State of Health in the EU Iceland IS Country Health Profile 2019 The Country Health Profile series Contents

The State of Health in the EU’s Country Health Profiles 1. HIGHLIGHTS 3 provide a concise and policy-relevant overview of 2. HEALTH IN ICELAND 4 health and health systems in the EU/European Economic 3. RISK FACTORS 7 Area. They emphasise the particular characteristics and challenges in each country against a backdrop of cross- 4. THE HEALTH SYSTEM 9 country comparisons. The aim is to support policymakers 5. PERFORMANCE OF THE HEALTH SYSTEM 12 and influencers with a means for mutual learning and 5.1. Effectiveness 12 voluntary exchange. 5.2. Accessibility 15 The profiles are the joint work of the OECD and the 5.3 Resilience 18 European Observatory on Health Systems and Policies, 6. KEY FINDINGS 23 in cooperation with the European Commission. The team is grateful for the valuable comments and suggestions provided by the Health Systems and Policy Monitor network, the OECD Health Committee and the EU Expert Group on Health Information.

Data and information sources The calculated EU averages are weighted averages of the 28 Member States unless otherwise noted. These EU The data and information in the Country Health Profiles averages do not include Iceland and Norway. are based mainly on national official statistics provided to Eurostat and the OECD, which were validated to This profile was completed in August 2019, based on ensure the highest standards of data comparability. data available in July 2019. The sources and methods underlying these data are To download the Excel spreadsheet matching all the available in the Eurostat Database and the OECD health tables and graphs in this profile, just type the following database. Some additional data also come from the URL into your Internet browser: http://www.oecd.org/ Institute for Health Metrics and Evaluation (IHME), the health/Country-Health-Profiles-2019-Iceland.xls European Centre for Disease Prevention and Control (ECDC), the Health Behaviour in School-Aged Children (HBSC) surveys and the World Health Organization (WHO), as well as other national sources.

Demographic and socioeconomic context in Iceland, 2017

Demographic factors  Iceland EU Population size (mid-year estimates) 343 000 511 876 000 Share of population over age 65 (%) 14.0 19.4 Fertility rate¹ 1.7 1.6 Socioeconomic factors GDP per capita (EUR PPP²) 39 100 30 000 Relative poverty rate³ (%) 8.8 16.9 Unemployment rate (%) 2.8 7.6

1. Number of children born per woman aged 15-49. 2. Purchasing power parity (PPP) is defined as the rate of currency conversion that equalises the purchasing power of different currencies by eliminating the differences in price levels between countries. 3. Percentage of persons living with less than 60 % of median equivalised disposable income. Source: Eurostat Database.

Disclaimer: The opinions expressed and arguments employed herein are solely those of the authors and do not necessarily reflect the official views of the OECD or of its member countries, or of the European Observatory on Health Systems and Policies or any of its Partners. The views expressed herein can in no way be taken to reflect the official opinion of the European Union.

This document, as well as any data and map included herein, are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area.

Additional disclaimers for WHO are visible at http://www.who.int/bulletin/disclaimer/en/

© OECD and World Health Organization (acting as the host organisation for, and secretariat of, the European Observatory on Health Systems and Policies) 2019

2 State of Health in the EU · Iceland · Country Health Profile 2019 Obest Bne drnn Smon 83 79 75 81 77 Life expectancy at birth,years EUR 1 EUR 3 potentially fatalconditions. provides effective acutecare for indicating thatthehealthsystem much lower thantheEU average, causes ofmortalityare also preventionpolicies. Treatable reflecting theeffectiveness of Preventable mortalityislow, Effectiveness Per capita spending(EURPPP) growing burden ofchronic diseases. strengthen the primary care systemandthe gatekeeping role of general practitioners tobetterrespond tothe care, butdisparitiesexistbetween income groups intermsofunmetneeds. An important challenge isto particular concern. The Icelandic healthsystem performs relatively well in providing good accesstohigh-quality are implicated inmore thanone-third deathsinIceland, ofall with poor nutrition and growing obesityrates of population is generally good, althoughthere are important socioeconomicinequalities. Behavioural riskfactors The lifeexpectancy oftheIcelandic population is well above theEUaverage andthehealthstatusof 1 EUR 2 per 100000population, 2016 Age-standardised mortality rate Preventble IS IS IS mortl t mortl t Tretble 773 797 Highlights

