- 11

fact that such visits are free of charge. Hence, they suggest, a fee should be charged for each visit to the doctor. This would reduce their numbers and, consequently, cut down the use of medication.

To us this opinion seems to contradict the social aims of health insurance. If the payment of a fee is to reduce the number of visits to the doctor, it must necessarily be more than a symbolic sum. This would result in a part of the population being deprived of any possibility of seeing a doctor, even when in dire need. On the other hand, for some people the payment would have no effect whatever.

There is no doubt that where the use of medicine is concerned, the remedy lies with the doctors. Even if a charge is made for medicines, the patient will buy them if the doctor gives him a prescription, It is, of course, a way of increasing the income of the health insurance institution, and might even be a justifiable way, but will this reduce the quantities of medicines used? In this connection it is essential to set up an information service and organizational measures both for the doctors and the patients.

However, all these factors, in spite of their importance, do not remedy the central problem which is that modern medicine is expensive, and will become more so if we wish it to develop, and if we say that the right to health is an elementary right of mankind, and if we wish to ensure that everyone has the right to enjoy it.

This is a fact of which we must make society fully aware.

Modern society understands that large financial investment is required in the advance of science and research, and in the development of new techniques. Society knows that in order to increase industrial or agricultural output, much must be invested in developing production methods,

- 12

Modern society is aware that if the Gross National Product is to be increased, and if living standards are to be improved, it is essential to examine and study and learn how to work better, more efficiently and more progressively. And that takes large investments of money.

However, when it comes to calculating expenses for public health, it is required that one makes an additional estimate - namely what is improved health to the population worth in terms of the Gross National Wealth.

The calculation of health insurance cannot be a marginal matter. It cannot be restricted to a balance-sheet of expenditure against income from contributions, from Government grants and from other sources. It will not be sufficient. For in the over-all budget of health insurance there is one vital factor which is the extent to which society benefits from the improvement in health standards of the population, and from its up-todate medical services. That is a very basic calculation. It is to be regretted we do not yet have the necessary norms against which to evaluate those benefits, and thus enable us to express the result in terms of co-efficients.

I would like to point out a number of questions which can exemplify the subject:

How much does society save by developing preventive medicine, motherand-child care, a reduction in the hospitalization period in maternity hospitals; in reducing the number of children's diseases?

How much does society save from mass immunization against several diseases?

How much does society save from the development of industrial medicine in terms of reducing industrial diseases, and thus reducing the number of work-days lost due to illness?

- 13

How much does society save and what advantages does it gain from high standard medical services which speed up the process of recuperation and reduces the number of incurably sick people, enables rehabilitation of the infirm allowing them to resume their activities, even if only partially?

All these find expression in positive, material and vital results. Thus, when one makes a general estimate of what public health must cost, this calculation must also be included.

There is no doubt that health costs a lot of money. Modern society must understand that if it wants a healthy nation, and a healthy individual, it must invest in it in exactly the same way as it invests in other national

resources.

HEALTH CARE IN SCANDINAVIA

INTRODUCTION

The Subcommittee visit to Scandinavia permitted it to make several important observations concerning the delivery of health care. Four (4) Scandinavian countries were visited by the Subcommittee staffDenmark, Finland, Norway, and Sweden. By far, the largest period of time was spent in Sweden. It was decided to study one Scandinavian ountry's health care system in detail, and to focus upon differences between it and the system of other Scandinavian countries, in order to learn as much as possible about each.

The Scandinavian countries have more similarities than differences, and this basic similarity includes geography, language, and general cultural characteristics, as well as health and other social welfare programs. All of the Scandinavian countries have extensively developed and highly socialized and organized social welfare systems.

Social benefits have envolved over many years in Scandinavia, more as a result of the general social and cultural milieu than of legislative fiat. Health services have been provided by the local communities for many hundreds of years. Consequently, almost all Scandinavian hospitals are owned and operated by the local commune, or county councils. As a result, Scandinavian health care systems have come to be highly hospital oriented.

During relatively recent times, the degree of involvement of the central governments has increased. In each of the countries the Subcommittee visited, state government subsidy for the operation of hospitals was substantial. In several of the countries, the degree of state subsidy is inversely proportional to the wealth of the subsidied county or commune. The central government thereby tends to equalize the distribution of funds for health faclities and in-hospital services throughout the country.

The central government in each of the Scandinavian countries is also responsible for the operation of "sickness insurance" funds which are either heavily regulated or owned and operated by the State. These funds pay a large percentage of out of hospital health care costs and provide cash benefits for lost income during periods of illness. In adition, Boards of Medicine in the various countries exist which set professional standards, determine the boundaries of health "districts", appoint district health officers, and, in some countries, determine the number and type of operational programs and health personnel to be allocated to each region. In terms currently popular in the United States, they function as areawide health planners in a very real sense. The Scandinavian system of medical education follows the European tradition. Undergraduate and post-graduate training is amalgamated into a 512 to 6 year program. Medical manpower tends to form a single labor market in Scandinavia, and doctors move rather freely among the Scandinavian countries.