In November 2010, the Australian Parliament passed the Australian National Preventive Health Agency Bill, investing $17.6 million in a new agency that will target smoking, obesity, alcohol consumption, and other substance abuse issues. Falling under an intergovernmental umbrella called the National Partnership Agreement on Preventive Health, the agency will be responsible for social marketing programs, a preventive health research fund, and a preventive workforce audit and strategy. By bringing together health experts to collect and evaluate evidence-based methods on the best ways to prevent chronic diseases, the group aims to encourage best practices and coordinate prevention campaigns across the country. Advice and recommendations will be released annually.

Sources:
http://www.health.gov.au/internet/ministers/publishing.nsf/Content/C9E613D4BE11C053CA2577DE007503B4/$File/nr175.pdf
http://news.smh.com.au/breaking-news-national/agency-to-push-prevention-rather-than-cure-20101117-17xiv.html

The number of Australians enrolled in the private health insurance market is at a record high, with more than 10 million covered privately in 2010. While public hospital care is provided free to patients to Australia, people have the option to pay for private care in public or private hospitals. In light of this trend, Prime Minister Julia Gillard has submitted a proposal to save the government $1.9 billion by eliminating private insurance rebates for higher-income Australians.

Currently all Australians, regardless of their income, are eligible to receive a government subsidy of at least 30 percent of their private health insurance premiums, with higher rebates (up to 40%) for older people. Under the proposed plan, insurance rebates would taper off and eventually disappear once incomes reach a certain level. Rebates would begin to taper off at $70,000 and end at $120,000 for singles. For families, rebates start to taper at $150,000 and are eliminated at $240,000. The average monthly premiums currently paid by singles and families are $750 to $1,000 and $1,500 to $2,000, respectively.

Similar proposals have been defeated twice in the Australian Senate. Opponents fear the resulting increase in private insurance premiums paid directly by the consumer could drive people to drop private coverage, thereby straining the public system. Australian Health Minister Nicola Roxon and proponents of the reform argue that the savings from rebate reform could be reinvested in other areas such as doctors, nurses, and hospital beds. The timetable for taking the proposal forward has not yet been decided.

Sources:
http://www.news.com.au/money/money-matters/australians-covered-by-private-health-at-record-level/story-e6frfmd9-1225954375982
http://www.health.gov.au/internet/ministers/publishing.nsf/Content/DFFDF09EE5F261B6CA2577DC001619E9/$File/nr172.pdf
http://www.theaustralian.com.au/news/health-science/health-rebate-means-test-battle-back-on/story-e6frg8y6-1225923032398

The Australian Ministry for Health and Ageing has launched MyHospitals, a new Web site that offers information about the services and performance of 759 public and 153 private hospitals. For the first time, Australian Health Minister Nicola Roxon said, patients can compare their local hospital with the national average on quality measures, such as wait times for elective surgeries and emergency department care. Additionally, patients can find out information on the number of beds and admissions, as well as hospital accreditation and the types of specialized services available, such as an obstetrics or intensive care. Users can search MyHospitals by hospital name and view all facilities available in a certain region.

The Web site measures and data were developed and compiled by the Australian Institute of Health and Welfare (AIHW), a national agency that works with the federal government and state and territory health departments to collect, analyze, and disseminate statistics and data. The AIHW plans to continue working with states, territories, and private hospitals to add more information to the site.

Sources:
http://www.theage.com.au/national/roxon-launches-myhospitals-website-20101210-18ryw.html
http://www.health.gov.au/internet/ministers/publishing.nsf/Content/46DF12DBEE03EE2DCA2577F50002B392/$File/nr204.pdf
http://www.myhospitals.gov.au/

The Australian federal government has made a $370.2 million commitment to develop 28 new General Practitioner (GP) Super Clinics, which offer a multidisciplinary, team-based approach to providing primary and specialized care in one central location. In 2007, the government pledged $275 million over five years to establish 36 GP Super Clinics in communities across the country. The new funding will also support upgrades to approximately 425 general practices, primary care and community health services, and Aboriginal Medical Services.

Super Clinics—which offer after-hours care—are a main focus of the Australian government's efforts to improve services for underserved populations and make it easier for patients to see a health professional when needed. To date, 26 of the first 36 GP Super Clinics are open or under construction. Proponents believe Super Clinics will free up emergency departments, attract medical students to the GP profession, and increase access to a wide range of care.

