The health and social welfare system in Norway is predominantly publicly financed, mainly by a national insurance tax. The national insurance, or social security, is a collective insurance scheme to which all in Norway belong. All wage earners contribute a fixed percentage of their earnings by paying the national insurance tax. In addition, employers contribute by means of a payroll tax. The latter is assessed as a percentage of wages paid by the employer. The self-employed contribute more to social security than wage earners do because they are exempted from the payroll tax. Housekeepers, the unemployed, students and others without wages are exempted from social security tax, but they still qualify for social security benefits. They have the same right to assistance and medical treatment as those with salaries. The size of unemployment compensation, sick pay and pensions depends on the amount of income the individual has previously earned.

When you become ill
Persons who fall ill in Norway are guaranteed medical treatment. The health service is a cornerstone of the Norwegian welfare state. Universal access to quality public health care is the Norwegian authorities' goal. As a basic principle, health services are to be distributed according to need - not according to ability to pay. Users' fees are limited - no one pays more than NOK 1,140 a year (in 1995) for public health services. This represents about seven percent of the average monthly industrial worker's wage (NOK 16,242 or about USD 2,700).

Equal across the country
Norway has a small population and is sparsely settled. The responsibility for the Norwegian health service is therefore decentralized. The country has five health regions, 19 counties, and 436 municipalities, each responsible for health service. Since the health service is run on both the county and the municipal levels, the state transfers funds to counties and municipalities according to a distribution factor which evens out the differences between rich and poor counties. This helps provide the population with an equable public health service

throughout the country. The counties and municipalities receive lump-sum allocations which provide leeway for local priorities and adjustments. These block grants are supplemented with itemized allocations - earmarked funds to priority problems or fields. These are intended to stimulate the local health service to adopt such priorities. In 1994 extra grants were given to, amongst others, the financing of the running costs of hospitals, rehabilitation, telemedicine, suicide prevention, and quality enhancement.

General practitioners in the fore
The municipal health service is the foundation for the Norwegian health care system. Preventive measures, general practice, rehabilitation, nursing and care are municipal responsibilities. For most ailments, patients should be able to visit their local health station or doctor and receive treatment. The task of general practitioners is to arrive at a diagnosis at an early stage, treat simple everyday problems and refer patients to specialists when necessary. The general practitioner service is well established in Norway. The doctor-patient ratio varies geographically, but it is biggest in the counties with sparse populations and inferior transport conditions, as in much of North Norway.

Many small hospitals
The counties own and run the hospitals in Norway. The existence of many small hospitals, often running in parallel with tandem specialties and services, has made it preferable for the state to increase its control. The aim is a stronger network between hospitals and a better coordination of their respective specialties. The five health regions will be given a more central role in the planning of hospital activities. The objective is to provide patients with the opportunity to choose between hospitals in their region. This will promote a cautious form of competition among hospitals.

Treatment abroad
If an ailment is potentially fatal or particularly burdensome, and Norwegian hospitals lack the professional competence to treat the malady, the social security covers the costs of treatment abroad. Instead of developing the competence in Norway to treat extremely rare diseases, the country pays for such service abroad. Demand for such treatment in foreign countries has risen distinctly in recent years.

The waiting list
The Norwegian waiting list system for hospital treatment is unique. All who make an appointment for an examination or treatment at a public hospital - with the exception of those in need of immediate treatment - are placed on the waiting list. As a result, at any given time it is known just how many patients need treatment, for which ailments, and at which hospitals.

The waiting list system is a useful device for the authorities. It's a tool for the evaluation of hospital capacity and the choice of priorities in accordance with national guidelines. Patients with first priority are given immediate treatment. Second priority patients - those who are seriously ill - are guaranteed treatment within six months. This is the so-called waiting list guarantee. All other patients have to wait for an opening. The waiting list system has existed since 1990.

In most cases the waiting list guarantee for treatment within six months has been possible to fulfill But the length of the deferment has varied from county to county and from medical field to field. The longest waiting periods are currently experienced by patients with orthopaedic and ear-nose-throat ailments.

Many challenges
Increasingly better diagnostic methods and highly specialized methods of treatment are being developed. Telemedicine and biotechnology are improving. Norway has also come relatively far in developing and utilizing statistics and medical data, and continued efforts will be made along these lines. The same can be said about the development of information technology.

The lifestyle-related heart and cardiovascular diseases are on the decline. But cancer, allergies, respiratory diseases, muscular- skeletal ailments and infirmities caused by the wear and tear of repetitious or hard physical work are still increasing. These are currently the most common causes of long-term sick leaves and disablement. Mental disturbances are also on the rise. More people are committing suicide, especially younger people and men over 80. Fortunately, this last trend appears to be leveling off.

