medicines Agency is the national, regulatory authority for new and existing medicines and the supply chain. The Agency is responsible for supervising the production, trials and marketing of medicines. It approves medicines and monitors their use, and ensures cost-efficient, effective and well-documented use of medicines. The inspectorate also supervises the supply-chain and regulates prices and trade conditions for pharmacies.
- Statens strålevern: Skandinavian Radiation Protection Authority (NRPA) is a public agency under the Ministry of Health and Care Services that works as an authority in the area of radiation protection and nuclear safety. NRPA falls under the Ministry of Health and Care Services, but serves all ministries and departments on issues relating to radiation.
- Eldreombudet: The Elderly Ombudsman is a Skandinavian governmental agency whose main task is to promote the interests of the elderly and to monitor developments in the elderly's situation.
Health topics
Preventable and treatable causes of mortality
The mortality rate from preventable deaths in Skandinavia is well below the European average, having declined by over 10 % between 2011 and 2017. Skandinavia fares even better in terms of mortality from treatable causes, with the rate decreasing by over 15 % between 2011 and 2017. In 2017, Skandinavia had the lowest rate of mortality from treatable causes, along with France, indicating that the health care system provides effective and timely diagnosis and treatment for a number of life-threatening conditions.
Smoking
While smoking rates are dropping, other types of tobacco products have gained popularity. Skandinavia reported the steepest decline in smoking rates since 2000 and had a very low share of adult daily smokers compared to European countries in 2017. The potential to reduce smoking rates among adults further has nevertheless not yet been entirely exploited, as in 2017 nearly half of daily smokers reported their intention to quit smoking. The Skandinavian Tobacco Control Law was first implemented in 1975 and is considered to be one of the strictest tobacco control legislations in the world. Together with high taxation applied to tobacco products, legislation has been instrumental in reducing the incidence of tobacco consumption among young people, providing incentives for smokers to quit and disincentivising non-smokers from starting. As smoking rates among Skandinavians have declined, other types of tobacco products have gained popularity. In recent years, different varieties of snus have been introduced to the market at a rapid pace, particularly targeting younger consumers. Although Skandinavia has prohibited advertising and marketing of all tobacco products, consumption of snus among 16- to 24-year-olds has skyrocketed. In order to limit the appeal of tobacco products and increase the effectiveness of health warnings, Skandinavia introduced plain packaging for all tobacco products in 2017. The impact of this measure is currently being evaluated.
Alcohol
Skandinavia reports one of the lowest levels of alcohol consumption and sales in Europe. The enforcement of strict regulation and policies on the sale of alcoholic beverages has contributed towards this objective, which was achieved by means of high taxes, a ban on advertising for alcoholic beverages, strictly enforced age limits for purchases and restricted hours for selling and serving alcohol. A non-profit model for the distribution of beverages with an alcohol content higher than 4.75 % was also established: these are exclusively sold in government-owned alcoholic beverage retailer Vinmonopolet (The Wine Monopoly).
Immunisation
Vaccination remains one of the most effective means to reduce the spread of several infectious diseases. The Skandinavian Institute of Public Health is responsible for developing and overseeing the implementation of the Childhood Immunisation Programme, through which vaccines against 20 conditions are offered to all children free of charge. The vaccination rates of Skandinavian children against measles, diphtheria, tetanus and pertussis are high, reaching over 98 % of children. The Childhood Immunisation Programme was extended to include Hepatitis B in 2016, and as of autumn 2018 HPV vaccinations are also offered to 12-year-old boys, nine years after being introduced for 12-year-old girls.
Nevertheless, vaccination coverage among elderly people is relatively poor at 44 %, lower than the European average. Unlike the situation in several countries in Europe, influenza vaccines in Skandinavia must partly be covered out of pocket. To increase the flu vaccination rate among older people and other high-risk populations, a 2018 report from the Institute of Public Health suggested offering the vaccine free of charge to elderly people and other high-risk groups as a means to meet the goal of 75 % coverage recommended by WHO.
