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Norwegian General Hospitals, 1970–2002: County Ownership—An Interlude between Welfare Localism and State Direction

Published online by Cambridge University Press:  26 July 2012

Tore Grønlie
Tore Grønlie
Affiliation:
Department of History and the Stein Rokkan Centre for Social Studies, University of Bergen, Nygårdsgaten 5, 5015 Bergen, Norway, e-mail: tore.gronlie@hi.uib.no
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Over the last three decades, Norway has experienced two fundamental reforms in hospital organization and direction. In 1970 the nineteen county authorities took over ownership and budget responsibilities for hospitals within their areas, replacing a highly varied and complex structure of ownership, typically generated locally. In 2002 hospitals were transferred to the state and amalgamated into five regional government enterprises. These, in turn, have organized all hospitals in their region under local health enterprises. Both regional and local enterprises are separate legal entities, with their own executive boards and managing directors. The Minister of Health appoints the boards of the regional enterprises, while their directors and the boards of the local enterprises are appointed by the regional boards. Both regional and local enterprises are supposed to have full autonomy for day-to-day operations, while being subject to strategic and political decisions by the Minister of Health as the ultimate authority of the enterprise assembly (foretaksmøte). The “enterprise” concept is, of course, borrowed from private business, modelled on companies of limited liability. The choice of this organizational model must be understood at least partly within the context of a general politico-administrative reform, inspired by the worldwide New Public Management movement. Each enterprise is a separate economic entity with a clear responsibility for balancing its budgets. Privatization (or part-privatization) and bankruptcy, however, are out of the question, as the state in the end retains full economic responsibility.

Type
Articles
Information
Medical History , Volume 50 , Issue 2 , 01 April 2006 , pp. 189 - 208
Copyright
Copyright © The Author(s) 2006. Published by Cambridge University Press

References

What are considered here are general somatic hospitals, not psychiatric institutionalized care or specialized institutions. In general, the state, at an early time, took greater responsibility for the building and running of psychiatric and specialized institutions, than for general somatic hospitals.

1 Drawing the dividing line between what are strategic or political questions on the one hand and day-to-day operations on the other, is a central and most difficult task in this form of public enterprise, as in all others. In the course of the four years of implementation of the reform the problem has already caused several conflicts and heavy media exposure. In the wider setting of general Norwegian public administration policy, this theme is discussed in Tore Grønlie, ‘Drømmen om en konkurransetilpasset stat –Ytre fristilling som styringspolitisk redskap –1945–1965’, in Tore Grønlie and Per Selle (eds), Ein stat? Fristillingas fire ansikt, Oslo, Det Norske Samlaget, 1998, pp. 66–106; Tore Grønlie, ‘Mellom politikk og marked – organisering av statlig næringsdrift’, in Bent Sofus Tranøy and Øyvind Østerud (eds), Den fragmenterte staten: reformer, makt og styring, Oslo, Gyldendal, 2001, pp. 301–32; Per Lægreid, Ståle Opedal and Inger Marie Stigen, ‘The Norwegian hospital reform – balancing political control and enterprise autonomy’, Paper to the 17th Nordic Conference on Business Studies, Reykjavik, 14–16 August 2003, Rokkansenteret, Working Paper 23, 2003; and Tom Christensen, Per Lægreid and Inger Marie Stigen, ‘Performance management and public sector reform: the Norwegian hospital reform’, Paper to the EGPA conference, Ljubljana, 1–4 September 2004.

