Editorial for the special issue in Nordic Journal of Health Economics: Challenges in Nordic Primary Care
Authors: Pedersen Line Bjørnskov 
Published: September 2024

Primary care in the Nordic countries have many similarities but are also different in crucial ways (Olsen et al. 2016). Among the similarities are that Nordic primary care is tax-based, aims to ensure equal and easy access to care for all citizens, and supply high-quality care at the lowest cost-effective level. Among the differences are the Nordic countries’ way of organizing primary care with respect to remuneration, incentives, and the use of general practitioners (GPs) as gatekeepers.
As other countries, the Nordic countries have experienced certain challenges in primary care in recent years. Demands from patients and third-party payers are increasing both with respect to quantity and quality of services expected for provision. Some of the reasons for this are ageing populations, more patients with chronic diseases, and third-party payers aiming to make primary care the main responsible for prevention and treatment of the chronically ill. At the same time, the supply of GPs continues to drop (especially in Denmark and Norway and with Finland as an exception), the share of avoidable hospital admissions of all hospital admissions is still too high, and the same holds for the share of inappropriate antibiotic prescriptions in primary care (OECD 2020). There is therefore still room for improvement, although primary care in the Nordic countries overall tend to be placed in the better half of the distributions compared to other OECD countries.
In the 2020 OECD report on the potential of primary health care, several actions were outlined that could help strengthen the efficiency, effectiveness, and access of primary care. To improve the efficiency of primary care, new recruitment and training strategies, better use of digital technology, and providing the right (financial) incentives were pointed out as potential tools. To improve the effectiveness and responsiveness of primary care, reorganization in teams and integrated networks, bundled payments, and improved information systems were pointed out as possible solutions. To improve access and equity in primary care, it was recommended to use technology and mobile clinics to reach rural areas, in occupational health in workplaces, and to revisit the roles of health care professionals (OECD 2020).
In this special issue in the Nordic journal of health economics, several studies from the Nordic countries focus on the challenges in Nordic primary care in different ways. The issue includes empirical studies from Sweden, Norway, Denmark, and Finland, as well as a theoretical contribution concerned with recruitment and retention in Nordic primary care. The studies all factor into the recommendations made in the OECD report on how to strengthen primary care. For example, in this special issue we will learn in a study by Glengård that characteristics that can be changed by primary care clinics themselves, such as division of labour and continuity of care are also the most important for patients’ experience of care relative to factors that are out of the primary care clinics’ control. On the positive side, this means that there is scope for improvements while on the negative side, improvements may be difficult due to challenges with GP shortages in Sweden, where the study was conducted.
Oxholm and colleagues are also concerned with the GP shortage issue and study the link between work pressure in general practice and job dissatisfaction of GPs. They find that the link between experienced work pressure and job dissatisfaction is stronger for GPs working in areas with an undersupply of GPs and for GPs in singlehanded practices. These areas could therefore be of special interest to policy makers when implementing new incentive schemes and structures affecting GPs’ work pressure. While reorganising primary care may be part of the solution to overcome the challenges in primary care, Aars and Kaarbøe offer insights into the recruitment and retention of GPs in a theoretical model to inform policy decisions. They show that there are conflicting effects as policies that have a positive effect on recruiting and retaining GPs can have a negative effect on GPs’ effort and services and that the effect is sensitive to GPs’ degree of altruism.
In a study by Snilsberg, who is concerned with how new team-based primary care delivery models in Norway can be effectively evaluated when there are potential issues with selection bias and small sample sizes, we learn that matching methods can be used to account for these issues and propensity score weighting is suggested. The paper also identifies several important predictors for joining the new primary care delivery models. Holster and colleagues are interested in how occupational healthcare in Finland is used and how the use is associated with other ambulatory service sectors and the distribution of care between these. Interestingly they find that the use of occupational healthcare seems to be associated with higher use of ambulatory care services overall, which suggests that ambulatory care is not allocated according to need. This raises important questions of equality in access to care.
Focusing on the challenges in Nordic Primary care from a health economic perspective is a first step towards understanding the mechanisms behind the problems. The health economics discipline and its tools can help uncover the issues and disclose where to set in to solve the problems. It can also explore the potential of the OECD recommendations in more detail and elicit in what areas the greatest potential is for improving efficiency, effectiveness, and equity. Recommendations for important next steps to solve the current issues could be to 1) gain inspiration from countries who (also) have well-run primary health care sectors (here Israel has been enhanced as an interesting example that performs well on a number of indicators (OECD 2012, Barua and Jacques 2018, Rotenberg et al. 2022)) and explore the contexts of these sectors, and 2) join forces with other academic disciplines, e.g. researchers from primary care, public administration, organizational theory etc. to shed light on the topic from different angles using different methods. Finally, it is of utmost importance to inform and guide policy makers about which interventions and organizational changes that are deemed successful and how Nordic primary care could best be improved.
It can turn out to be a strength that the covid-19 pandemic has forced the health care system and professionals to adapt quickly to the new situation, to collaborate on the treatment of patients between health care sectors, and to develop and provide technological solutions to consult and treat patients at the distance. The next years will tell whether these rapid changes in primary care have accelerated technological progress and led to permanent changes in behaviour that is assumed to enable the realisation of unexploited potential in Nordic primary care. Health economists can contribute to this understanding by investigating whether such changes provide higher quality of care at a more cost-effective level.