Traditionally, the political culture of the Scandinavian countries has been based on broadly social democratic policies, with health systems built on the principles of universality and equity: all inhabitants have the same access to health services, whatever their social status or geographic location. This strong emphasis on equity has been combined with a tradition of decentralization in which there is regional democratic control of the county and municipal health-care institutions. The municipalities play an important role in providing primary health services (except in Denmark) and various prevention, rehabilitation and health-promotion activities for their inhabitants. This decentralized approach distinguishes the Scandinavian countries from the more centralized tax-based system in the United Kingdom.

The Scandinavian countries belong to the family of integrated single-payer hospital systems. Scandinavian health-care systems are tax-funded health systems with no premium-based financing. Because there is only a minor connection between individual health risks and costs, which are limited to out-of pocket payments, voluntary health insurance has traditionally not played a major role, except as supplementary coverage for services that are not fully covered by the public system, such as eyeglasses and dental care for adults in Denmark. Hospitals are predominantly publicly owned (state or county) and have traditionally been financed through global budget schemes. Another distinguishing feature of Scandinavian healthcare systems is their governments’ traditional tendency to oppose the expansion of private health-care services. The common understanding has been that health care should be under the control of democratically elected bodies and not subject to commercial market forces. The tradition of voluntary or nonprofit health care in the Scandinavian countries since World War II has been weak, and ‘private’ is therefore usually equated with ‘for profit’ ( vretveit, 2003). A few specialty hospitals are owned by patient organizations, but they are strongly integrated into the public planning system. Fewer than 5% of hospital beds are located in private for-profit hospitals in Scandinavia. Patients’ rights have been important in the health-care policy debate in Scandinavia, and all three countries have extensive legislation relating to patients’ rights. Another common feature is the introduction of patient choice of hospital in the past decade. In addition, all three countries have introduced waiting time (or treatment) guarantees to address persistent issues of long waiting times. The Danish waiting time guarantee provides access to foreign or private treatment facilities if the expected waiting time at public hospitals exceeds one month (less for life-threatening diseases). Yet, there are also important differences in the healthcare structures of the respective countries. Far from being uniform, the Scandinavian model is constantly evolving through incremental and more radical change processes. One quite striking difference is related to the organization of health-care services: whereas all three Scandinavian countries have relatively decentralized systems, there are important variations in the number of local authorities and the political and/or administrative level of policymaking. After the Norwegian hospital reform of 2002, the responsibility for primary and specialist health care is divided between the municipalities and the five new health regions, with no role left for the counties. In 2007, Denmark underwent a similar reform that moved responsibility for hospital and primary care services from the counties to five new and larger regions. Sweden is considering some type of structural reform, but has so far maintained county-level health-care institutions. Another intra-Scandinavian variation relates to the financing of specialized health services. Whereas Norway since 1997 has used activity-based financing with a relatively high share of diagnosis-related group (DRG) compensation, the other two countries employ combination models predominantly based on frame budgeting and a smaller degree of DRG/activity-based funding. Sweden also stands out from the other Scandinavian countries because of its willingness to experiment with purchaser provider models in the health-care sector. In Sweden and Denmark the municipalities typically are relatively autonomous in terms of taxation authority, implying that the correspondence between the local population’s financial contributions and the services offered is higher in those countries.