An issue of morality

Charlotte Haug About the author

Are the public health services being threatened by a discussion of various models for self-payment? Or is the absence of such a discussion even more serious?

Photo: Einar Nilsen

«For the first time, Norwegian authorities are considering whether children should pay a patient’s charge for vaccines at the health centre. It’s a disgrace!» Preben Aavitsland wrote on Twitter on 1 June 2012 (1). The background to his comment was that in its meeting on 4 June, the National Council for Quality and Priorities in the Health Services planned to discuss whether the rotavirus vaccine should be included in the national programme for vaccination of children (2). Like most new drugs, the vaccine is costly. The disease that it is intended to prevent is uncomfortable, but not very serious, and it passes in a few days. Nearly all children are infected by the rotavirus before they turn five, and many fall ill. In total, this adds up to a lot of days absent from work for the parents, and hence incurs a large cost to society and employers. The essence lies in balancing the inconvenience of having children vomiting and suffering from diarrhoea for a few days – or even going to hospital – against the monetary cost and the healthcare resources involved in vaccinating all Norwegian infants. Vomiting and diarrhoea are uncomfortable, but since the advantage of the vaccine mainly consists in fewer days absent from work for the caregivers, some countries that have introduced the vaccine demand a patient’s charge from the parents. One could also consider the willingness of employers to pay for or subsidise the vaccine, similar to current practices pertaining to the flu vaccine. These were among the topics that some members of the council wished to discuss. Aavitsland, on the other hand, found such a discussion disgraceful.

Preben Aavitsland resigned as Deputy Head of Division at the National Institute of Public Health in February 2012, having worked there for numerous years on issues related to vaccines and the prevention of communicable diseases. Currently, he is one of three candidates for the directorship after Geir Stene Larsen, who was recently appointed to the position of Director General in the Department of Public Health of the Ministry of Health and Care Services. The Institute of Public Health recommends that the rotavirus vaccine should be included in the national programme for vaccination of children. The fact that Aavitsland pleads for this cause is thus neither very surprising, nor very questionable. But why does he think it is disgraceful to discuss various payment alternatives for the vaccine?

In no. 9/2012 of this journal I wrote about private health insurance (3). It is a fact that a growing section of the population buys such insurance policies. It is self-evident that this trend has a number of questionable aspects (4, 5). Not least, this violates our Norwegian ideals of equality, because in the world of insurance some are more equal than others. Not everybody can have the opportunity to acquire private health insurance. For example, the client should preferably be healthy and have no known risk factors for illness. Only in this way can the insurance companies make a profit – by convincing people that they are at greater risk that something will befall them in the future (for example a serious illness) than they really are, so that they will be willing to pay an insurance premium that over time is higher than the disbursements made by the insurers. Those who really need insurance do not get any, and those who have less need for it, do. This is unfair. This notwithstanding, my reason for voicing the view that we ought to lift the taboo on the discussion of private health insurance was to highlight the fact that out-of-pocket payment for health and care services is already practised on a large scale, and that in my opinion it is better to discuss the arrangements for co-financing openly, rather than just to close our eyes and pretend that all is well. Many welcomed this debate, others claimed that just raising the issue could serve to undermine the public health services. Nobody has so far stated that I ought to be ashamed of myself, but there are implications that it is bordering on the improper to suggest that one alternative to not providing a public service at all is to provide it to those who want to contribute out of their own pockets.

We proudly describe our healthcare system and our welfare schemes as being equally and fairly distributed, and that those who need it are provided with help according to their needs and not according to the size of their wallets. But is this true? For example, we have a sickness benefit scheme which is the envy of workers in many other countries: Full compensation from day one in case of illness – nobody should be punished financially for being ill. That’s excellent! It is harder to explain to outsiders why this principle applies for only one year, and only if you are employed when you fall ill. If you are seriously ill over a long period, your Norwegian sickness benefit is cancelled after one year. If you are unemployed and fall ill, you receive no sickness benefit at all. Nor is it so easy to explain why we have chosen to address problems with vision and teeth separately. Most countries perceive dental and optical care as the self-evident responsibility of the public health services.

Norwegian health care has many positive aspects, but also significant problems in keeping pace with everything that ought to and could be done for the patients. It is unlikely that we will be able to provide all the necessary resources by way of increased taxes and public transfers. Furthermore, the population also has varying preferences with regard to the health services they wish the public sector to pay for. This applies especially to less serious diseases – such as a rotavirus infection. Some parents will not object to giving their child a vaccine to reduce the risk of diarrhoea, vomiting and having caregivers stay away from work. Others, on the other hand, would prefer the district nurse to spend more time on other things.

In its meeting, the priority council spent several hours discussing the rotavirus vaccine. They recommended that it should not be included in the national programme for vaccination of children. They would rather seek to ensure that those who want the vaccine should be provided with it in other ways (2, 6). It is reassuring to see that we have a priority council that can say no and is willing to engage in these difficult, but necessary debates.

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