Health Policy A policy for Iceland's health services until 2030 - Government of Iceland Ministry of Health
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Health Policy
A policy for Iceland’s health services until 2030
Government of Iceland
Ministry of Health
Health Policy A policy for Iceland’s health services until 2030
A policy for Iceland’s health services until 2030 Published by the Icelandic Ministry of Health 2019 Translation by Jeffrey Cosser Printed by Pixel Designed by Hvíta húsið ISBN 978-9935-477-70-5
Table of Contents
A message from the Minister of Health, Svandís Svavarsdóttir..........................................................................................4
Introduction.....................................................................................................................................................................................5
Why is a policy needed?................................................................................................................................................................6
Health in a broader context ........................................................................................................................................................ 7
A healthy nation: opportunities and challenges ...................................................................................................................8
We face challenges ... ...................................................................................................................................................................9
... but also many opportunities................................................................................................................................................ 11
The health system in a broader context................................................................................................................................. 13
Trends in the Nordic healthcare systems .............................................................................................................................. 14
Future vision and policy up to the year 2030........................................................................................................................ 15
1. Leadership for results .................................................................................................................................................. 16
2. The right services in the right place ......................................................................................................................... 19
3. People in first place......................................................................................................................................................24
4. Active users .................................................................................................................................................................... 27
5. Efficient service purchasing .......................................................................................................................................29
6. Quality first......................................................................................................................................................................32
7. Thinking about the future............................................................................................................................................34
Implementing the policy ............................................................................................................................................................39
Principal sources..........................................................................................................................................................................39
Health Policy 2030
A message from the Minister of
Health, Svandís Svavarsdóttir
ity and outcomes in the health services to reflect
how well they meet the requirements of users and
society at large. By having the funding and payment
systems include important incentives designed to
ensure that patients and their health problems will
be treated as part of an overall vision instead of
focusing on individual consultations with specialists
or individual referrals for hospitalisation. By intro-
ducing new methods of treatment, new medications
and equipment, together with demands regarding
skill and experience when they are applied. By giving
patients and the general public guidance and ena-
The health system is one of the cornerstones of bling them to play an active part in their own treat-
our society and part of our social contract. At some ment and take informed decisions on issues regard-
point in our lives we all need the health services, ing their own health. Finally, the policy addresses
and access to quality health care is one of the basic the staffing of the health system, leadership and
preconditions for being able to live in our country. administration, the working environment, science
and education and many other things.
Iceland’s health services have long been ranked
highly in comparison with other countries, and in Allocations to health care in Iceland amount to
many areas their outcomes rank among the best in just over a quarter of the state budget. The state
the world. must be in control when funds are spent, acting as
a responsible, well-informed and critical purchaser
Our health system is based on certain values on of services on behalf of us all. The role of the Min-
which a general consensus reigns throughout soci- ister of Health is clearly defined: the law states that
ety. The underlying principle is that the state guar- the minister is to lay down policy on health issues,
antees all people in Iceland the necessary health decide on the priority ranking of tasks and ensure
services, irrespective of their financial standing or that funding is available for them.
other circumstances. The structure rests on a social
foundation, with everyone enjoying equality of enti- The health policy published here belongs to us all.
tlement to the services in a system that is for the Its roots go back a long way: it draws on the accumu-
most part publicly funded. lated experience and expertise of many individuals
and much of what appears here has been discussed
By its nature, the health system is complex and and presented in reports and analyses by various
many-sided, with a high degree of specialisation and bodies and experts over the past few years.
a large number of service providers. It falls to the
authorities, in collaboration and consultation with Now all this work has been brought to fruition by the
institutions within the system, to create a holistic adoption of a parliamentary resolution on a health
system that will ensure seamless services to patients policy until the year 2030. At the same time, we face
at the appropriate service level, combining quality, a new challenge, since now begins the work on put-
safety, efficiency and cost-effectiveness. All this can ting the policy into practice – a policy that will guide
only be achieved by having a clear vision and long- us in building up a comprehensive, strong and even
term policy for the health services. better health system for us all in the future.
The present health policy until 2030 outlines ways Svandís Svavarsdóttir, Minister of Health
of working towards these goals: by adopting greater Reykjavík, June 2019
flexibility in structure, division of labour and respon-
sibilities so as to improve services to patients. By
the introduction and application of criteria on qual-
4
Health Policy 2030
Introduction
Work on drawing up a health policy until 2030 began of these made substantive criticisms, as was to be
in the Ministry of Welfare in April 2018. It was based expected when such a complex and important issue
on many surveys and analyses of various aspects of is under discussion; others resulted in revisions of
Iceland’s health services made in recent years, and wording to produce a clearer description and to
reference was also made to data from the WHO and embrace the dissimilar positions of the various play-
other materials, including Health 2020, the European ers involved.
policy for health and well-being up to 2020, and also
the goals set out in the United Nations’ Agenda for The Minister of Health submitted the policy to the
Sustainable Development. 149th legislative session of the Althingi with a pro-
posal on its adoption as the nation’s health policy
In October 2018, the Ministry of Welfare held a two- until the year 2030 (Parliamentary Document 835
day workshop for representatives of all the regional – Matter No. 509). Following the first debate in par-
health authorities, calling for their future visions and liament, the proposal was discussed in the Welfare
priorities to be taken account of in compiling the Committee, which invited comments from large num-
The Health Policy until 2030 will be
implemented by means of five-year action
plans, which will be revised annually during
the lifetime of the policy. The action plans
will be submitted to the Althingi by the
Minister of Health.