Demographically, Norway is growing older. In particular, the oldest segment of the population is expanding, and this represents an extra burden for the health care system. Nursing and care for the aged must be given more priority.

A vital question is where to draw the demarcation line between the health service's responsibilities and the duties of certain sectors in the welfare system. Wage inequality, unemployment, and an inadequate social network comprise risk factors which increase the incidence of sickness, injuries and social problems. The issue is whether dealing with everyday problems and crises is a responsibility of the health service, or whether there are other sectors that should be better equipped to prevent the development of these problems.

Sick pay for the employed
All employed persons have a right to sick pay from the first day of absence. The employer covers the costs for the first two weeks. After that, sickness benefits are covered by the national insurance. Sick pay equals normal wages, upwards to a ceiling corresponding to six times the so-called base sum in the national insurance scheme. (The base sum is currently NOK 39,230 a year or about USD 6,300.) However, the state, the municipalities and individual companies cover the difference between sickness benefits and regular wages, so that those with higher salaries receive the equivalent of full compensation.

The sick pay scheme and the frequency and length of absences are matters of recurring debate. It is generally agreed that absenteeism is too high, and a less generous compensation scheme would help lower the rate. Jobholders can receive sickness benefits for as long as a year. After twelve months, if they are still unfit for work, the national insurance scheme provides other forms of economic support: rehabilitation benefits and disablement benefits. In addition, many who have become disabled receive a supplemental pension from their former employers. Quite a few Norwegians also have private insurance which provides additional disablement compensation.

People with congenital disabilities or who have been disabled from an early age also qualify for disablement benefits. These are granted when medical grounds are ascertained by a doctor. Unless the disabled person once again becomes able-bodied, such benefits are paid until retirement age, when the benefits are replaced by an old age pension. Social security also provides dysfunctional persons with support for medicinal expenses, practical help and care at home, the acquisition of technical aids, and if necessary even a specially equipped car.

Over eight percent of Norwegians in the occupational age group currently subsist partly or wholly on disablement benefits. The number has doubled in the past twenty years despite the fact that the population growth has been minimal. The increasing number of disabled is a matter of concern to the authorities as well as to professionals in the health and social welfare sectors. Unemployment and substance abuse are responsible for much of the increase.

When you need social assistance
While the National Insurance Act establishes the state's responsibility to residents and thus secures their rights, the Social Care Act establishes municipal welfare responsibilities. The latter law is far more subject to interpretation. A social committee appointed by the municipal council is responsible for the municipality's social services. The Ministry of Social Affairs has supervisory powers to ensure that the law is obeyed.

All who contact a municipal Social Security Office and apply for welfare - whether the request relates to housing problems, economic difficulties or the need for some practical help - can demand that their case be processed and decided. Those who qualify for support in accordance with the National Insurance Act must contact the Social Security Office in their municipality. Those who do not qualify for assistance according to the National Insurance Act can receive help from the municipality. Examples are youth who cannot find employment after completing their educations, persons who are unemployed for more than 80 weeks and no longer qualify for unemployment benefits, and others who simply don't earn enough to manage their living expenses.

The number of social welfare recipients has increased sharply in recent years. There is a consensus across established party lines that access to such assistance should be reduced. For instance, it's being debated whether recipients should be required to participate in work to the benefit of society, and whether help can be cut off if able-bodied welfare recipients refuse to do such work.

The municipal social service is also required to help substance abusers; e.g., by finding placements for them at treatment institutions. The law allows for the commitment of persons with serious alcohol or drug abuse problems. Such treatment takes place at institutions which are either run by the counties or managed privately with public funding. A substance abuser can be committed to an institution for a maximum of three months.

Municipalities also have responsibility for helping the mentally handicapped. A plan of action for state stimulation of mental health care was initiated in 1991. A key objective of the plan was the reorganization of care for the mentally ill. In the course of the past decade, several institutions have been downsized and the trend is for shorter stays at institutions. About 80 percent of persons with serious mental problems live outside the institutions for shorter or longer periods.

When you become old
Care of the elderly is a subject which never seems to leave the agenda. Seven out of ten Norwegians over the age of 70 are in good health and manage themselves. Some 20 percent of the elderly are dependent upon help at home. The remaining 10 percent spend their last years in an institution, mainly with geriatric problems. The quality and availability of institutional care and home help services used to vary greatly between municipalities. A working committee appointed in 1993 has suggested a harmonization of regulations to make care for the aged as equal as possible on a nationwide basis.

The municipalities have upgraded their health care services in recent years - particularly home help. The number of man-labor years in the home help service increased by 94 percent from 1986 to 1993. The goal is to create conditions to provide the elderly, the physically disabled and long-term mental patients with home medical attention, access to day centres, and electronic alarm equipment so that they can live at home as long as possible. For some services, users must pay a fee, but the lion's share of the costs are covered by the municipality.