2 For the British case, see John Mohan, Planning, markets and hospitals, London, New York, Routledge, 2002.

3 The question raised is central to the research project ‘Autonomy, transparency and management, three reform programs in health care: a comparative project’ at Rokkansenterert (Stein Rokkan Centre for Social Research), University of Bergen, see Haldor Byrkjeflot, ‘The making of the health care state? An analysis of the recent hospital reform in Norway’ (Paper to the Bergen Workshop on the History of Health and Medicine, 18–19 March 2004), in Astri Andresen, Tore Grønlie and Svein Atle Skålevåg (eds), Hospitals, patients and medicine, Conference Proceedings, Rokkansenteret, Report 6, Bergen, Stein Rokkan Centre for Social Studies, 2004, pp. 55–76; Haldor Byrkjeflot and Simon Neby, ‘Norge i Norden: Fra etternøler til pioner i reformering av sykehussektoren’, in Ståle Opedal and Inger Marie Stigen (eds), Helse–Norge i støpeskjeen: søkelys på sykehusreformen, Bergen, Fagbokforlaget, 2005, pp. 47–61. For international comparison, see, for example, Richard Freeman, The politics of health in Europe, Manchester University Press, 2000; Richard B Saltman, ‘Convergence versus social embeddedness: debating the future direction of health care systems’, Eur. J. Public Health, 1997, 7 (4): 449–53; Richard Freeman and Michael Moran, ‘Reforming Health Care in Europe’, in M Ferrera and M Rhodes (eds), Recasting European welfare states, London, Frank Cass, 2000, pp. 35–58.

4 Freeman, op. cit., note 3 above, pp. 5–7; Simo Kokko, Petr Hava, Vicente Ortun and Kommo Leppo, ‘The role of the state in health care reform’, in Richard B Saltman, Joseph Figueras and Constantino Sakellarides (eds), Critical challenges for health care reform in Europe, Buckingham, Open University Press, 1998, pp. 289–307. There is no space here to go into nuances and historical developments and change. Models like these in general exaggerate differences between health care systems and downplay historical change. Freeman himself warns against relying too much on rigid classifications, as all health systems are mixtures of different principles of organization and finance (pp. 6–7). Moreover, tensions and conflicts of a general nature of the type focused on in this article are found in all countries, whatever the systems. Models are put forward here mainly as a point of departure for a more qualified, empirically based analysis of the development of the Norwegian hospital system.

5 John Mohan, ‘Voluntarism, municipalism and welfare: the geography of hospital utilisation in England in 1938’, Trans. Inst. Br. Geogr., 2003, 28 (1): 56–74; Martin Gorsky, John Mohan and Martin Powell, ‘British voluntary hospitals, 1871–1938: the geography of provision and utilisation’, J. Hist. Geog., 1999, 25 (4): 463–82; Mohan, op. cit., note 2 above, pp. 21–67.

6 See, for example, Rolf Danielsen, ‘Kommunaliseringsprosessen i norske byer 1880–1920’, in Anne-Hilde Nagel (ed.), Velferdskommunen: kommunenes rolle i utviklingen av velferdsstaten, Bergen, Alma Mater, 1991, pp. 53–60.

7 Tore Grønlie, ‘Velferdskommunen’, in Nagel (ed.), op. cit., note 6 above, pp. 43–52; Edgar Hovland, ‘Grotid og glanstid. 1837–1920’, in Hans Eyvind Næss, Edgar Hovland, Tore Grønlie, Harald Baldersheim and Rolf Danielsen, Folkestyre i by og bygd: norske kommuner gjennom 150 år, Oslo, Bergen, Stavanger, Tromsø, Universitetsforlaget, 1987, pp. 127–43; Tore Grønlie, ‘Velferdskommune og utjevningsstat, 1945–1970’, in Næss, Hovland, Grønlie, Baldersheim and Danielsen, ibid., pp. 251–78.

8 Anne-Lise Seip, 'Velferdskommuen og velferdstrekanten – et tilbakeblikk, in Nagel (ed.), op. cit., note 6 above, pp. 24–42.

9 Aina Schiøtz, Folkets helse – landets styrke 1850–2003, series: Det offentlige helsevesen i Norge 1603–2003, vol. 2, Oslo, Universitetsforlaget, 2003, pp. 320, 322–24; Aage Engesæter and Johs B Thue, Sogn og Fjordane fylkeskommune gjennom 150 år, Oslo, Det Norske Samlaget, 1988, pp. 217–24; Finn Henry Hansen, ‘Sykehusstruktur i historisk perspektiv’, in Finn Henry Hansen (ed), Sykehusstruktur i endring: de langer linje og utviklingen siste tiår, Samdata sykehus report 3/01, Trondheim, SINTEF Unimed, NIS SAMDATA, 2001, pp. 35–63. The localized origin of hospitals is underlined also in the British case, see Mohan, op. cit., note 2 above, pp. 1–20.