Sources:
http://www.health.gov.au/internet/ministers/publishing.nsf/Content/FCDE8D507FDE9802CA2577EE0024BD11/$File/nr197.pdf
http://www.health.gov.au/internet/ministers/publishing.nsf/Content/mr-yr10-nr-nr011.htm?OpenDocument&yr=2010&mth=01

Secretary of State for Health Andrew Lansley announced proposals to shift toward a new value-based pricing system for branded medicines in the U.K. The proposed policy would be introduced in 2014 after the current Pharmaceutical Price Regulation Scheme (PPRS) expires at the end of 2013. The PPRS, in existence since 1957 and renegotiated roughly every five years, regulates the profits drug companies are allowed to make on sales in the National Health Service (NHS).

In 1999, the National Institute for Health and Clinical Excellence (NICE) was established to assess the efficacy of individual products. Currently, NICE also evaluates whether new technologies—medicines or medical products—are cost-effective relative to existing treatments, meaning whether the extra clinical benefit of a given drug or product justifies the extra cost. If NICE then "recommends" a product as clinically and cost-effective, the NHS is required to provide funding for reimbursement within three months. If NICE concludes that a drug or product is not cost-effective, it is unlikely that NHS providers will fund these products, although this can be challenged on an individual basis.

According to Lansley's plan, NICE would continue to conduct pharmacoeconomic evaluations of new medicines. However, under the new system, the NHS would use NICE's assessments to determine at what price (or up to what maximum price) a drug is considered to provide value for money, taking into account clinical effectiveness and cost-effectiveness as well as other societal benefits and innovations. By linking a medication's value to its price, the NHS will therefore be able to propose that drug companies make drugs available at prices reflecting their value. This, in essence, would grant the NHS the ability to negotiate and potentially reduce drug prices or for drug companies to increase the price if a technology is subsequently shown to be more valuable.

Sources:
http://www.dh.gov.uk/en/Consultations/Liveconsultations/DH_122760
http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_122829
http://uk.reuters.com/article/idUKTRE66B44420100712
http://www.bbc.co.uk/news/health-11664684
http://online.wsj.com/article/SB10001424052748704865104575588531025262518.html?mod=googlenews_wsj (subscription required)

In December, Secretary of State for Health Andrew Lansley published a paper that details the Coalition Government's long-term plans for the National Health Service (NHS). A follow-up to last July's "Equity and Excellence: Liberating the NHS," the new document, "Liberating the NHS: Legislative Framework and Next Steps," paved the way for the Health and Social Care Bill, which was introduced in Parliament in January.

The plan involves broad decentralization of the English NHS, including phasing out England's government-run Primary Care Trusts and strategic health authorities, and giving newly created general practitioner (GP) commissioning consortia—overseen by a new NHS Commissioning Board—80 percent of the NHS budget to directly commission (or contract out) health care, including hospital and specialist care, for their patients. The NHS Commissioning Board would also be responsible for issuing guidance to GP commissioning consortia.

The proposed reforms allow private companies to compete with the NHS. The bill proposes that Monitor, the independent body that currently authorizes and regulates only NHS Foundation Trusts, become a full-blown economic regulator responsible for managing competition and regulating the entire NHS marketplace.

The government consulted on its health reform plans from July until October of last year, during which time it received over 6,000 responses. "Liberating the NHS" includes modifications to the original proposal based on this feedback, such as creating a GP consortia pathfinder program to phase in the introduction of GP commissioning. The revised plans also broadly require Monitor and the NHS Commissioning Board to set prices together, whereas the original plans proposed that Monitor set prices, and the board have the ability to appeal. In addition, the latest document detailed a reversal of previously proposed plans for price competition: the plan no longer proposes differential pricing for different classes of providers in the NHS. The introduction of price competition in the NHS had been met with concern that competition on price would lead to a fall in quality.

