The sustainability of universal health care



    Our national health service is on the brink of collapse due to the way that resources are being used. We highlight three major threats and call for a rethink and for unity.

    In Norway, there has been broad political agreement and little debate about the value of a national health service based on quality, equality and solidarity. For 70 years, this public good has been a cornerstone in a society characterised by a sense of community and trust. But that is now starting to falter. The national health service is under threat from several quarters, and we must ensure its sustainability.

    The concept of sustainable development can be used to highlight situations where there is concern that the way we use resources will cause serious or irreparable harm, as described in the UN report 'Our Common Future' published in 1987 (1). In the report, Gro Harlem Brundtland set out the risk that the earth faces of becoming uninhabitable for future generations due to the senseless management of resources.

    The primary threat to the sustainability of our health service lies in the overuse of health care, i.e. more extensive examinations and treatment than is beneficial to the patients. According to the OECD, 20 % of the health service resources in member countries are wasted (2). Norway spends a larger proportion of public funds on the health service than most countries. It also has more doctors and nurses and takes more MRI scans per capita (3–5). Nevertheless, the reality is that the resources are not always suffice or are not always channelled to where the need is greatest. More is not always better, and effort beyond an optimal level will eventually do more harm than good (6). Meanwhile, resources are being drained from key tasks, which is pushing up demand and creating justified dissatisfaction among patients and their families, as well as burn-out and loss of meaning for healthcare professionals.

    The health service as we know it is heading towards the precipice of irreversible collapse

    Another threat to our health service is the growing leakage of resources from publicly organised services to private healthcare providers. A sustainable health service can include some elements of private enterprise, provided that the work is based on an overarching social contract. However, what is currently taking place is the uncoordinated emergence of private healthcare providers who are likely to increase both the supply and demand for low-value services (7). These healthcare providers tend to offer high salaries and convenient working hours. Their recruitment methods are aggressive and entice disillusioned professionals into leaving the public sector (8). The national health service as we know it is heading towards the precipice of irreversible collapse. This will lead to a growing uptake of private healthcare services among the more affluent in society, even those who want a system based on solidarity and equality. If this does happen, Norway will no longer be able to offer first-class health care to those with the greatest need and the least ability to pay.

    A third argument for a rethink has to do with the climate crisis, which the World Health Organization ranks as the greatest threat to global health (9). A rapid deterioration in basic living standards and life circumstances is being seen in many parts of the world, with a negative impact on the health of large population groups. The climate crisis is changing the spread of diseases and leading to poverty and desperate migration. In the next phase, existing infrastructure, including the health service, will be overloaded. Juxtaposed with this are the large emissions of greenhouse gas by the health service itself. Although Norway joined the UN's COP26 Health Programme, this only commits hospital trusts to 'climate neutral operations' by 2045 (10, 11). A first step to securing our collective future should be to eliminate activity in the health service that gives marginal health benefits, can cause harm and leaves a large carbon footprint (12).

    In her speech to the hospital sector in 2023, the Minister of Health and Care Services painted a grim picture of the future reality. What we were missing, however, was visionary holistic thinking that could ignite hope in the face of the threats to the health service. The Government has identified the UN's Sustainable Development Goals (SDGs) as its political superstructure (13). In light of this, Ingvild Kjerkol, the Minister of Health and Care Services, should have presented an objective to regulate private healthcare providers in accordance with a social contract of solidarity and explicitly addressed the health service's own climate responsibilities. However, the Minister made it clear that overuse of laboratory services and medical imaging must be identified and reduced. Our own professional community must continue to lead the way and identify activities and interventions that do not improve health and may be harmful. Examples of such initiatives related to the Choosing Wisely Norway campaign (Norwegian Medical Association) include 'Value-based radiology in Western Norway', 'Don't jab me without a reason' (University Hospital of North Norway) and 'Sustainability in general practice' (Norwegian College of General Practice).

    We have been too indifferent to overdiagnosis and overtreatment, solidarity is waning, and global warming is threatening both our infrastructure and living conditions. A rethink is needed posthaste. Can we agree on a change of course before it is too late?

    Reply to article

    Recent Articles

    Made by Ramsalt Using Ramsalt Media