10 Hovland, op. cit., note 7 above, pp. 131–2.

11 Hansen, op. cit., note 9 above, p. 38: ‘nærmest “anarkisk”’.

12 Jens Arup Seip, Tanke og handling i norsk historie, Oslo, Gyldendal, 1968, pp. 22–71.

13 NOS IX.2, Sunndhetstilstanden og medisinalforholdene 1930, Det Statistiske Centralbyrå, Oslo, 1933. The pattern of institutionalization, the institutional profile of different actors and owners, and variations over time and across regions has so far not been subjected to historical analysis in any detail. A project focusing on these problems is under way at the Rokkansenteret (Stein Rokkan Centre for Social Research), University of Bergen. Basic statistics and listings of institutions by ownership and geography in both 1960 and 1964 are given in ‘Innstilling om sykehusordningen’, Innstilling II fra komiteen til utredning av sykehusordningen (Sykehusordningskomiteen), 1963, Appendix 2, parliamentary documents (Norway), Ot.prp. nr. 36 (1967–68), ‘Om lov om sykehus’ (On law on hospitals).

14 See, for example, Hansen, op. cit., note 9 above, pp. 36–8. Accounts of inter-war municipal hospital expansion in Britain are given in John V Pickstone, Medicine and industrial society, Manchester University Press, 1986; Roger Lee, ‘Uneven zenith: towards a geography of the high period of municipal medicine in England and Wales’, J. Hist. Geog., 1998, 14 (3): 260–80; Mohan, op. cit., note 5 above, pp. 56–73; and Mohan, op. cit., note 2 above, pp. 21–44.

15 See, for example, Schiøtz, op. cit., note 9 above, pp. 320, 322–7; Engesæter and Thue, op. cit., note 9 above, pp. 217–24; Tor Selstad, Trøndelags romlige utvikling. Historier og scenarier 1030-2030, Rapport nr. 2 fra Trøndelagsprosjektet, Trondheim, NTNU, Geografisk institutt, 2002; and Astri Andresen, ‘Sykehuset – fra utkanten av helsevesenet til sentrum’, in Marit A Hauan, Einar Niemi, Helge A Wold and Ketil Zachariassen (eds), Karlsøy og verden utenfor. Kulturhistoriske perspektiver på nordnorske steder, Tromsø Museum, Universitetsmuseet, 2003, pp. 232–49.

16 Tore Grønlie, ‘1945–1972’, in Anders-Bjarne Fossen and Tore Grønlie, Byen sprenger grensene 1920–1972, vol. 4 of Bergen bys historie, Bergen, Universitetsforlaget, 1985, pp. 788–98. The running of hospitals was paid for by national health insurance (collected through taxation) on the basis of rates supposed to be sufficient to cover care on a day-to-day basis. Before the Second World War rates were set unilaterally by the hospital owner. During and after the war rates were set by the State Directorate of price controls, generally at a level considerably below the actual costs. The hospital owner had to cover the deficits. In 1980 a system of block grants was introduced. After 1997 a percentage of block grants (thirty initially, growing to sixty over the years) were made dependent on hospital activity.

17 The same kind of split between cities and towns on the one side and counties on the other, was found in the pre-NHS system in Britain, see Mohan, op. cit., note 2 above, pp. 21–67.

18 Grønlie, op. cit., note 16 above, pp. 788–98; Karl Egil Johansen, På sjølvstyr gjennom 150 år. Hordaland fylkeskommune 1837–1987, Bergen, J W Eide, 1987, pp. 164–70.

19 Engesæter and Thue, op. cit., note 9 above, pp. 217–24; Selstad, op. cit., note 15 above, pp. 27–8; Andresen, op. cit., note 15 above, pp. 232–49.