2000 000 000 000 Smon EU EU EU 2005 17 Obest Alcohol 21 22 62 % of adults 2011 77 ltres 9 % 10 139 IS 15

19 2017 EU 27 % 2017 809 826 Countr EU pocket by households, primarily for pharmaceutical anddentalexpenses. above theEUaverage of79%. Mostoftheremaining spending is paid outof expenditure accountedfor82%ofhealthexpenditure in2017, slightly in theEUrecent years, butaccountsforalower share ofGDP. Public Health spending per capita totheaverage inIcelandhasbeensimilar Health system countries. alcohol consumption inEurope, atabout20%lessthantheaverage inEU rate ofEUcountries. Icelandicadultsalsohave oneofthelowest levels of are among thelowest. Lessthanoneintenadultssmoke daily –halfthe higher thaninany EUcountry. However, tobaccoandalcoholconsumption More thanoneinfourIcelandicadults(27%) were obesein2017, arate Risk factors lagged behindthe gains ofthehighereducated. level have widened since2011asthe gains among theleasteducated drove these gains. However, inequalitiesinlifeexpectancy by education EU average. Reductionsindeathsfrom ischaemic heartdiseaseandstroke between 2000and2017toreach 82.6 years, almosttwo years above the Life expectancy atbirthinIcelandincreased by nearly three years Health status Countr EU % reporting unmet medical needs, 2016 unmet needsformedicalcare, Icelanders generally report low Accessibility EU IS countries. remain higherthaninmany EU surgery have beenreduced, but country. Waiting timesforelective EU average andany otherNordic income groups are larger thanthe although disparitiesbetween %01 0% Hh ncome %01 State of Healthin the EU ·Iceland ·Country HealthProfile 2019

EU Countr All 3% Low ncome 6% innovative andefficient ways. from population ageing in responding to growing demands system facesthechallenge of providers, butthe primary care to primary care andothercare simpler servicesfrom hospitals in hospitalcare andtransferring achieved inimproving efficiency technologies. Progress hasbeen ageing andnew of population in thefuture because is expectedto grow Health expenditure Resilience 3

ICELAND 2 Health in Iceland ICELAND

Life expectancy in Iceland is higher than However, the progress in life expectancy since 2000 the EU average, but gains are slowing has been slower than in some EU countries that now have a higher life expectancy (Spain, Italy and France). Life expectancy at birth in Iceland increased over the On average, women live 3.2 years longer than men last decade to reach 82.6 years in 2017, almost two (84.3 compared to 81.1 years), although this gender years above the EU average of 80.9 years (Figure 1). gap is smaller than the EU average of 5.2 years.

Figure 1. Life expectancy at birth in Iceland is more than one year above the EU average

Yers 2017 2000 90 –

Gender gap: Iceland: 3.2 years 85 – 834

831 EU: 5.2 years 827 827 826 825 824 822 822 821 818 817 817 816 816 814 813 812 811 811 809

80 – 791 784 78 7 78 773 76 758 753 749 748 75 –

70 –

65 – EU Sp n Itl Frnce MltCprusIrelnd Greece Polnd Ltv  NorwIcelndSweden Austr F nlndBel um Czech Eston Crot  Bul r  Portu l Sloven GermnDenmr Slov Hun rL thun Romn  Luxembour Netherlnds Un ted † n dom

Source: Eurostat Database.