policy. Further meetings were held to involve health- bers of people and held meetings with healthcare
care workers’ professional associations and trade professionals. It received 38 submissions in all. The
unions and other providers of healthcare services. Welfare Committee completed its examination of the
matter in May, and on 3 June 2019, Iceland’s Health
On 2 November, the Minister of Health held a health Policy until 2030 was approved unanimously by 45
conference at which a draft text of the policy was members of the Althingi.
unveiled, followed by discussion of the future vision
and the main tasks facing the health system in the The policy will be implemented by means of five-
coming years. year action plans, which will be revised annually
during the lifetime of the policy. The action plans
The draft policy was published for comment via will be submitted to the Althingi by the Minister
the government’s consultative portal between 28 of Health.
November and 19 December 2018. Comments were
received from health authorities and educational
institutions, professional associations, patients’
associations, local authorities and individuals. Some
5
Health Policy 2030
Why is a policy needed?
Everybody needs to make use of the health ser- While the Minister of health, as the director of health
vices at some time in their lives. Individual needs affairs in Iceland, has great responsibilities, the
vary from person to person, ranging from general country’s healthcare institutions, and other bodies
health-promoting measures and support so as to under the ministry of health, play an important role
enhance well-being and prevent disease to more in implementing the necessary changes. It is also
complicated services to deal with the consequences unavoidable that other ministries, such as those
of accidents and chronic or acute illnesses. of finance and economic affairs, education, culture
and science, and the Ministry for the environment
Iceland’s health system is in many ways sound and and natural resources, play a part in implementing
comes out well, in terms of the results it achieves, in the health policy adopted, together with the local
international comparison. It has well-educated and authorities, trade unions of the health service work-
competent staff in all areas of the service. Never- ers and consumers’ NGOs.
theless, there is room for improvement. Depending
on whereabouts people live, there are sometimes
problems with access to some parts of the service,
waiting-lists for certain types of operation are too
long and patients’ need for seamless services are
not met as they should be. Last but not least, there
has been a lack of clear policy for the development
of the health services. At times, the supply side of
the service has weighed more heavily in steering the
course than have the public’s needs; decisions on
policy have not been taken and prioritisation criteria
have not been clear.
The main goal of Iceland’s health legislation is that
all people in the country should have access to the
best possible services that can be provided at any
given time to protect their mental, physical and
social health. Discrimination of all types is prohib-
ited, and if it proves necessary to prioritise patients
in access to treatment, then this is to be done first
and foremost on medical considerations and other
grounds of a professional nature. The authorities
must tackle the challenge of improving the perfor-
mance of the health services within the financial
framework applying at any given time.
Health 2020, the European policy for health and
Well-educated and competent staff are important in
well-being up to 2020, which the WHO Regional
determining the quality of performance in the health
Office for Europe published in 2012, is based on
services, but to maximize efficiency in all areas it is
certain fundamental values: fairness, sustainability,
vital that staff share a common vision of the pur-
quality, transparency, responsibility, gender equal-
pose and aims of the service, its future organisation
ity, respect and the right to participate in decision
and the best way of structuring their work.
making. These basic values encourage the develop-
By law, the Minister of Health is to set out a policy ment of people-centred health services on a social
for the health services and ensure that it is applied. basis, the promotion of health at all stages of life
This means that the minister both may and must and equality and health for all. The health policy set
take account of the results achieved by the service, out here extends to the year 2030, and the WHO’s
in both the short and long term, and take measures aforementioned policy has been taken into account
to improve them when necessary. in its preparation. The present report covers matters
6
Health Policy 2030
including health and the health services in a broader • Active users
context, trends in the Nordic healthcare systems and
the main challenges and opportunities faced by the • Efficient service purchasing
health services in the future. In addition, a future
vision is set out regarding the fundamental pillars
• Quality first
of Iceland’s health services. Seven key topics are
examined to illustrate this future vision:
• Thinking about the future
• Leadership for results
• The right services in the right place
To implement the health policy up to 2030, an action
plan will be drawn up for five years at a time; this
• People in first place
will be updated every year during the policy period.