20 See Andresen, op. cit., note 15 above, pp. 232–49.

21 Engesæter and Thue, op. cit., note 9 above, pp. 217–24.

22 Schiøtz, op. cit., note 9 above, pp. 318–26; Grønlie, op. cit., note 16 above, pp. 788–98; Johansen, op. cit., note 18 above, pp. 164–70. There are striking similarities between the organizational shortcomings of the Norwegian hospital system and the lack of integration or coordination in the UK system before the establishment of the NHS in 1948, and between the political debates in the two countries, for example, Charles Webster, The National Health Service: a political history, Oxford University Press, 2002, pp. 3–7; Mohan, op. cit., note 2 above, pp. 21–67; Pickstone, op. cit., note 14, pp. 251–95.

23 Schiøtz, op. cit., note 9 above, p. 319; Hansen, op. cit., note 9, pp. 38–41.

24 Schiøtz, op. cit., note 9 above, p. 321; Hansen, op. cit. note 9, pp. 41–4.

25 Y Flo, Mellom stat og sjølvstyre: fylket i norsk styringsverk etter 1945, LOS-senter Report 0003, Bergen, LOS-senter, 2000, pp. 24–34.

26 It has been suggested that counties gradually took on an “unwritten responsibility” (det uskrevne ansvar) for hospital development, see Kari Martinsen, ‘Helsepolitiske problemer og helsepolitisk tenkning bak sykehusloven av 1969’, Historisk Tidsskrift, 1987, 3: 357–72, p. 366. Finn Henry Hansen similarly talks of an “anticipation” of a future county model of hospital ownership, Hansen, op. cit., note 9 above, p. 45.

27 Johansen, op. cit. note 18 above, p. 169; Engesæter and Thue, op. cit., note 9, pp. 296–307.

28 Partnerships were used for managing conflicts of interests between cities, towns and counties in pre-NHS Britain also, but developed to highly varying degrees, see Mohan, op. cit., note 2 above, pp. 45–67, esp. pp. 50–1. See also Pickstone, op. cit., note 14 above, pp. 272–95; and Martin Gorsky, ‘“Threshold of a new era”: the development of an integrated hospital system in northeast Scotland, 1900–39’, Soc. Hist. Med., 2004, 17 (2): 247–67.

29 An overview of hospital cooperation and partnerships is given in ‘Innstilling om sykehusordningen’, appendix 22, note 13 above.

30 Hansen, op. cit., note 9 above, p. 46.

31 Grønlie, op. cit., note 16 above, pp. 788–98; Johansen, op. cit., note 18 above, pp. 164–70; Astrid Forland, ‘Universitetet i Bergens historie 1946–1996’, in Astrid Forland and Anders Haaland, Universitetet i Bergens historie, 2 vols, University of Bergen, 1996, vol. 1, pp. 350–9.

32 For a review of the general contents of this law and the processes leading up to it, see Martinsen, op. cit., note 26 above, pp. 357–72.

33 Trond Nordby, Karl Evang: en biografi, Oslo, Aschehoug, 1989, pp. 171–92, 215–18, on p. 218; Martinsen, op. cit., note 26 above, p. 358.

34 Hansen, op. cit., note 9, p. 48.

35 Martinsen, op. cit., note 26 above, pp. 367, 371.

36 Flo, op. cit., note 25 above, pp. 52–8.

37 Ibid., pp. 38–43. Counties were not always enthusiastic about county ownership of hospitals, obviously fearing rising costs, see Johansen, op. cit., note 18, pp. 218–24.

38 Flo, op. cit., note 25 above, pp. 37–57; Grønlie, ‘Velferdskommune og utjevningsstat’, op. cit., note 7 above, pp. 199–281.

39 Engesæter and Thue, op. cit., note 9 above, p. 278; Johansen, op. cit., note 18 above, pp. 218–24.

40 Regionalization is, of course, a key issue in hospital politics in most countries, see, for example, Mohan, op. cit., note 2 above, pp. 45–67; and Daniel M Fox, Health policies, health politics: the British and American experience, 1911–1965, Princeton University Press, 1986.