Social inequalities in life Figure 2. The education gap in life expectancy is expectancy are widening about 5 years for men and 3.5 years for women

Inequalities in life expectancy in Iceland exist not only by gender but also by socioeconomic status,

including education and income level. In 2018, the life expectancy of men at age 30 with the lowest level of 562 526 ers 537 ers education was almost five years lower than for those ers 488 ers with the highest level. This education gap in longevity was smaller among women, at 3.6 years (Figure 2).

Between 2011 and 2018, the gap between those most Lower Higher Lower Higher and least educated widened by 1.5 years, as there was educated educated educated educated women women men men virtually no gain among the least educated (Statistics Education gap in life expectancy at age 30: Iceland, 2019). Iceland: 3.6 years Iceland: 4.9 years This education gap in life expectancy can be EU21: 4.1 years EU21: 7.6 years

explained partly by differences in exposure to Note: Data refer to life expectancy at age 30. High education is defined various risk factors and lifestyles, including higher as people who have completed tertiary education (ISCED 5-8) whereas smoking rates, poorer nutritional habits and higher low education is defined as people who have not completed secondary education (ISCED 0-2). obesity rates among men and women with low Sources: Statistics Iceland (data refer to 2018) and Eurostat Database for levels of education (see Section 3).It is also related the EU average (data refer to 2016). to differences in income level and living standards, which affect exposure to other risk factors and access to health care.

4 State of Health in the EU · Iceland · Country Health Profile 2019 -100 health, compared to84%inthe highest(Figure 4). 70 %inthelowest income group report being in good incomes are lesslikely toreport being in good health: However, asinothercountries, people onlower a higher proportion thantheEUaverage of70%. Three-quarters of people report being in good health, health, but disparities by income group persist Most Icelandicpeoplereport being in good Source: Eurostat Database. in diagnostic anddeath registration practices. Note: Thesize of thebubbles isproportional to themortality rates in2016. Theincrease inmortality rates from Alzheimer’s disease islargely dueto changes Figure 3. Cardiovascular diseases are still the leading causes of death inIceland heart disease. deaths inIceland2016 were toischaemic attributed consumption (see Section3). Nevertheless, 13%ofall (Figure 3), partly duetoareduction intobacco decreased substantially between 2000and2016 The mortalityrate from ischaemic heartdisease from Alzheimer’s diseaseisincreasing ischaemic heartdisease, but mortality The maincauseofdeath inIcelandremains 100 % c -50 50 0 hn Br e 2000-16(orner Prostte cncer est cncer 20 Pneumon est Pncretc cncer

er) Colorectl cncer 40

Chronc obstructvepulmonr dsese Str o­e State of Healthin the EU ·Iceland ·Country HealthProfile 2019

Lun cncer cancer. by cancer, followed by colorectal cancerand prostate Lung themostfrequent cancerisstill causeofdeath changes indeathregistration practices. due atleast partly toimprovements indiagnosis and cause ofdeathinIceland, althoughtheincrease is increased greatly since2000, making thisthesecond Mortality rates from Alzheimer’s diseasehave for Iceland 2016). Source: Eurostat Database, based onEU-SILC (data refer to 2017, except incomes are roughly thesame. Note: 1.Theshares for thetotal population andthepopulation on low level are similarto theEU average Figure 4. Inequalities inself-rated healthby income Unted ‰n dom Luxembour Netherlnds 80 Low ncome Ae-stndrdsed mortlt rteper100000populton,2016 Romn† Germn Lthun Denmr€ Hun r Portu l Sloven Slov€ Alzhemer’s dsese Bul r Bel um Norw Sweden Czech Eston Greece† Fnlnd Crot Icelnd Austr Polnd Cprus Irelnd Frnce Ltv Mlt Spn Itl† EU 0 100 % of dults whoreport ben n ood helth Totl populton 20

40 Isc 120 60 hemc hertdsese H h ncome 80 140 100 5

ICELAND Several years of life in old age are lived with In 2017, Icelanders aged 65 could expect to live some diseases and disabilities more than 20 years, with women expected to live an additional 21.4 years and men a further 19.8 years ICELAND The share of people aged 65 and over is steadily (Figure 5). However, this gender gap is reversed when growing in Iceland because of rising life expectancy it comes to the number of years lived with disability and declining fertility rates. In 2019, 14 % of people because women live a greater proportion of their lives were aged 65 and over, up from 10 % in 1980, and this with chronic diseases and disabilities. Women aged 65 is projected to reach 25 % by 2050. and over are also more than twice as likely as men to report depressive symptoms.