Health in a broader context
While good health services contribute to life expec- stances of various types play a large role, but indi-
tancy and individual health and well-being, other viduals themselves can also make an impact through
factors are more important. Environmental factors, the lifestyles they adopt. These include choices
such as access to clean air and water and whole- regarding diet, exercise and contact with family and
some food, are of great importance. Economic fac- friends. It is not necessary to go into detail about
tors, social factors and the existence of a good wel- the damaging effects of smoking, excessive alcohol
fare system also make important contributions. Also, consumption and drug abuse.
individual responsibility for one’s own health and
well-being is an important consideration. All of this Promoting health is a process that enables people
is covered in the United Nations’ Agenda for Sustain- to have greater influence on their own health, and
able Development, which Iceland, in collaboration to improve it, with a comprehensive approach as
with other nations, is involved in implementing. the key to results. Iceland’s public health policy was
laid down in 2016. In it, a future vision was stated
in which the school system, workplaces and insti-
tutions would become ‘health-promoting’ and work
to increase the amount of exercise people took and
the time they spent out of doors, improve their diet
and encourage the cultivation of mental health, as
There are 17 goals in the UN Global Development all of this results in better health and well-being.
programme which are intended to promote peace Health considerations were to be a guiding principle
and freedom in the world. The eradication of poverty in all policymaking (an approach summed up in the
is one of the largest global goals and is an absolute phrase health in all policies). Surveys of health and
condition for sustainable development. The third well-being in Iceland indicate that both children and
goal is to ensure healthy lives and promote well-be- adults do not get enough sleep; this is a problem
ing for all at all ages. Statistical indicators have shared with many other western nations. Insufficient
been laid down for assessing progress towards its sleep inevitably leads to numerous psychic and
achievement. somatic illnesses among both children and adults,
and is, unfortunately, frequently underestimated as
The World Health Organisation defines health as a an underlying cause.
state of physical, mental and social well-being, and
not merely the absence of disease or infirmity. At all Over the past ten years, the Directorate of Health
stages of life, a great number of factors affect our has deliberately encouraged health-promoting
ability to look after our health and enjoy a fulfilling work in schools and workplaces and entered into
life. As was mentioned above, external circum- agreements with many local authorities in Iceland
7
Health Policy 2030 on establishing a ‘health-promoting society.’ This They intended as a way of enabling local authorities includes a focus on improving both people’s man- and health services to assess their standing within made and social environments, reducing inequality their regions, identify their strengths and weak- and the incidence and consequences of chronic nesses and understand the needs of their inhabit- illnesses by means of preventive and health-pro- ants and patients so as to make it possible to col- moting work of many types. The directorate also laborate on improving health and well-being. maintains core health indicators, publishing them for each healthcare administration region in Ice- land. Core health indicators are designed to provide insight into public health in each region and to ena- ble comparisons with figures for the whole country. A healthy nation: opportunities and challenges As mentioned above, the Icelandic health system government areas and schools across the country. is in many ways good and it scores well in inter- Iceland’s natural environment, with easy access national comparison: this is demonstrated in the to fresh air and clean water, provides a favourable OECD’s regular ‘Health at a Glance’ surveys. Through- framework for attaining good health. out, it is manned by well-educated and competent staff. There is a general consensus that the service All the factors listed above are clear strengths in the should be publicly funded, and there is broad and Icelandic health system. The same may be said of firm support for the view that health care should be the country’s demographic structure, as the popula- a priority in the allocation of shared resources. The tion is still relatively young. Databases on illnesses way the system is structured, with one large health- and Icelanders’ genetic characteristics and propen- care institution in each regional division, makes for sities provide a rich potential for scientific studies flexibility and opens the way to adapt the services for the benefit of the Icelandic people, the training to the needs of the local people. The Directorate of of healthcare workers and the development of the Health attends to important public health projects health services. and supports health-promoting measures in local 8
Health Policy 2030
According to Statistics Iceland, the average
From the 2017 survey by Icelandic woman lives 84 years and the
the Directorate of Health average man 81 years; these figures are
among the world’s highest.
21% of Icelanders regarded their
mental health as passable or poor
• According to projections by Statistics
26% of Icelanders regarded their Iceland, the number of people aged 80
physical health as passable or poor and above will rise by about 5,700 by the
27% of Icelanders had a Body Mass year 2030, an increase of 46%.
Index of >30
• According to the OECD in 2018,
240 hip-replacement operations were Icelanders aged 65 could expect to live
performed per 100,000 of the another 20 years on average. Of these
population
20 years, men can expect four years with
On average, 67 people were waiting a reduced level of health; women could
for places in nursing homes at any expect six such years.
given time
On average, people consulted medical
specialists 1.4 times a year Iceland’s geographical isolation counts for little in
the modern world, since the rapid development
On average, people consulted primary of transport and communications has opened the
health centres 2.6 times a year country to international influences in all areas of
There were 42,139 hospitalisations society. The health services are no exception to this,
and it is clear that the process will continue with
There were 315,802 out-patient- ever-increasing foreign contact and globalization.
department visits
We face challenges ...
Life expectancy has risen appreciably in the past with the highest life expectancy. It can therefore be
few decades in Iceland, and the population is ageing expected that the incidence of the illness will rise
even though it is still young in comparison with most considerably by 2030.
other western countries. This trend poses various
challenges, including as regards the welfare system, Chronic illnesses affect not only the older genera-
where the need for services grows as the number of tion. The World Health Organisation ranks chronic
elderly people becomes a larger proportion of the illnesses, such as cardio-vascular diseases, cancer,
whole. Health problems connected with certain life- pulmonary diseases, diabetes and psychiatric disor-
style-related diseases and chronic health conditions ders as the principal threats to human health. They
have also become more common and led to growing are estimated to case about 70% of all deaths in the
strain on the health system in recent decades. Exam- world each year. They can largely be attributed to
ples of this are obesity and various serious problems the lifestyle that has become dominant in western
associated with it, addictive illnesses and a range countries in recent decades.
of psychiatric disorders. These and other challenges
Obesity is a growing problem in Iceland as in other
are examined in further detail below:
countries, and both children and adults are affected.