41 Schiøtz, op. cit., note 9 above, pp. 330–1 (translated by Tore Grønlie): “Konfliktlinjene har gått mellom sentrum og periferi, mellom sentralpolitikere og lokalpolitikere, mellom fagekspertise og lekfolk, mellom profesjoner og mellom fageksperter lokalt og sentralt. De har dreiet seg om lokaliseringsspørsmål, om hvem som skal betale for hva, om kvalitetsbegrepets innhold og om hvem som er best egnet til å styre sykehusene—leger eller ikke leger.”

42 The continual conflicts of Norwegian hospital history are stressed as well by Finn Henry Hansen, scholar of political science and an experienced top-level health administrator, Hansen, op. cit., note 9 above, p. 36. In the case of Britain, Mohan shows how the 1962 Hospital Plan was envisaged to solve structural problems inherited from the pre-1948 system, but achieved only limited success, Mohan, op. cit., note 2 above, pp. 132–57.

43 Flo, op. cit., note 25 above, pp. 68–113.

44 Schiøtz, op. cit., note 9 above, p. 324, 374–79; Engesæter and Thue, op. cit., note 9 above, pp. 217–24; Hansen, op. cit., note 9 above, p. 54.

45 Hansen, op. cit., note 9 above, p. 54: “lite mer enn symbolske overbygninger”. Tore Grønlie's translation.

46 Ståle Opedal and Inger Marie Stigen (eds), Evaluering av regionalt helsesarbeid: sluttrapport, NIBR-rapport 2002:22, Oslo, NIBR, 2002; Schiøtz, op. cit., note 9 above, pp. 328–9.

47 O V Slåttebrekk and H P Aarseth, ‘Aspects of Norwegian hospital reforms’, Eurohealth, 2003, 9 (2): 14–16.

48 Schiøtz, op. cit., note 9 above, pp. 379–80; Maren Skaset, ‘Reformtid og markedsgløtt: Det offentlige helsevesen etter 1985’, in Schiøtz, op. cit., note 9 above, pp. 499–548, on pp. 505–7. A system of block grants from the state was introduced in 1980 after years of debate. From 1997, 30 per cent of block grants, rising to 60 per cent in 2003, was made dependent on hospital activity. There still is no thorough historical analysis of the development of the system of hospital financing in Norway.

49 Schiøtz, op. cit., note 9 above, pp. 382–3; Skaset, op. cit., note 48 above, pp. 506–7.

50 The present article focuses on basic and persistent conflicts and tensions concerning political and administrative direction and management of hospitals. A complete analysis of the successes and failures of the county authorities as hospital owners would have to include indicators more directly pertinent to patient care, such as waiting lists, access, questions of equality across counties and regions, etc. In Norway, historical research on this side of county hospital performance is still in its infancy.

51 F H Hansen, ‘Sykehusstruktur: fortid–nåtid–framtid?’, in Hansen (ed.), op. cit., note 9 above, pp. 185–6; Opedal and Stigen, op. cit., note 46 above, pp. 5–12.

52 See parliamentary documents (Norway): Ot.prp., nr. 60 (2000–2001); Innst. O., nr. 118 (2000–2001); O. tid. (2000–2001), pp. 666–89, 712–31; L. tid. (2000–2001), pp. 47–9.

53 Sturla Herfindal, ‘Veien frem til sykehusreformen. En studie av beslutningsprosessen bak lov om helseforetak’, MA thesis (hovedfagsoppgave), University of Bergen, 2004, Rokkansenteret Report 5, Bergen 2004.

54 Harald Baldersheim, ‘Det regionpolitiske regimet i omforming – retrett frå periferien; landsdelen i sikte!’, Norsk Statsvitenskapelig Tidsskrift, 2003, 3: 276–307; Harald Baldersheim and Larry E Rose, ‘Kampen om kommunen: Foran et nytt kommunalt hamskifte’, Norsk Statsvitenskapelig Tidsskrift, 2003, 3: 231–9.

55 Flo, op. cit., note 25 above, pp. 43–9.

56 See parliamentary documents, note 52 above. The negative attitude towards democratic input is central to recent British hospital reform as well, see Mohan, op. cit., note 2 above, p. 220.