Figure 5. Two-thirds of Icelanders aged 65 or over report a functional limitation

Lfe expectnc t e 65 Women Men

43 63 214 198 ers ers 151 155

Ye rs wthout Ye rs wth ds blt
ds blt

% of people ed 65+ reportn % of people ed 65+ reportn lmttons functonl lmttons n ctvtes of dl lvn (ADL) Women Men Women Men

19% 13% 27% 33% 44% 48%

29% 19% 82% 87%

No lmt tons Some lmt tons No lmt ton At le st one Severe lmt tons n ADL lmt ton n ADL

% of people ed 65+ reportn depresson s mptoms3 Women Men

11% 5%

Note: 1. Functional limitations include physical and sensory limitations (seeing, hearing and walking). 2. Basic activities of daily living include dressing, walking across a room, bathing or showering, eating, getting in or out of bed and using the toilet. 3. Based on the PHQ-8 index, people are considered to have depression symptoms if they report two or more depression-related problems (out of eight variables). Source: Eurostat Database for life expectancy with and without disability (data refer to 2017); European Health Interview Survey for other indicators (data refer to 2015).

6 State of Health in the EU · Iceland · Country Health Profile 2019 third highestrate inEurope. and girls were overweight orobesein2013-14, the to 27 %in2017. Oneinfive 15-year-old Icelandicboys increased over the past decade, from 12%in2002 cancer. Obesityrates among Icelandicadultshave diseases, andisalsoariskfactor forsomeformsof diabetes, heartattack andothercardiovascular Obesity results inahigherriskofhypertension, in Iceland than inmostEUcountries Overweight andobesityrates arehigher Source: IHME(2018), GlobalHealth Data Exchange (estimates refer to 2017). consumption; andtobacco include smokingandsecond-hand smoking. can beattributed to more thanoneriskfactor. Dietary risksinclude14components suchaslow fruitandvegetables diet, highsugar-sweetened beverages Note: Theoverall numberof deaths (800) related to these riskfactors islower thanthesumof each onetaken individually(850), because thesamedeath Figure 6. More thanoneinthree deaths inIceland are attributed to modifiablelifestyle riskfactors well ashighsugarandsaltconsumption. Tobacco in 2017, including low fruitand vegetable intake, as tomorerisks contributed deaths thanoneinsixofall one-third deathsinIceland(Figure ofall 6). Dietary Behavioural tomore riskfactorscontribute than deathsthan one-thirdofall inIceland Behavioural riskfactorsaccount formore 3 EU 18% Icelnd 17% Detr rss Riskfactors State of Healthin the EU ·Iceland ·Country HealthProfile 2019

EU 17% Icelnd 15% Tobcco deaths, thesameasEUaverage. activity was estimatedtoberesponsible for3%of far lower thantheEUaverage of6%. Low physical estimated toberesponsible foronly 1%ofdeaths, deaths.all Incontrast, alcoholconsumption was smoking) was responsible foranestimated15%of consumption (including direct andsecond-hand one-third) andclose totheEUaverage (Figure 7). eating a portion of vegetables per day islower (about countries. The proportion of adults who report not every day, ahigher proportion thaninmost EU that they donoteven eatasingle portion offruit obesity rates. In2017, nearly halfofadultsreported poor nutritional habitsare likely to tocontribute children, as well asadults, thaninmostEUcountries, physical activity being more frequent inIcelandic activity in (14%)andboysgirls (25%). Despiteregular is astarkdifference between therates of physical higher thantheEUaverage (15%)althoughthere in moderate to vigorous physical activity, which is In contrast, oneinfive (19.5%)of15-year-olds engage EU 3% Icelnd 3% ctvt phscl Low Alcohol EU 6% Icelnd 1% 7