Dementia is an example of a chronic illness that It can have serious consequences, both in terms
affects older people. Reports from the OECD show of health and social well-being. According to the
that dementia is most common in the countries Directorate of Health’s core health indicators, about
a quarter of the Icelandic population have a body
9Health Policy 2030
mass index (BMI) of over 30, which is the definition contribution during this training period, in addition
of obesity; the situation varies from region to region. to which some of them end up living and working
abroad. Consequently, there is a need to invest con-
Changes in the composition of the population, with stantly in the education and training of all health-
an increasing proportion of people of foreign origin, care workers and to create a working environment
are impacting the expectations made of the health in Iceland that will stand comparison with the best
services. Immigrants take time to gain competence in our neighbouring countries. It is also important to
in Icelandic and become acclimatised to the local strengthen interdisciplinary team work involving all
culture. When planning services in the future, it is occupations in the health system and to develop and
important to take account of the demands made by improve jobs in the system on a continuous basis.
a multi-cultural society. One example of this is the
need for access to interpreters and the publication New medicines and medication use. One of the
of information in various foreign languages. important challenges in the health system is to
ensure Icelanders a sufficient supplies of necessary
Access to the health services is uneven in some medications and also their quality and responsible
respects, though it is generally good. Specialists use. Overuse of antibiotics results the emergence
tend to be concentrated in the metropolitan area, of bacteria that are immune to these drugs; this
with access more difficult in the rural areas in pro- has been recognized as one of the greatest threats
portion to the distance from the capital. Measures that humanity faces. In this respect, Iceland is still
must be taken to remedy this. The same may be in a relatively good position, but there are evident
said of the waiting lists for certain operations; in signs that we have been using excessive quantities
some cases they are far too long. Furthermore, it of broad-spectrum antibiotics. The growing supply
needs to be taken into account that people with of new, extremely expensive drugs results not only
mental and physical disabilities, serious psychiat- in huge costs but also leads to difficult ethical ques-
ric disorders, addiction problems and diminished tions regarding prioritisation in the health system.
capacity of other types may find it difficult to make
use of the services that are available unless special Purchase of health services: this is one of the chal-
measures are taken to meet their needs. lenges ahead. One intention behind the Health
Insurance Act, No. 112/2008, was to structure the
Staff recruitment in the health services is an inter- purchase of health services by the state in the same
national challenge, not least as regards nurses and way as is generally the case in the other Nordic
physicians. Competition for staff in these profes- countries. Icelandic Health Insurance (Sjúkratryggin-
sions is becoming tougher, and changing conditions gar Íslands) was entrusted with doing this. According
regarding transport, for example, have enabled to a report by the Icelandic National Audit Office
Icelandic healthcare workers to take employment, from 2016 on the outcome of the application of
part-time or full-time, in the other Nordic countries, the act, there are many indications that the aim of
where they are in great demand. For the most part, the act as regards the purchase of health services
Icelandic physicians have to take elective courses has not been achieved. The National Audit Office’s
or further training in other countries, with the result report pointed out that contracts on the purchase of
that the Icelandic system is deprived of their labour services were not based on in-depth cost analyses
10Health Policy 2030
and that purchasing was not subject to sufficiently specialists operating in their own clinics where it is
rigorous priority ranking on the basis of patients’ difficult to provide composite services to meet the
needs; this could result in poor cost-effectiveness. needs of chronically ill patients and elderly people
The report also pointed out that stricter demands suffering from a number of health problems. One of
needed to be made regarding service quality, and the consequences of this trend is that Landspítali
that the state should at all times take the initiative has had to engage specialists on a part-time basis
on the purchase of health services. In addition, the to a greater extent than previously, which interferes
report says it is high time that service-based funding with the normal circulation of patients and makes
was introduced at the National University Hospi- it more difficult for the management to organise
tal (Landspítali) so as to maximize efficiency and the functioning of the hospital. In this connection,
streamlining in its operations. it is sufficient to refer to the McKinsey 2016 report
Lykill að fullnýtingu tækifæra Landspítalans (‘The
Spending on health care in Iceland comes to just key to utilising Landspítali’s opportunities to the
over ISK 200 billion each year, representing c. 8.7% full’). Spending on health care is rising in most
of GDP. This proportion has fallen since the begin- countries, and Iceland will be no exception to this in
ning of this century, when it was c. 10%. Furthermore, the future. In the same way, it is natural to make the
GDP was significantly reduced following the financial demand that resources already spent on the health
crisis of 2008, and the health system did not escape services be utilized in the best possible way, e.g.
unscathed. During this time, the health system has by making changes as regards workloads, the pur-
undergone changes of various types which it would chase of services and the general structuring of the
be difficult to defend as being for the better in the health system.