As institutional capacity is reduced, the average institutional patient requires more care than before. Few new nursing homes are now being built in Norway. Nevertheless, in the future many elderly will still be spending the remainder of their lives in institutions. In Norway there is no strong tradition for the young to care for their old. In the modem urban society, the young and old often live far apart, and most women have jobs outside the home. There is thus less opportunity to provide private care within the family than there was a few decades ago.

The economics of old age
The retirement age in Norway is 67. For the rest of their lives, retired Norwegians receive an old age pension from the National Insurance Fund. All Norwegian residents are guaranteed a

minimum pension. Home workers responsible for children under age seven, adults in need of care, and the mentally handicapped too receive three pension points a year, enabling them to earn the right to an adequate pension without having been wage earners. The minimum pension for a single pensioner is NOK 63,376 a year. This corresponds to about a third of an average industrial worker's income (NOK 194,900 or USD 32,0OO).

The size of an old age pension depends upon how long one has been a wage earner and how big an income one earned. Now, most male pensioners and also quite a few females have attained the right to complete pensions. Thus they receive about half their previous salaries. The highest salaried persons experience a relatively greater drop in income upon retirement, because pensions are not calculated from the top portion of their salaries.

Many companies also have their own pension schemes - employees pay a share with the knowledge that they are augmenting their old age pensions. Public employees receive a pension corresponding to two-thirds of their former salaries - a level common among private pension plans. Some Norwegians also pay into private individual pension schemes.

If you are out of work
About 4.6 percent of the Norwegian labor force was unemployed in May 1995. Youth are the hardest struck - for the first time since the second world war they are proceeding directly from school to the unemployment queue.

All who have been previously employed and earned a certain minimum income have earned the right to unemployment benefits from the National Insurance. A state labor office which administers the distribution of benefits can be found in all cities and larger municipalities. Benefits amount to a certain share of prior earnings. The maximum of such benefits is well under the average industrial worker's salary and payment is limited to 80 weeks. Applicants for unemployment benefits are required to register themselves at a job center as job-seekers and they must take any jobs given them. Work is also provided through various labor market measures including re-schooling, additional education and training, care and maintenance jobs, and other initiatives.

If unemployment lasts longer than 80 weeks, one loses benefit for a 13-week period before becoming eligible for another 80 weeks of unemployment benefit. During the 13-week interim, the jobless person can receive support from the municipality.

When you have children
When giving birth, women who have been employed for at least six months of the last ten months are entitled to a maternity leave with full pay, limited upwards to six times the basic national insurance sum. The mother can choose between 42 weeks of leave with full pay or 52 weeks with 80 percent pay. Three weeks of this leave must be taken prior to the birth. Four weeks of the period must be taken by the father (the paternity quota).

A time account scheme enables fathers to refrain from using their entire quota in one consecutive period. They can retain unused days in their "accounts" and use them freely within a two-year period.

Women who haven't been employed and don' t qualify for a paid maternity leave receive a NOK 25,625 (USD 4,271) grant upon giving birth.

Child benefits are given to all children up to age 16. The benefit for one child is NOK 881 per month. This represents about 5.4 percent of an average industrial worker's salary.

The need for kindergartens still exceeds capacity but the authorities' explicit goal is complete coverage by the year 2000. Currently, 37 percent of all children under age seven attend kindergartens. An opportunity to attend kindergarten for all who apply is the goal.

In connection with an ongoing school reform, children will soon begin first grade a year earlier, at age six. Care for children at school before and after class hours is subsequently being extended and developed for kids aged six to ten.

Children's own minister
The Norwegian Government has a special minister to attend to issues concerning children and families. The minister's sphere of responsibility embraces child care, kindergartens and sexual equality. Norway was the first country in the world to appoint a special ombud for children.

The most important law affecting children throughout their childhood is the Child Welfare Act. Municipal social welfare committees are required to observe the living conditions of children and young people - also in their own homes. The municipality can intervene in cases where conditions are unsatisfactory and give guidance, economic support or practical help. If such preventive measures do not improve matters, the municipality can take over care of the child and remove it to foster parents or an institution. The flow of people to the main cities, increasing divorce, women's entry into working life, the growing recourse to alcohol and drugs - all these factors point to a decrease of sound and stable conditions.

Special white paper on welfare
In 1995 the Government put forth a white paper - Stortingsmelding no. 35 (1994-1995) - known as the white paper on welfare. The bill provides an overview of welfare in Norway for the past, present and the future. It contains a number of estimates regarding how the welfare society will evolve, the costs of maintaining the welfare state, how the Government plans to finance it, as well as a number of proposals to uphold the Norwegian welfare system well into the next century.

Author. Malfrid Bolstad, a freelance journalist.

Publication: Norwegian Information, printed September 1995.