What became of solidarity?

Mette Brekke, Torben Wisborg About the authors

Maintaining a health service characterised by solidarity requires everyone to do their part. Private health insurance schemes run counter to such solidarity.

We can be proud of today’s health service in Norway. It has been built up over several generations and is funded by the community (1). The service today allows each inhabitant to have their own GP who specialises, follows clinical guidelines and is concerned to avoid overdiagnosis (2). If we become severely ill, we have access to an advanced, specialist health service, irrespective of income or where in the country we live – without having to sell the house or jeopardise our children’s schooling in order to pay for it.

This universal health service is based on solidarity. Solidarity (from the Latin solidum) means ‘an awareness of shared interests, objectives, standards, and sympathies creating a psychological sense of unity of groups or classes.’ (3). We all contribute jointly to the health services through our social insurance payments – irrespective of whether we are healthy or ill, or whether we lead a healthy lifestyle or one fraught with risks. If and when we need it, society is there for us. We trust that the resources will be fairly allocated, even when the resources are scarce and we need to join a queue and wait, for example.

Some measures are clearly marked by solidarity. The healthy among us give blood – because we know that some need it, but also bearing in mind that someday it may be our turn. Most of us are willing to donate our organs (4). We vaccinate our children, even though they are robust and may well withstand both measles and the rotavirus. We know, however, that there are other children with immunodeficiency for whom such infections may pose a serious risk, and that failure to vaccinate weakens herd immunity. In the Norwegian population there is great willingness to give first aid – another act of solidarity. Nobody asks about income or insurance status when a patient is acutely ill or seriously injured. Emergency treatment is provided to everybody in a demonstration of solidarity.

Is the value basis for and endorsement of these universal, solidarity-based and needs-based health services in the process of eroding? There are signs that this may be so. The proliferation of private health insurance – or more correctly: treatment insurance – is a case in point. In 2016, these insurance schemes encompassed a little more than half a million Norwegians, and the number is rising (5). Treatment insurance ensures treatment within a defined time ‘both by a specialist and for surgery’ and offers an additional online medical service ‘as a supplement to the regular GP’ (5). This guarantees rapid treatment for those with insurance, even when there is waiting time for the public services.

Solidarity implies the fundamental notion that we all depend on each other, and that what benefits society will also benefit each individual in the long term

Such insurance schemes run counter to the principle of solidarity at several levels. First, they are based on the presumption that the public health services are unable to cater to exactly my need as quickly and as smoothly as I want. The mass of the population may resign itself to waiting times and limitations, but I want to go directly to the head of the queue. Second, they are designed for those who have the least need for comprehensive, full-scale health services, namely the young, healthy and able-bodied section of the population. Third, they drain all public health service sectors of qualified personnel. After all, there is only a limited supply of radiologists, physiotherapists, neurosurgeons etc. The vicious circle has been set in motion, and ‘the inverse care law’ is entering into force (6): those who need the most receive the least, and vice versa.

This effect can be reinforced if the section of the population with the most resources ceases to endorse public health services that they themselves have little use for. The consequence could be that resource availability in the public health service is further weakened, which in turn provides better growth opportunities for private health insurance, etc. Is this the type of health service that we want?

Maintaining health services based on principles of solidarity requires everyone to do their part. Short-term personal gain, such as treatment insurance, moving abroad to avoid Norwegian taxes or buying a place at the head of the queue from private healthcare providers may be tempting, but it destroys the legacy that we share. Moreover, using your education, which has been paid for by society, for the benefit of society is also important and valuable.

Solidarity implies the fundamental notion that we all depend on each other, and that what benefits society will also benefit each individual in the long term (7). A health service based on commercial principles violates this. We have created a unique health service in response to the poverty, suffering and fear of previous generations. Now, we are responsible for managing it wisely for the benefit of future generations.

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