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Waiting lists are

revenues, accounting for approximately 13 per-

rationing care in Norway. In some cases, care

cent of all government expenditures.172 In the-

may be denied altogether if it is judged not to

so long and so

be cost-effective. As Knut Erik Tranoy,

ory, the NHS operates within an annual global

prevalent that the

Professor Emeritus at the Centre for Medical

budget for health care spending. In reality, it

European

Ethics of the University of Oslo and an origi-

regularly exceeds this budget by a wide margin,

nal member of the government's Health Care

necessitating supplemental funding. Portugal

Observatory on

Priorities Commission, explains:

is one of the few OECD countries where public

Health Systems

health care spending has been rising as a pro-

It is important to see (a) that, in a public

portion of total health spending, up more than

says that they

four percentage points since 1997.173

health service of the Nordic type, any

veer toward "de

given amount of resources always has

Theoretically, benefits under the NHS

facto rationing."

alternative uses. And (b) it is neither

include all necessary inpatient and outpatient

medically nor morally defensible to put

health care services including specialists, diag-

scarce resources to uses which will fore-

nostic tests, mother and child care, and pre-

seeably yield less favorable outcomes

scription drugs. On paper, no health-related

than other uses--save fewer lives, cure

expense is specifically excluded from coverage

fewer patients.168

by the NHS, though in reality services such as

dental care and rehabilitation therapy are sel-

dom provided.174 Copayments are required for

Tranoy differentiates between Norwegian-

style systems of national health care and "a

diagnostic tests, hospital admissions, consul-

health care system where patients buy ser-

tations with specialists, and prescription

vices in a market, and where justice means

drugs, where copayments can run to 40 per-

cent or higher.175

equality of opportunity to buy what you

need. Decisions about alternative use are

Primary care physicians and hospital-

then (largely) patients' decisions."169

based physicians are public employees, paid

directly by the NHS. However, NHS doctors

While Norwegians generally report that

are permitted to practice privately as well,

they are "fairly satisfied" with the way their

and roughly half do so.176 Specialists are

health care system is run, there has been grow-

ing discontent over such issues as the ability to

often in private practice and are reimbursed

choose a health care provider, involvement in

by the NHS on a contractual basis.

decisions regarding care or treatment, and

About 25 percent of the population, mostly

waiting times--which has been an ongoing

government workers, military, telecommuni-

issue in Norwegian politics.170 However, at this

cation workers, and their families, remain

under a series of industry or occupation-based

time there doesn't appear to be any widespread

insurance schemes, known collectively as "sub-

movement for larger reform.

systems," which are a legacy of the country's

pre-NHS health care system.177 These plans

Portugal

were originally intended to be incorporated

into the NHS, but their powerful constituen-

cies have prevented that from occurring.

The Portuguese health care system is a clas-

Participants in the subsystems pay a premium

sic, universal, centrally run National Health

equal to approximately 1 percent of their

System, a single-payer system funded through

salary. Benefits are generally superior to those

taxes with comprehensive benefits provided

free or with little cost at the point of service.171

offered through the NHS.178 Not surprisingly,

premiums fall far short of what is needed to

Also, a number of occupation-related health

finance benefits. The resulting shortfall is

insurance schemes--originally intended to be

shifted to the NHS.

integrated into the NHS--now coexist with it.

In addition, approximately 10 percent of

The primary source of care is the NHS,

the population has private insurance, usually

which is funded primarily through general tax

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