57 After two years of mounting criticism about the lack of democratic influence over the regional hospital boards, the coalition government of the Labour Party, the Agrarian Party and the Socialist Left, which came to power after the 2005 elections, has promised to reinstate county politicians on the boards.

58 Baldersheim and Rose, op. cit., note 54 above, pp. 231–9; Anne Lise Fimreite, Der hvor intet er, har selv keiseren tapt sin rett! Om lokalt folkestyre og rettigheter, Rokkansenteret Report 8, Bergen, 2003; Anne Lise Fimreite and Yngve Flo, ‘Den besværlige lokalpolitikken’, Nytt norsk tidsskrift, 2002, 3: 310–21.

59 Øyvind Østerud, Fredrik Engelstad and Per Selle, Makten og demokratiet: en sluttbok fra Makt- og demokratiutredningen, Makt- og demokratiutredningen 1998–2003, Oslo, Gyldendal, 2003, pp. 9–151.

60 Grønlie, ‘Velferdskommunen, op. cit., note 7 above, pp. 43–52; Hovland, op. cit., note 7 above, pp. 127–43.

61 Fimreite, op. cit., note 58 above; Fimreite and Flo, op. cit., note 58 above.

62 Christopher Pollitt and Geert Bouckaert, Public management reform: a comparative analysis, Oxford University Press, 2000; Tom Christensen and Per Lægreid (eds), New public management: the transformation of ideas and practice, Aldershot and Burlington, VT, Ashgate, 2001; Bengt Jacobsson, Per Lægreid and Ove K Pedersen, ‘Robust and flexible states: the transnationalisation of Nordic central administration’, Zeitschrift für Staats- und Europawissenschaften, 2004, 1: 1–24; Tom Christensen and Per Lægreid, ‘New Public Management i norsk statsforvaltning’, in Tranøy and Østerud (eds), op. cit., note 1 above, pp. 67–95.

63 Grønlie, ‘Mellom politikk og marked’, op. cit., note 1 above, pp. 301–32; Øyvind N Grøndahl and Tore Grønlie, ‘From the Swedish ideal to EU direction: Scandinavian central state administrative reform in the 1980s and 1990s, in a post-1945 perspective’, Jahrbuch für Europäische Verwaltungsgeschichte, 2004, 16: 151–96.

64 Grønlie, ‘Mellom politikk og marked’, op. cit., note 1 above, pp. 319–22.

65 Lov om helseforetak mm. (Law on health enterprises and more), §30; Vedtekter (statutes), §9.

66 Grøndahl and Grønlie, op. cit., note 63 above, pp. 168–83.

67 See Grønlie, ‘Mellom politikk og marked’, op. cit., note 1 above, pp. 301–32.

68 It now seems possible to draw some preliminary conclusions from the ongoing social science research on the four years of putting the reform into effect. The reform, hailed by proponents as an instrument of decentralization, so far, displays clear signs of centralization. Regional enterprises have been subjected to detailed instruction from highly active Ministers of Health, both through the use of extraordinary “enterprise assemblies” and through departmental politico-administrative instruction. Paralleling this, Parliament and individual members of Parliament have been more active in hospital affairs than before state take-over, often delving into conflicts concerning the balance between localism and centralization, thus in many ways filling the vacuum left by the elimination of county politicians from hospital politics and organization. See, for example, Lægreid, Opedal and Stigen, op. cit., note 1 above; Christensen, Lægreid and Stigen, op. cit., note 1 above; Ståle Opedal and Hilmar Rommetvedt, ‘Foretaksfrihet eller stortingsstyring?’, in Opedal and Stigen (eds), op. cit., note 3 above, pp. 64–85; Ståle Opedal, ‘Helsedepartementets styring av helseforetakene – rollemangfold og styringsutfordringer’, in Opedal and Stigen (eds), op. cit., note 3 above, pp. 86–106; Haldor Byrkjeflot and Tore Grønlie, ‘Det regionale helseforetaket – mellom velferdslokalisme og sentralstatlig styring’, in Opedal and Stigen (eds), op. cit., note 3 above, pp. 198–218.