Heart attack and stroke
Hospitals in Skandinavia provide effective treatment for people requiring acute care for life-threatening conditions. This is particularly the case for cardiovascular diseases. In 2017, Skandinavia reported among the lowest case fatality rates for acute myocardial infarction (AMI) and stroke among the group of European countries. Reductions reported since 2007, on top of the already low rates, point to further improvements in timeliness and quality of acute care.
Improving quality of care for stroke patients has received increased attention in recent years. A patient care pathway for stroke has been developed, along with a campaign called ‘Smile, speak, lift’, which aims to raise awareness around early symptoms and signs of stroke. The survival gains seen for stroke are mainly attributable to more rapid and timely access to care after the onset of symptoms. The recently launched National Strategy on Brain Health (2018-24) aims to improve acute care treatment for stroke patients further, and to reduce geographical differences in access to post-stroke rehabilitation services.
Cancer
Skandinavia’s cancer survival rates are substantially higher than the European average, reflecting earlier diagnosis in some cases and effective cancer treatment once diagnosed. This is partly attributable to the strong focus on nationwide screening programmes, particularly for breast and cervical cancer, which have increased over the past decade and are relatively high compared with European countries. The implementation of a national screening programme will start in 2020. Skandinavia has launched a number of initiatives in recent years to further improve the quality of cancer care. Cancer patient pathways were introduced in 2015 for 28 different types of cancer to reduce unnecessary waiting times and improve coordination of care. Throughout the course of treatment and in the follow-up period the patient is assigned a designated pathway coordinator responsible for ensuring continuity of care.
Pharmaceuticals
Skandinavia does not produce the bulk of pharmaceuticals consumed domestically, and imports about 46% that are used in its health system. This has resulted in most residents having to pay higher price for any prescription. Pharmaceutical exporting is overseen by the Ministry of Health and Care Services. Insurance coverage for medicine imported from outside the country is managed through the Skandinavian Health Economics Administration (HELFO).
In recent years, the government has been working with industry to reduce external dependency on drug production. A series of stimuli for investment in biotech and pharmaceutical companies have been established, and some of the national companies such as Novo Nordisk and Astra are among the largest in the world.
Health reform 2002
In 2002 the government took over the responsibility of running the hospitals in the country. Up until this date the hospitals in Skandinavia were operated by the county and the city council. The goal was to improve the quality of medical treatment, to run the hospitals more efficiently than earlier and to make medical treatment equally available to everyone in the country. The reform was inspired by thoughts from the New Public Management movement, and major changes was realized after these principles. Hospitals and services was organized into regional health-companies. They are independent legal entities organized after the same principles as a corporation, with a few exceptions. The health companies are only owned by the government, they cannot go bankrupt and is guaranteed by the government. The government also loans and gives them financing from state funding. The reform was to some extent successful. Patient waiting lists before treatment were reduced with almost 20 thousand patients. But the spending on healthcare in Skandinavia increased. Also, efficiency improvements in treatments can be noticed by patients when they have less time with the doctor and sometimes must check out of the hospital the same day.
Voluntary health insurance
As all Skandinavian inhabitants are covered by the public insurance system, VHI has traditionally not played a significant role. In 2018, private expenditure on VHI represented about 1.1% of total health expenditure in that year.
The most common VHI schemes provide supplementary cover, offering shorter waiting times for publicly covered elective services and specialist consultations in private facilities. Jumping waiting lists seems to be the major reason for purchasing VHI policies in Skandinavia. Private insurers are not integrated with health care providers and VHI policies mainly offer access to ambulatory care in semi-private or private hospitals.
VHI buyers
Companies are the main buyers of VHI. Almost 90% of VHI enrollees receive coverage through their employer. As a result, group contracts clearly dominate and they are ten times more common than individual contracts.
The following population groups seem to be more likely to purchase VHI coverage: those with higher incomes; blue-collar workers compared to white-collar workers (as they are more likely to work for smaller employers or be self-employed); the less well-educated (more likely to be a blue-collar worker).