long term. For example, the activities of the day-
care and out-patients’ departments of the hospitals
have, to a large extent, been replaced by private
... but also many opportunities
Many opportunities are concealed in the challenges becoming increasingly aware that one’s lifestyle
that the health system is currently facing, and it is can promote good health. Good results have been
important to make use of them. Ways of doing this achieved in reducing smoking and the damaging
include improving public health and influencing abuse of alcohol, and an understanding of the ben-
people’s lifestyles. Health-promoting measures for efits of good diet and suitable exercise is becoming
elderly people should be a particular priority here in more widespread. Nevertheless, there is room for
the light of the advantages to be gained from them. improvement here, particularly among children and
Making use of technological innovations opens up the elderly. The Directorate of Public Health has
opportunities of many types; this applies also to put great effort into promoting health all over the
changes in the funding of the health services and country through active counselling and support to
participation by users of the services in their costs, schools and local authorities. It is vital that this
the development of primary health care and the work receive support from the government and that
development of Landspítali. These and other oppor- the health services, in particular the primary health
tunities are examined in further detail below. clinics, participate in this work.
Health-promoting measures and improved public Good psychiatric and mental health opens the way
health. By stressing the importance of preventing for individuals to play a full part in their community,
diseases and making it easier for people to choose make use of their abilities and make their contribu-
a healthy lifestyle it is possible to reduce the like- tion to society. This is discussed in the Policy and
lihood that they will experience poor health later Plan of Action in Mental Health up to the Year 2020,
in life or defer the deterioration of their state of which was approved by the Althingi in April 2016. The
health. It is therefore important to give priority to plan of action stated that the main emphasis was to
measures aimed at achieving better public health be laid on integrating services for people with mental
for all sectors of the population. Icelanders are problems and for their families and preventive and
11Health Policy 2030
health-promoting measures in the field of mental rise to many ethical questions that will need to be
health in which attention is to be directed in particu- addressed before the technology is introduced in
lar to children and young people. In addition, meas- the health services.
ures should be defined and taken to accommodate
various peripheral groups and people at vulnerable The same applies to new technology and techniques
stages of life in order to reduce the prevalence of that are already available in the health services,
prejudice and discrimination. The primary health such as the genetic profiling of individuals, stem-cell
clinics are assigned an important role in providing research and the possibility of diagnosing illnesses
effective mental health services, including by main- long before they become apparent. While all this
taining special mental health teams throughout the offers exciting possibilities, persistent moral and
country and making the services of psychologists ethical questions also pop up which will need to be
available as part of the clinics’ operations. answered before the technologies are in general use
in the health system.
Easy access to medicines and their rational use are
very important factors in securing good performance Greater equality is the guiding principle in improving
in the health services and can have great impact access to the health services for everyone. Certain
on people’s health and well-being. In May 2017, the steps have been taken in this direction with the
Althingi approved a draft resolution on medications introduction of new payment systems for medica-
up to the year 2022. The emphasis in this policy is on tions and health services and through agreements
access to necessary medications, their quality and on the payment of a larger share of the costs of den-
safety and their efficient use. tal treatment for children, the elderly and disabled
people to be borne by Icelandic Health Insurance.
Technological innovations in the health services. A ceiling has been placed on patients’ payments;
The development and introduction of technological further moves towards achieving equality could be
innovations with an application in the health ser- taken by further reducing the share that they pay.
vices represents a rich field of opportunity. Iceland
has already outstripped many other countries in this Promotion of the primary health clinics as the first
area by building up a coordinated medical records port of call for users of the health services has long
system throughout the country which enables been a matter of official policy; it is based on law
health workers to access the necessary information and is a matter of broad consensus. Various moves
on patients no matter where they have come for have been made towards this end, e.g. increasing
help. This system could be improved still further by the number of professional groups employed within
facilitating the registration of data and simplifying the clinics and increasing their intradisciplinary
its use. The development and application of solu- cooperation in order to meet the range of patients’
tions in the field of distance healthcare offers many needs and promote continuous and integrated
opportunities too, e.g. as regards equalizing access services. Charges for consultations in the primary
to the services for people living in the rural areas. health clinics have been systematically lowered and
Information technology (IT) and digital solutions a reference system has been introduced for chil-
will play a key role in the development of the health dren, ensuring them services without charge. In the
services in the years ahead. Iceland’s health system, metropolitan area, a new financing system has been
with its small size, together with the high level of introduced for the primary health clinics which is
technical literacy in Iceland and the IT infrastructure seen as having strengthened them, improved their
already in place, offers countless opportunities for productivity and broadened access to their services.
improving quality and efficiency. Primary health clinics play an important role in con-
tinuing to support the good results that Iceland has
Mention must also be made here of IT development scored for decades now, e.g. in infant care, pre-natal
that has not yet made an impact in Iceland but is care and preventive measures against cardiac dis-
just around the corner. Plans are already afoot to eases, cancer and various infectious diseases.
use artificial intelligence (AI) in diagnosing diseases,
which will doubtless have a great impact on the jobs Landspítali (the National University Hospital) is the
of health workers in the future. Robots are already corner-stone of the Icelandic health system, and
being developed, as are monitoring systems using this status is likely to become further confirmed as
electronic cameras and transmitters that are inte- its development continues, including a new central
grated with the GPS positioning system. These tech- treatment unit, a laboratory building and a patients’
nologies could be employed, in particular, in services hotel. Work is also in progress on expanding the
to elderly people who, as has been mentioned activities of its day-care and outpatient depart-
above, are becoming an ever-greater proportion of ments. These projects bring various opportunities
the population in Iceland, as elsewhere. While these that will make it possible for the hospital to develop
developments offer great potential, they also give in step with future expectations.