"Liberating the NHS" was published in tandem with the NHS Operating Framework for 2011–12, which sets out what NHS organizations must do in the next year to prepare for the reforms. Notably, the Framework will expand the best-practice pricing for secondary care (hospital care and specialists) and the first value-based pricing in England. Value-based pricing is designed to pay more for approved clinical pathways and thereby encourage the use of cost-effective, peer-reviewed pathways to reduce variations, improve outcomes, and achieve long-term savings. Currently, the Department of Health fixes prices of hospital services based on diagnosis-related groups (DRGs), and hospitals' trusts can only compete on quality. The new best-practice pricing would be set higher than current DRG payment levels, but would effectively serve as a cap, below which hospitals could compete on price, if the new GP consortia agree. Payment levels of the best-practice tariffs would rely on meeting quality standards aligned with National Institute for Health and Clinical Excellence guidelines.

The Operating Framework also sets out the Primary Care Trust allocations which directly grants the trusts £89 billion to commission frontline services, including money for commissioning pharmacy services, dental and eye services, and, for the first time, to support social care, or care for vulnerable populations, including mental health services as well as social services such as education and housing. This funding represents an increase of £2.6 billion (US$4.3 billion) from the 2010–11 year, a roughly 3 percent increase.

Sources:
http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_122687
http://www.ft.com/cms/s/0/decd7324-45b7-11e0-acd8-00144feab49a.html#axzz1HGJiIGMj
http://www.independent.co.uk/life-style/health-and-families/health-news/nhs-reforms-will-lead-to-supermarketstyle-discount-surgery-deals-2164837.html

The Department of Health recently published the first National Health Service (NHS) Outcomes Framework, which sets out the national aims for improving quality of care and patient outcomes in the NHS in 2012–13. The framework is organized into five areas: 1) preventing premature death; 2) improving quality of life for chronically ill patients; 3) improving recovery following illness or injury; 4) ensuring positive patient experience; and 5) improving patient safety, including preventing avoidable harm.

The framework identifies national outcomes goals and corresponding indicators for which, subject to Parliamentary approval, the Secretary of State for Health would hold the NHS Commissioning Board accountable. The Secretary of State for Health and the Department of Health would not be setting out how the outcomes would be delivered. Rather, the NHS Commissioning Board, in cooperation with general practitioner (GP) commissioning consortia, would be tasked with determining how to deliver improvements. Specifically, the NHS Commissioning Board would commission the National Institute for Health and Clinical Excellence to develop evidence-based quality standards for particular conditions, which would then be use to develop local-level outcomes and indicators. A quality premium would be linked to certain outcomes.

Sources:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_122944
http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_122995

Secretary of State for Health Andrew Lansley announced that the first groups of general practitioner (GP) practices, pilot GP consortia to be known as pathfinders, have been selected to take on commissioning responsibilities. The Department of Health asked strategic health authorities to identify groups of practices eager to test working together—and with local authorities and the colleagues in the National Health Service—to manage local budgets and to commission care, including hospital and specialist care as well as primary care, directly for their patients. Fifty-two groups of GPs from across England were selected to be pathfinders. The groups include 1,860 GP practices that provide care to nearly 13 million people, or about a quarter of the English population.

The GP consortia will formally take on the new responsibilities beginning April 2013.

Sources:
http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_122399
http://www.hsj.co.uk/news/primary-care/gp-consortia-pathfinder-guidelines-published/5021118.article (subscription required)

Secretary of State for Health Andrew Lansley has released "Healthy Lives, Healthy People," a public health strategy that calls for a dedicated public health service to be established within the Department of Health in April 2012 and creates the first annual public health budget of £4 billion (US$6.2 billion). The plan aims to improve citizens' health by tackling lifestyle issues including smoking, obesity, excessive drinking, and other causes of premature illness and death, as well as to reduce health inequalities.

Public Health England, to be established within the Department of Health in April 2012, will set the overall public health outcomes framework and support local authorities by providing resources, ideas, and funding. It will also be responsible for national programs, including immunization and screening programs, as well as monitoring and responding to population-wide health threats such as flu pandemics. Local authorities and their individual public health directors are at the center of the strategy and will receive individual, protected budgets, which they will determine how to use for public health interventions in their communities.

The strategy also creates an incentive payment to address health disparities, which will be given to local authorities for health improvement. Disadvantaged areas will receive greater premiums if they make progress, but areas making no progress potentially would not receive funding increases for services where outcomes have not improved.