ICELAND Adolescent tobacco and excessive alcohol binge drinking1) during the past month in 2015, the consumption rates are very low lowest rate in Europe. Icelandic adults also consume much less alcohol compared to most EU countries. ICELAND The smoking rate in adolescents is lower in Iceland than in any EU country, with only 5 % of 15- and The low rates of tobacco and excessive alcohol 16-year-old boys and 7 % of girls reporting that they consumption among adolescents are partly had smoked cigarettes in the past month in 2015. This attributable to Iceland’s prevention approach, which rate has been steadily decreasing since 1995. Among was launched in the late 1990s. This initiative sought Icelandic adults, less than 10 % reported smoking to strengthen community protective factors, including daily in 2018 – a share that is among the lowest in parental monitoring, parental communication, Europe. However, the proportion of smokers among social involvement and adolescent participation in the population with limited education is more than organised sports to decrease risk factors (Kristjansson double that among the highly educated population. et al., 2016).

Excessive alcohol consumption is also more limited in Iceland than in many EU countries. Around 7 % of 15- and 16-year-old boys and 8 % of girls reported at least one episode of heavy alcohol drinking (also called

Figure 7. Obesity is a major public health issue in Iceland

Smon (chldren)

Veetble consumpton (dults) 6 Smon (dults)

Frut consumpton (dults) Bne drnn (chldren)

Phscl ctvt (dults) Alcohol consumpton (dults)

Phscl ctvt (chldren) Overweht nd obest (chldren)

Obest (dults)

Note: The closer the dot is to the centre, the better the country performs compared to other EU countries. No country is in the white ‘target area’ as there is room for progress in all countries in all areas. Source: OECD calculations based on ESPAD survey 2015 and HBSC survey 2013-14 for children indicators; and EU-SILC 2017, EHIS 2014 and OECD Health Statistics 2019 for adults indicators. Select dots + Effect > Trnsform scle 130%

1: Binge drinking is defined as consuming five or more alcoholic drinks on a single occasion for children and adolescents.

8 State of Health in the EU · Iceland · Country Health Profile 2019 4 000 accounted fornearly oftheremaining all spending EU average (79%). Out-of-pocket (OOP) payments of current healthexpenditure in2017, above the expenditure inIceland, amounting toalmost82% Public expenditure ofhealth accountsforthebulk Most healthspending ispublicly funded S of GDP Figure 8. Healthexpenditure percapitainIceland isslightlyhigherthantheEU average, butlower asashare medical specialists were abletosetup private primary care sectorexercising a gatekeeping role, regulation andcontracting. Intheabsenceof and fragmented andhasresulted intheneedfor This hasmadehealthcare provision more diverse for-profit providers hasincreased in recent years. number andscopeof private non-profit and private mosthealthcareWhile providers are public, the The private sectorhas grown rapidly through theannual nationalbudget. and thenationalhealthinsurance systemisfinanced state-run system). There are seven healthcare regions purchaser-provider relationship (atax-based, funded, covering residents, all with a partly integrated The healthsysteminIcelandismostly publicly with universal coverage Iceland hasastate-centred system 4 EUR PPPpercpt 2 000 5 000 3 000 1 000 ource: OECD Health Statistics 2019 (data refer to 2017). Government &compulsor nsurnce 0 Norw Thehealthsystem

Germn

Austr

Sweden Netherlnds

Denmr

Luxembour„Frnce

Bel„um

Irelnd Voluntr schemes &household out-of-pocet pments

Icelnd Unted ‰n„dom Fnlnd State of Healthin the EU ·Iceland ·Country HealthProfile 2019