12Health Policy 2030
Iceland’s health services are among the best in the The policy set forth below addresses the main points
world in many areas, and have been for decades. It that must be borne in mind if the health system is
is important, however, to be alert in maintaining this to meet the challenges it faces. Its aim is that the
position and to take seriously all indications that we health system should be still better prepared to
are not embracing progress and innovation in health nurture the health and well-being of the people of
services as this could lead to our falling behind our Iceland through all stages of their lives.
neighbouring countries.
The health system in a
broader context
A health system is not an isolated service system: it policy is obvious. For this policy to work, it is vital
should be integrated and connected with all aspects that it enjoy broad support; in fact, it must be part
of society. Its obvious role consists in providing of a social contract reflecting the attitudes and
people with services in diagnosing and treating expectations of the general public towards the wel-
diseases, preventive measures and advice of many fare system.
types on the maintenance of good health and living
a healthy life. As most people generally enjoy good By its nature, the health system is complex and
health, only a tiny fraction of the population needs many-faceted. There is a high degree of special-
to make use of the services at any given time. From isation within it, and many service providers are
the point of view of the general public, it is of great involved. One of the greatest challenges is to create
importance that it should be able to feel confidence a holistic system that will ensure seamless services
in the health system and its staff and be sure of to patients at the correct service level in each indi-
receiving the appropriate services when the need vidual instance. If this goal can be achieved, it will
arises. It is important to have easy access to simple reduce the likelihood of the emergence of a problem
and clear information and guidance on the health known to attend health systems: that parts of the
services and where to go for help when it is needed. system seek to maximise their own gains without
this resulting in better results for the system as a
whole. An example of this is when service providers
69% of people
seek to accept, primarily, “easier” patients and not
those who are suffering from more complicated
in Iceland have health problems that are more expensive to treat.
This danger exists when financial incentives do not
confidence in the serve the overall objectives of the system.
health system The following are fundamental points that must be
observed when developing a good health system
-Gallup poll, February 2019 with the aim of providing users with quality and
seamless services in the most economical manner.
• When health services are delivered, it must be
The health system is also part of a broader infra-
ensured that patients will be able to move without
structure network, and is significant in terms of both
hindrance between the various units within the
employment and the economy and social well-being
system so that services will be seamless and serve
of regions of the country outside the metropolitan
their needs in the best possible way.
area. One of the preconditions for people being
able to live in these regions is that they can rely • Greater flexibility must be established in human
on good health services; thus, they are one of the resource management within the health system
fundamental pillars of society. In the light of this, so as to make it easier to make changes in the
the importance of a clear and sophisticated health division of labour and responsibility on the part
13Health Policy 2030
of healthcare professions when this is needed in to healthcare professionals or individual referrals
order to improve services to users. for hospitalisation.
• Criteria on the quality and outcome of the health • The administrative and legislative framework for
system must reflect how well the services meet health issues must include sufficient flexibility for
the requirements of users and society at large. development and innovation.
• The funding and payment systems used in the • It must be ensured that new technology and new
health services must include incentives that will medications will only be adopted in the health
encourage a holistic approach to patients’ prob- services if the most stringent demands regarding
lems rather than concentrating on individual visits tried and tested knowledge are met.
Trends in the Nordic
healthcare systems
The healthcare systems of Iceland’s Nordic neigh- tal beds; this has been due in part to changes in
bours have undergone great changes in the last 30 the funding of the system and in part to the great
years. One of the reasons for this has been rapidly expansion of day-care and outpatient depart-
rising costs, even though it is not necessarily the ment services. However, the main explanation
case that there has been a corresponding increase in lies not in greater economizing but rather in a
quality. The main changes have been as follows: shift in priorities, bringing services closer to users
and their daily lives and reducing the risk of the
• Funding. Service-related funding has been health problems that may accompany long stays in
adopted instead of lump-sum budget allocations. hospital.
This fundamental change has created motivation
for shortening the time during which patients
occupy hospital beds and raising productivity and
cutting costs. • Greater quality demands. For many years now,
purchasers of health services have demanded that
• Reduction in the number of beds. There has been service providers submit certain core indicators
a considerable reduction in the number of hospi- to demonstrate the quality of their outcomes. In
14Health Policy 2030
certain cases, payment is subject to the condition – íslenska heilbrigðiskerfið á krossgötum (‘The key
that these core indicators be produced, demon- to utilising Landspítali’s opportunities to the full
strating the attainment of the standards required. – Iceland’s health system at a crossroads’) for the
Budget Committee of the Althingi and the Ministry
• Expansion of service areas. Organisational of welfare. The report was compiled to clarify what
changes have been undertaken, with service areas changes needed to be made to Iceland’s health
being expanded and services structured as first, system so as to develop more comprehensive ser-
second and third-level services, in which the first vices for the people of Iceland. According to the
level is the primary health clinic and the third is a report, the most urgent move would be to introduce
hi-tech hospital. the DRG (Diagnosis Related Groups) classification
system, and thereafter to link the funding of the
Work has been done on the above points with a view health system to services. In this, funding allocations
to enabling the health system to taken on new func- reflect defined quality standards and the outcome
tions without this entailing excessive costs. of services is made visible. In addition, it is regarded
as necessary to give patients with complex health
Iceland’s health system has been moving along
problems access to day-care and outpatient hospital
lines comparable to those described above, but in
departments.