Sources:
http://www.dh.gov.uk/en/Publichealth/Healthyliveshealthypeople/index.htm

The National Health Service (NHS) Quality, Innovation, Productivity, and Prevention Programme recently published the NHS Atlas of Variations in Health Care for England to promote awareness of variation in medical resources and services that cannot be attributed to patient population differences. Similar to the Dartmouth Atlas of Health Care for the United States, the NHS Atlas comprises 34 geographical maps that document how much each of the 152 English primary care trusts spends on a variety of clinical services, and links this spending to health outcomes.

The Atlas highlights a 14-fold variation in spending on broken hips and a 50-fold difference in spending on anterior cruciate ligament (ACL, or knee ligament) reconstruction. Examples of variation in care include a six-fold difference between primary care trusts in emergency admissions for children with asthma, and a four-fold difference in emergency bed days for people with chronic obstructive pulmonary disease.

The Atlas is expected to help commissioners of care improve services and achieve better value by enabling them to identify low performers and potential for improvement; determine the appropriateness of care; and reveal where there may be overuse of services or where low-value services are being used.

The NHS Atlas is publicly available at: http://www.rightcare.nhs.uk/atlas/.

Sources:
http://www.bmj.com/content/341/bmj.c6809.full
http://www.guardian.co.uk/society/2010/nov/25/government-publishes-uk-health-atlas

The Department of Health's first set of clinical quality indicators for hospital emergency department and ambulance services has been published, replacing existing requirements that patients spend no more than four hours in emergency departments from arrival to admission, transfer, or discharge. In the preface to the implementation guide, Professor Matthew Cooke, National Clinical Director for Urgent and Emergency Care, wrote that, "The purpose of the new set of [Accident and Emergency] indicators is to provide a balanced and comprehensive view of the quality of care, including outcomes, clinical effectiveness, safety, and experience, as well as timeliness, and to remove the isolated focus on faster care."

Five of the measures also include "performance management triggers," which will require hospital managers to investigate poor emergency department performance. While the four-hour requirement no longer applies, hospital management will be expected to investigate if greater than 5 percent of patients wait longer than 15 minutes for an initial assessment and longer than four hours before being seen.

The new guidelines will be implemented in April of this year.

Sources:
http://www.dh.gov.uk/en/Healthcare/Urgentandemergencycare/DH_121239
http://www.dh.gov.uk/en/MediaCentre/Pressreleases/DH_122877
http://www.guardian.co.uk/society/2010/dec/17/government-accused-scaling-back-ambulance-services
http://www.guardian.co.uk/society/2010/dec/17/accident-emergency-waiting-time-target

Canada had the highest ovarian and lung cancer survival rates in an International Cancer Benchmarking Partnership (ICBP) report analyzing one-year and five-year cancer survival rates in Canada, Australia, Denmark, Norway, Sweden, and the United Kingdom. The report, published in The Lancet last December, looked at 2.4 million patients diagnosed with colorectal, lung, breast, and ovarian cancer between 1995 and 2007, with a follow-up done in December 2007. Rates were consistently higher in Australia, Canada, and Sweden, and survival rates improved over time in all jurisdictions.

Alberta, British Columbia, Manitoba, and Ontario all participated in the study, with Ontario ranking first among provinces for colorectal cancer survival rates and third among all health jurisdictions examined. Cancer Care Ontario's President and CEO Terrence Sullivan said in a press release that the results "confirm that the cancer control strategies Ontario has put in place for early screening, timely diagnosis, and improved access to care are resulting in improved survival rates." However, Sullivan also advised that much work remains, including more screening and treatment options, better disease management, and prevention in primary care.

The ICBP is an international partnership of clinicians, academics, and policymakers in the six participating countries, which, for the first time, are collaborating to examine international disparities in cancer survival rates. Their research aims to investigate how and why cancer survival rates differ by examining epidemiology; population awareness and beliefs; primary care systems and behaviors; root causes of diagnosis and treatment delays; and treatment, comorbidity, and other factors.

Sources:
http://info.cancerresearchuk.org/spotcancerearly/ICBP/
http://www.cancercare.on.ca/cms/One.aspx?portalId=1377&pageId=85058
http://www.nationalpost.com/news/canada/Canada+ranks+high+cancer+survival+study/4017628/story.html

French President Nicolas Sarkozy has announced his new cabinet and appointed Xavier Bertrand to the new position of Minister for Labor, Employment, and Health. Minister Bertrand held the post of Minister of Labor, Social Affairs, and Solidarity from 2007 to 2009. He also served as Secretary of State for Health in charge of health insurance reforms from 2004 to 2005.

