Norwegian health care

Norway is a Nordic country with a population of approximately 5,6 million, known for its strong welfare state and commitment to social equity. Its tax-based government funded health care system is a central pillar of this model, emphasizing universal access, equity, and high quality of care. Norway provides universal health care coverage to all residents through membership of the National Insurance Scheme (4). Four regional health authorities, owned by the central government, are responsible for provision of specialist health services for the population in their region, while primary health care is the responsibility of 357 municipalities.

Like many other developed countries, Norway faces challenges such as an aging population, waiting times for elective procedures, workforce shortages, and balancing cost containment with innovation and quality. The Norwegian health care system is often ranked in the top tier in the Commonwealth Fund’s international survey of health systems (5) and in other international comparisons of system performance like OECD’s international comparative report Health at a Glance (6). Coordination of care across and within service levels continues to be a challenge due to lack of an integrated electronic health record, lack of organizational structures, different financing models and regulatory frameworks across the two levels of the health care system.

Since the Norwegian health care system is predominantly publicly funded, most hospitals are owned by the government, and most municipalities are small in population size, exposure to integrated and digitally mature health systems in other countries may model and inspire new ways of delivering health services. The last 15 years, Norway’s participation in the Harkness fellowship program has been important for exchange of ideas and inspiration to how health care systems and health care delivery can be improved.

The Harkness Fellowship program

The aim of the Harkness Fellowship program is to develop international leaders in health policy and practice by providing them with the opportunity to conduct comparative research on critical health care issues in the U.S. Applicants must demonstrate a commitment to improving health care systems, especially for vulnerable populations, and have a strong track record in policy, research, or leadership. The Commonwealth Fund appoints up to 13 Harkness Fellows each year. The typical current annual distribution is one each from Australia, Canada, and France; two each from Germany and the Netherlands; one each from New Zealand and Norway; and four from the United Kingdom.

Fellows are placed at leading U.S. universities and health care organizations. Each fellow is paired with one or more mentors based in the U.S. who offers mentoring, guidance, technical expertise, and provides access to networks and data.

Harkness Fellows build a strong international network of health policy experts, and during their year in the U.S. they are expected to produce policy-relevant outputs such as journal articles, policy briefs, or multimedia content.

Fellows usually start their year in the U.S. in August or September. The fellowship program starts with an orientation week held at the Commonwealth Fund headquarters in New York City. During this week Harkness fellows are introduced to each other and to the Commonwealth Fund, and they learn about current health care delivery system and health policy issues in the U.S.

The fellow program contains regular seminars, site visits to health care organizations and agencies, and policy briefings. Fellows are given the opportunities to meet with policy leaders, academics, and health care professionals who are involved in innovation and improvement of health care service delivery. During a week in Washington D.C. fellows get a firsthand understanding of how health policy is developed and implemented in the U.S. Fellows meet with members of Congress, experts in Medicare and Medicaid policy, leaders of political advocacy organizations, and political strategists. The year is closed with a final reporting seminar where fellows present their findings. The Fund arranges dinners for family members and partners.

During the final lunch, all the fellows are asked to share their most important experiences from their stay. One question that everyone is asked during this round is the following: If you were to fall ill and need medical care, after having observed the U.S. healthcare system for about a year, would you choose to be treated here or in your home country? Interestingly, as far as is known, all Norwegian fellows have chosen the Norwegian healthcare system over those in the U.S.

Norwegian Harkness Fellows

John-Arne Røttingen, who served as Chief Executive of the Norwegian Knowledge Centre for the Health Services (Nasjonalt kunnskapssenter for helsetjenesten) from 2004 to 2011, initiated Norwegian participation in the Harkness Fellowship program from 2010. The Norwegian Knowledge Centre for the Health Services served as the Norwegian collaborating institution for The Commonwealth Fund until 2016, when the Knowledge Centre was incorporated into The Norwegian Institute of Public Health. Since then, The Norwegian Institute of Public Health has been the responsible collaborating institution in Norway. The Research Council of Norway has been a reliable sponsor of the Norwegian Harkness fellowship program from the onset in 2010 throughout the last 15 years.