important areas it has not yet progressed so far. In
2016, the consultancy McKinsey & Co produced the
report Lykill að fullnýtingu tækifæra Landspítalans
Future vision and policy
up to the year 2030
The following future vision is hereby laid down for to be followed to strengthen the health system.
the Icelandic health system, the guiding principle These key topics are closely interrelated and can-
being that the people of Iceland should have relia- not be separated if the system is to function as an
ble and efficient health services to which everyone entity towards the achievement of the goal and offer
is guaranteed access: seamless services in which the patients’ interests are
the guiding principle. Here follows an examination of
• Iceland’s health services stand com- each of these key topics.
parison with the best in the world;
public health work focuses on the
promotion of health and preventive
measures play a part in all services,
particularly those of the primary
health clinics.
• The health services’ performance is
assessed by measuring the quality of
services, their safety, their accessibil-
ity and their cost.
As has been stated above, seven key topics are
stated in the policy which are to mark out the route
15Health Policy 2030
1. Leadership for results
including as regards its structure, prioritisation of
This section examines: work within it and the efficiency, quality and safety
of services and access to them.
• management and coordination, The Health Services Act provides for the structure
of health services in Iceland. The term ‘health ser-
vices’ covers health care of all types: treatment by
• legislation on the health system, physicians, nursing, general and specialised hospital
services, transport of patients, prosthetic services
• management and leadership ability, and the services of healthcare workers both in and
outside health institution when these are rendered
in order to support health or to prevent, diagnose or
• ethical considerations and value treat illnesses and to rehabilitate patients. For the
assessment. most part, the health services in Iceland are funded
by taxation revenues, and allocations are made
in the national budget for each year. Most health
services are provided by public bodies according to
Why is this important? the structure laid down in the Health Services Act,
but a sizeable part is provided by private operators.
Healthcare systems, no matter how well they are The general rule is that the state, as the purchaser
structured, cannot play their role without an effi- of these services, is to take the initiative on what
cient managerial system and managers with sound services are to be purchased, in what quantity and
leadership qualities. The legislature and the execu- subject to what requirements regarding performance
tive are involved in deciding how the health services and quality.
are organised; they define their role, monitor to
ensure that the system meets public expectations It is important that services be at all times provided
and see to it that funding is spent on the most at the appropriate service level. The local authorities
urgently needed services. In addition, the legislature have an important role to play in the services they
and the executive must ensure that the necessary are required to provide under the Local Authorities’
demands are made regarding staff education and Social Services Act, the Senior Citizens Act and the
skills, that the necessary quality standards are Services to Disabled Persons with Chronic Support
demanded of institutions providing health services Requirements Act. Steps must be taken to ensure
and that the need for new equipment and medicines that it is clear to everyone where the divisions lie
is assessed (HTA – Health Technology Assessment). regarding the various roles of central and local gov-
The cost of the services has to be worked out; it ernment in this area: otherwise, there is a danger
must then be priced, with measures to ensure that that users of the services will not receive the right
the sale and pricing of medications follow the rules services at the right level and will bear the brunt
and that scientific work is in conformity with domes- of disputes between these parties regarding the
tic and international rules. A breakdown in any of division of costs. It is desirable that decisions on
these procedures can have serious consequences services be taken as close as possible to those who
for users of the system and for the state, which need them and that healthcare institutions and the
pays for it. local authority where patients live should collabo-
rate closely.
The Health Services Act, the Patients’ Rights Act, the
Health Insurance Act and the Directorate of Health
and Public Health Act are the cornerstones of health
legislation in Iceland, setting out the framework for The merging of healthcare institutions within the
the health services and defining how they are to regions, which was completed in 2014, has created
be managed. The Minister of Health is to lay down opportunities for simplifying and clarifying the
policy for the health services. The minister may take administrative structure of the services. Provisions
the measures necessary to implement this policy, are made, in the Health Services Act and in letters
of appointment to managers, on the responsibilities
16Health Policy 2030
and range of powers of the heads and managers of tion in healthcare – conclusions of the committee on
healthcare institutions. The heads of these institu- prioritisation’) in 1998. In 1997, while this committee
tions are faced with comparable tasks and the same was still at work, the Icelandic Medical Association
challenges regarding their operation and services to published a report of its own, Um forgangsröðun í
be provided to the people living in their administra- heilbrigðisþjónustu (‘On prioritisation in the health
tive regions. It is therefore essential that they con- services’); the association was also brought in to
sult each other regularly under the leadership of the comment on the report appointed by the minister.