President Sarkozy appointed Nora Berra as the new Secretary of State for Health. Dr. Berra had been State Secretary for the Elderly since 2009. A trained physician, her political career began as a municipal councilor in Neuville-sur-Saône in the Rhône region of eastern France in 2001. She was elected to the Municipal Council of Lyon in 2008 and to the European Parliament in 2009.

Following an Institute for Quality and Efficiency in Healthcare evaluation that found a relationship between the quality of care of very premature babies and a hospital's volume of neonatal cases, the German Federal Joint Committee ruled that hospitals will only get reimbursed for neonatal intensive care if they care for more than 30 babies a year weighing less than 2.76 pounds each. The ruling by the committee—which is the organizational body that sets policy for and regulates sickness funds and providers—has since been lifted temporarily to allow for more discussion.

The committee's ruling, which was scheduled in go into effect on January 1, 2011, would limit the care of very low-birthweight babies to 70 German hospitals. This decision to restrict care to a smaller network of neonatal centers was welcomed by parents' groups, neonatologists, and health insurance companies. The German Medical Association and the German Hospital Association opposed the ruling, arguing that extra travel time could put premature babies and mothers at risk, and that hospitals might change admission practices in order to reach the yearly threshold. After the ruling, several German states allotted special allowances to 14 hospitals that fell below the threshold.

The Joint Committee temporarily lifted the ban on small hospitals on December 16, 2010. To date, a final decision is pending.

Sources:
http://www.bmj.com/content/341/bmj.c6881.full (subscription required)
http://www.bmj.com/content/342/bmj.d156.full (subscription required

The federal government is planning to introduce a German Patients' Bill of Rights in 2011 to improve health care services provided by hospitals and doctors, according to the German newspaper Suddeutsche Zeitung. Jens Spahn, a parliament member who sits on the health committee, told the paper that this legislation would provide hospitals with financial incentives to have only two patients in a room—some hospitals now have shared rooms with up to four patients. The plans for such a law could provoke criticism from German hospitals, as some generate revenues by giving priority for two-bedded rooms to patients with private health insurance. Furthermore, it will be expensive to create this standard for all hospitals.

Other aspects of the envisioned Patients' Bill of Rights include: 1) requiring specialists to keep appointments within a three-week range; 2) malpractice suit reforms; and 3) automatic approval of medical device applications if German sickness funds do not process them within a defined period of time.

Sources:
http://www.thelocal.de/national/20101227-32053.html

Health Minister Edith Schippers announced that the Dutch Healthcare Authority, the Dutch Order of Medical Specialists, and the Dutch Association of Hospitals have come to an agreement on medical specialist salaries for 2012. In the Netherlands, most specialists are hospital-based, with two-thirds self-employed and organized in partnerships, and the remainder salaried. Dutch specialists are among the highest paid in the world, with remuneration ranging from €150,000 to €500,000 (US$200,000 to US$675,000) annually; these rates are similar to salaries of their U.S. counterparts.

In 2009, Dutch medical specialist salaries totaled €2.7 billion, exceeding the federal budget for specialists by €700 million. The salary agreement for 2012 comes after resistance from medical specialists to previous Health Minister Ab Klink's proposal to set an income ceiling at €285,000 (US$397,264) for medical specialist salaries. In place of a firm income ceiling, the agreement calls for the Dutch Healthcare Authority—the agency responsible for overseeing health care markets in the Netherlands—to set the total budget for medical specialist salaries (€2.2 billion in 2012). Leadership within the hospitals will then negotiate salaries with collectives of medical specialists. This allows hospitals to determine salaries for their individual doctors, and grants hospitals the flexibility to better reward higher-performing specialists. The Order of Medical Specialists has agreed to an average salary of €250,000 to €300,000 per year.