Applications for the fellowship has each year been openly invited from «skilled professionals in the healthcare sector who are mid-career and are engaged in improving the healthcare system through analysis and research, as well as leadership». The target group for the fellowship has been researchers, leaders or journalists who are in a phase of their professional development where the experiences gained from such a scholarship can have significant value for their future work.

The selection process has been managed by a Norwegian Harkness Selection Committee in cooperation with the Commonwealth Fund. The selection Committee has included representatives from the Norwegian Knowledge Centre for the Health Services, the Norwegian Institute of Public Health (from 2016), the chairs of the Board for the Research Programme on Health and Care Services (until 2015) and the Board of the Health, Care and Welfare Services Research (HELSEVEL) (until 2024) at the Norwegian Research Council, and Norwegian experts on health care. Advertising for next year’s scholarship usually begins in the preceding spring, with an application deadline in November the year before. The committee may approach and nominate potential applicants.

The applications contain a statement of professional objectives, a curriculum vitae, four letters of reference, and examples of work products, such as journal articles, reports, or other pieces of writing. Candidates are also asked to include an outline of a research project of interest and relevance both to Norwegian and U.S. health care policy in their application. The last three years, the number of applicants has varied between three and four well-qualified professionals. During winter and springtime, applicants have been interviewed and a new fellow selected. The choice of placement and mentors has been administered by the Commonwealth Fund.

Except from the academic year 2020–2021, when the program was paused due to the COVID-19 pandemic, a Norwegian Harkness fellow has been selected each year since 2010. So far, 14 fellows, seven women and seven men from various Norwegian universities, colleges, research institutes, and agencies, have completed the program. They represent a diverse background from medicine, nursing, ethics and health economics (table 1).

Impact and experiences

In this book, 13 Norwegian Harkness fellows share their experiences and reflections. They were invited to describe their research projects, main findings, and how the project has had an impact nationally and internationally. Further, we invited them to share their thoughts on how the experiences and exposure to U.S. health care and health policy has had an impact career-wise. We also welcomed any reflections on future research or policy work to promote access, equity, and quality.

Norwegian Harkness fellows have been placed at different institutions, including Harvard University, University of Pennsylvania, Yale University, Dartmouth College, Brown University, Cornell University, and Stanford. The fellows’ projects cover a wide range of topics, including health care expenditure and financing models, priority setting, methods for evaluating heath policies, leadership development, over-diagnosis, use of «bid data», coordination of care, value-based health care, innovative health care delivery models for dementia and other chronic conditions, price negotiations for prescription drugs, and the uptake of telemedicine in mental health care (7–19). Several projects explicitly address health disparities, equity, and access to health care.

A salient feature of U.S. that differs significantly from Norway is the state-by-state variation that works as «a «laboratory» for research using comparative methods», as Unni Gopinathan puts it (14). The Norwegian fellows have learned how different regulatory frameworks, delivery systems, and financing models operate, and these insights are particularly relevant for the Norwegian health care systems with less variation.

The fellows have shared their insights and findings through presentations at conferences and meetings. Several fellows have contributed through policy advice and Norwegian government reports and White papers.

The impact of the Harkness Fellowship extends way beyond the research project. The fellows recount positive experiences of interacting with experts, academics, policy makers, and other fellows from around the world. Many fellows have made new professional contacts and have taken part in new research initiatives during or after their year in the U.S. Their accounts clearly show that new and lasting research collaborations have been formed.

Several fellows emphasize the personal development and leadership insights that the fellowship fostered, as Iselin Dalen Syversen puts it (18):

«Reflecting on my fellowship year, I didn’t just gain new knowledge and skills about disparities research—I acquired a whole new perspective on leadership. Before heading to the United States, I thought leadership was about big decisions and grand gestures, but I learned that true leadership lies in the everyday actions and interactions—sharing knowledge, offering resources, and helping others shine.»

We would argue that the Norwegian participation in the Harkness Fellowships program, and the financial support from the Research Council of Norway, has benefited Norwegian health policy, health care and health services research. The Norwegian Fellows’ accounts demonstrate that being exposed to the diversity of U.S. health care as a Harkness fellow nurtures curiosity, refines research and leadership skills, and provokes new ideas and questions. Further, Norwegian fellows return from the fellowship program with an international perspective, novel insights, research findings and an international network that represent steppingstones for improvement and innovation of health care services and health policy in Norway and internationally.