Minister of Health and the Ministry of Health. Though no further account of the conclusions of this
work, either in Iceland or in its neighbouring coun-
It is vital that managers in all parts of the health tries, will be given here, it can be said that the find-
system have good leadership abilities, as these will ings were all similar. It is worth bearing in mind that
be necessary to meet the challenges of the future; discussion on prioritisation in the health services is
these will call for creativity and innovation both in something that is never finished: it is a never-ending
technological matters and in working procedures. quest. The following are the fundamental consid-
For managers to meet these challenges, it is nec- erations on which consensus has emerged, both in
essary to give them greater room for action, where Iceland and in its neighbouring countries:
their powers, both as regards financial and profes-
sional management, will be balanced by responsi-
bility. Performance management and greater dele- Personal dignity; respect for the
gation of power call for the observance of certain individual
values by both managers and other staff.
All people are equal and have the
same right to protection of their lives
Culture and values
and maintenance of their health.
Every day, managers and employees in the health
services face numerous difficult decisions that affect
people’s lives and health. Prioritisation is part of Need and solidarity
health workers’ day-to-day routine. Advances in
Those who are most in need of the
diagnostics and treatment, with rising costs, make it
increasingly important for the state, which finances health services at any given time are
the health services, to set out priorities in the use of to be given priority.
the funds available. Prioritisation by the authorities The rights of those who are in a fragile
must be based on clear criteria and ethical values position, no matter for what reason,
that are known to everyone and evident when deci- and are consequently unable to ex-
sions are taken, whether health workers or patients ercise their rights or to defend them,
are involved, and there must be broad general shall be respected.
approval of these values in society at large.
An extensive debate emerged in the Nordic countries
in the closing decades of the twentieth century, and Economy and efficiency
other parts of the world, on the need for prioriti- The health services are to be focussed,
sation in the health services. Norway was the first productive and as economically
country to publish a report on the topic in 1987, in efficient as possible.
which four prioritisation categories were set out,
with criteria defined. During the following years this
debate assumed greater proportions in the other
Those considerations that are intended to protect
Nordic countries, and in 1997 the Swedish parliament
the most important ethical values are to take prece-
passed a motion defining the values and ethical
dence over others. Thus, personal dignity is ranked
principles that were to underpin prioritisation in the
first, before need and solidarity, and economy and
Swedish health system.
efficiency come last.
At the beginning of 1996, Iceland’s Minister of Health
Since publication of the report of the committee
and Social Insurance appointed a committee to
appointed by the Minister of Health and Social
make proposals on how prioritisation was to be
Security on prioritisation in the health system in
effected in the health sector in Iceland. It submitted
1998, there has been little discussion of the subject
its proposals to the minister in the form of a sub-
among politicians in Iceland; for example, the report
stantial report, Forgangsröðun í heilbrigðismálum
has never been formally discussed by the Althingi
– niðurstöður nefndar um forgangsröðun (‘Prioritisa-
in the same way that the Norwegian and Swedish
17Health Policy 2030
parliaments discussed their respective reports. It at any given time. The Patients’ Rights Act also states
should be mentioned that in Norway, prioritisation that no discrimination may be practised against
in the health services is discussed every year in con- patients on the grounds of their personal qualities
nection with the national budget, and, as was men- or their standing in society. It also states that if it
tioned above, the Swedish parliament approved the should prove necessary to rank patients in an order
values and ethical principles that are to underpin of priority for treatment, then medical considera-
prioritisation in the Swedish health system. tions are to be paramount. When policy is laid down
for the health system, it is important that it should
Icelandic health legislation reflects a certain ethical be based on a sound moral and ethical foundation,
standpoint regarding the entitlement of people in with a consensus regarding the values that are to
Iceland to the health services; this is the same as guide the path to the goals set.
that in the other Nordic welfare systems. The Health
Services Act states that all people in the country are
equally entitled to the best health services available
What will the situation look
like in 2030?
1. Legislation on the health services will be clear, 7. The responsibilities and powers of managers of
with unambiguous provisions on the roles of the institutions which either come under the Min-
healthcare institutions and other health service istry of Health or undertake tasks on its behalf,
providers and how they are to communicate will be compatible and well defined.
with each other.
8. Managers in all fields in the health system will
2. The role and financial responsibilities of central be chosen on grounds of their professional
and local government regarding the provision of skills, with requirements made regarding,
health services will be well defined. amongst other things, leadership abilities and
experience of policy-based management. They
3. There will be smooth cooperation between the will be given regular support and training in
health services and the social services, the role these areas.
and responsibilities of each having been well
defined. 9. The directors of the regional health authorities
in Iceland will be the administrators of health
4. There will be a general consensus of agreement issues within their regions, maintaining regular
on the ethical principles underlying prioritisa- consultation between themselves on the health
tion and decision-making in the health system; services under the leadership of the Ministry
at the same time, there will be ongoing discus- of health.
sion of the guiding principles.
10. The role and range of responsibility of Land-
5. Each year, institutions under the Ministry of spítali and the Akureyri Hospital towards other
Health will draw up their own working pro- providers of health services will be well defined,
gramme, based on the health policy and the creating a secure foundation for the coordina-
concomitant plans of action drawn up by the tion of services.
Minister of health.
6. The aims of the health policy will be clear to
everyone, and information on the results it pro-
duces, measured against quality criteria, will be
accessible by the public.
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