Sources:
http://www.rijksoverheid.nl/ministeries/vws/documenten-en-publicaties/kamerstukken/2010/12/15/bekostiging-medisch-specialisten[2].html
http://www.rijksoverheid.nl/ministeries/vws/nieuws/2010/12/15/onderhandelingsresultaat-medisch-specialisten-ziekenhuizen-en-minister-volksgezondheid.html
http://www.volkskrant.nl/vk/nl/2672/Wetenschap-Gezondheid/article/detail/1075171/2010/12/15/Medisch-specialisten-krijgen-2-2-miljard-euro.dhtml http://www.oecd.org/dataoecd/51/48/41925333.pdf

Over 1 million Dutch, roughly 7 percent of the total Dutch population, changed health insurers for 2011. This marks a significant increase from recent years, when an average of 300,000 to 400,000 people, or 1.8 percent to 2.4 percent, changed health insurance plans during the open enrollment period at the end of each year.

Since the current health system was implemented in 2006, all Dutch residents are required to purchase basic health insurance coverage. Coverage is provided by private health insurers and regulated under private law. Insurers are required to provide a basic benefits package defined by the government, and most Dutch also voluntarily purchase supplemental private health insurance for services not covered by the basic benefits package.

In 2010, the average annual premium for adults was €1,256 (US$1,715) with a variation of up to €275 between the least expensive and most expensive plans. (The government pays for the premiums for children up to age 18.). From 2010 to 2011, premiums for basic health insurance rose an average of €120. At the same time, changes were made to the basic benefit basket, such as dropping coverage for dental care for people ages 18 to 21, contraceptive pills from age 21, and antidepressants for a number of conditions, as well as adding coverage for smoking cessation courses. It is believed that this combination of premium increases and the changes in the basic benefit basket led a higher number of people than usual to look for both a cheaper basic plan and for supplemental insurance.

Sources:
http://www.volkskrant.nl/vk/nl/2672/Wetenschap-Gezondheid/article/detail/1365820/2010/12/29/Recordaantal-mensen-wisselt-van-zorgverzekering.dhtml
http://www.independer.nl/zorgverzekering/info/wijzigingen-zorgverzekering-2011.aspx
http://www.dutchnews.nl/news/archives/2010/12/more_than_one_million_set_to_c.php

The New Zealand government recently released its first national child cancer service plan, which aims to strengthening child cancer services by achieving national agreement on a service delivery model that is clinically safe, effective, and sustainable. The Ministry of Health and the National Health Board developed the cancer service plan in conjunction with District Health Boards (DHBs) and the Paediatric Oncology Steering Group, the medical associations, and patient advocacy groups.

The plan recommends that New Zealand have a two-center model to deliver pediatric oncology specialist services, at Starship Children's Hospital at Auckland DHB and Christchurch Hospital at Canterbury DHB, with shared care arrangements with District Health Boards across New Zealand. The plan would also establish a National Clinical Network for Child Cancer Services in New Zealand, which would be responsible for implementing the plan and overseeing care.

Approximately 150 new cases of child cancer are diagnosed annually in New Zealand, with about 320 children receiving active treatment at any one time.

Sources:
http://www.moh.govt.nz/moh.nsf/indexmh/national-plan-child-cancer-services-nz-nov2010
http://www.stuff.co.nz/national/health/4399762/Child-cancer-leader-vows-shared-care-will-be-safe/
http://www.stuff.co.nz/national/health/4391018/Former-DHB-chief-alarmed-by-national-child-cancer-plan
http://www.stuff.co.nz/national/health/4378386/Capital-child-cancer-care-in-doubt-again

A key issue on the government's health policy agenda in Norway is determining the number of hospitals the country should have. Since the 1960s, many hospitals have been built around the country, often in small rural villages, in order to provide people in all parts of the country access to emergency care. During the last 10 years, however, the effectiveness and efficiency of this policy has been questioned by health authorities, with the debate currently under way in Western Norway.

After the national reorganization of hospital ownership and governing in 2002, several initiatives to reduce the number of hospitals were undertaken. In almost all of these cases, the initiatives are met with strong opposition from the affected populations. The three parties — Labour, Socialist, and Centre — in the coalition government disagree on the matter of hospital reduction. While the Labour Party views reduction favorably, the Socialist and Centre parties are strongly opposed.

The high number of hospitals and emergency units in Norway is considered a significant factor in health care spending. However, the empirical evidence regarding the quality of care between different hospitals in Norway is inconclusive.

Sources:
http://www.adressa.no, Dec 28, 2010
www.nrk.no, December 12, 2010