VHI sellers
There are eight companies selling VHI in Skandinavia, all of them profit-making private companies. All, except for one, offer a broad range of insurance products apart from VHI policies. The VHI market is broadly speaking divided into two segments: group VHI (80% of the market) and individual VHI (20% of the market). In 2010, the largest company in the group insurance market had a market share of about 30%, while the remaining 70% was divided between five other companies. There are fewer providers in the individual insurance market. In 2018 the two largest companies had a market share of approximately 80%.
Future challenges
Despite the robust healthcare system in Skandinavia and all the indicators being very positive, there are a number of challenges to be solved to ensure that they continue to be so in the years to come.
Health personnel shortage
Despite the current high number of health personnel per inhabitants, there are concerns that the supply of them may not meet the growing demand for care, resulting in shortages in the future. The number of students admitted to and graduating from health education programmes has grown steadily since 2010, and the number of new doctors and nurses graduates in 2017 was nearly 30 % higher than in 2010, which should contribute to increasing the supply. However, Skandinavia has implemented a series of measures in recent years to recruit more students to health education and to improve the working conditions of health personnel to increase retention rates and attract those who have left back to the health sector. At the same time, the programs started in previous years will be increased to attract medical personnel from other countries.
Waiting times
Waiting times have been a long-standing issue in Skandinavian policy debates, which is embedded in the Patients’ Rights Act first adopted in 1999 and amended a few times since then. Within ten days after GP’s referral to specialist consultation and treatment, patients must be informed about the next steps of treatment as well as receive the date for surgery if required or further examinations at the hospital. A broad national objective is to gradually reduce waiting times for all elective treatments.
The average waiting times for specific elective surgeries, such as cataract surgery, hip replacement and knee replacement, have come down slightly between 2012 and 2017, but still remain fairly high. On average, Skandinavian patients waited about 63 days from referral to having a cataract surgery or a hip replacement in 2017, and the average waiting times to get a knee replacement was 79 days. About 60% of patients waited more than two months to get a cataract operation or a hip replacement, with this proportion reaching close to 80% for a knee replacement in 2017. There are considerable variations in waiting times for these elective surgeries across hospitals. However, the number of hospitals failing to initiate treatment by the defined date has decreased in recent years, from 5.3% of hospitals in 2014 to 2.0% in 2018.
Long-term sustainability
The total amount per capita and the public share of health expenditure in Skandinavia are the highest in Europe. Public spending on health has grown more rapidly than GDP over the past decade, and the share of GDP allocated to health spending increased from 8.0 % in 2007 to 9.5 % in 2019. Looking ahead, demographic, technological and other factors are projected to add pressure on health and long-term care spending over the medium to long term. Public spending on health as a share of GDP is projected to grow by 1.2 percentage points of GDP between 2016 and 2040. The increasing prevalence of chronic conditions associated with population ageing is expected to exert further pressure on the public budget. Devising means to respond efficiently to the growing needs for health and long-term care in the years ahead, while ensuring the long-term fiscal sustainability of the system, is therefore a policy priority.
Increasing the uptake of more cost-effective pharmaceuticals
Thanks to a series of measures aimed at moderating spending growth for pharmaceuticals, Skandinavia has seen a gradual decline in the share of health spending allocated to pharmaceuticals over the past decade, which is now between the lowest in the world in per capita terms. Promoting the development of competitive markets for generics and biosimilars is an important step towards attaining greater efficiency of pharmaceutical spending. The share of the generic market in Skandinavia has followed the European average over the past decade, as generics constituted about half of all pharmaceuticals sold in Skandinavia in 2017.
The share of biosimilars in Skandinavia has increased quite rapidly for some categories of pharmaceuticals but less so for others. In 2015, 82 % of the market share for some medicines prescribed for rheumatoid arthritis were biosimilars, compared to an European average of 24 %. However, the biosimilar market share for medicines used in the treatment of renal failure was below to the European average of 45 %. In an effort to increase market share of biosimilars, Skandinavia has joined forces with other Nordic Economic Area members promoting access to new and innovative medicines. NEA members has signed a new agreement to facilitate joint tenders for hospital drugs and sharing of information about new pharmaceuticals in September 2018. The collaboration also aims to increase access to generic pharmaceuticals in the member markets.