EU Mlt

Itl of 9.8%. of itsGDPonhealth, much lessthantheEUaverage EU average ofEUR2884. However, Icelandspent8.3 % differences in purchasing power), slightly above the capita amounted toEUR3055in2017(adjustedfor percentage ofGDP(Figure 8). Healthspending per slightly higherthan theEUaverage, butlower asa Health expenditure per capita inIcelandis person onhealth, but lessasashareofGDP Iceland spendsmore than the EUaverage per system as well as value-based financing. the importance of integration across thehealthcare emphasising the gatekeeping role of primary care and adopted thatseekstoaddress many oftheseissues– services. A new healthcare policy hasrecently been Agency, which isthemain public purchaser of payments with theIcelandicHealthInsurance clinics andenter intocontract-based fee-for-service medications required during hospitalisation. Inpatient care isfree ofcharge, as are testsand all or exemptions are provided to vulnerable groups. dental care and pharmaceuticals, butreductions are mainly co-payments for primary care visits, slightly above theEUaverage ofalmost16%. These – almost17%ofhealthexpenditure in2017– Spn

Czech

Sloven

Portu„l

Cprus

Greece

Slov

Lthun

Eston

Polnd

Hun„r

Bul„r

Crot

Ltv Shre of GDP Romn % of GDP 00 25 50 5 7 100 125 9

ICELAND A large share of funding goes to inpatient share than the EU average of 16 %. Through a range and outpatient care, but little to prevention of measures, Iceland has brought down the share it spends on pharmaceuticals and medical devices from ICELAND Iceland spends the largest share of its health more than 18 % in 2010 to 14 % in 2017. Only 2.5 % of resources on inpatient and outpatient care, health spending was allocated to prevention in 2017 allocating to each slightly more than 30 % of the (below the EU average of 3.1 %). total (Figure 9). In 2017, it also spent one-fifth (20 %) of health expenditure on long-term care, a larger

Figure 9. Inpatient and outpatient care are the two main expenditure categories

EUR PPP per cp t Icelnd EU

1 200 32% 31% of totl of totl 1 000 spend n spend n 958 946 800 858 835 20% of totl spend n 600 611 14% of totl spend n 522 400 471 414

200 25% of totl spend n

0 7777 89 Inpt ent0 cre‚ Outpt ent0 cre€ Lon -term0 cre Phrmceut cls0 Prevent on0 nd med cl dev ces

Note: Administration costs are not included. 1. Includes curative-rehabilitative care in hospital and other settings; 2. Includes home care; 3. Includes only the health component; 4. Includes only the outpatient market. Source: OECD Health Statistics 2019; Eurostat Database (data refer to 2017).

The number of doctors and nurses after-hour services. There are also private PCCs, which is higher than the EU average provide the full range of primary care services based on a contract with the Icelandic Health Insurance Iceland has a high number of doctors and nurses Agency. per capita compared to the EU average (Figure 10). However, a large share of doctors are specialists, with Iceland has a comparatively high number of nurses, general practitioners (GPs) accounting for only one including both registered professional nurses and in six doctors in 2017 (16.5 %), compared to an EU associate practical nurses. However, the demand average of more than one in four (27 %). The high for nurses is increasing rapidly due to population number of specialists compared to GPs results in ageing and the resultant increased demand for their higher visit rates to specialists compared to other services in both hospitals and nursing homes. Training Nordic countries. and recruiting sufficient numbers of new nursing professionals has proved challenging, exacerbated by In the absence of a GP gatekeeping and referral a considerable proportion of the nursing workforce function, the primary care sector is relatively weak. approaching retirement (Icelandic National Audit The first point of contact is often a private medical Office, 2017). specialist. Nevertheless, there are public primary care centres (PCCs) throughout the country, where GPs are salaried. These centres offer a broad range of primary care services, including home nursing, school nursing, health promotion and disease prevention, as well as

10 State of Health in the EU · Iceland · Country Health Profile 2019 average ofabout8days. hospitals (about6days in2017)islower thantheEU have decreased, andtheaverage length ofstay in converted tolong-term care beds. Hospitaladmissions 5.0) andsomeacutecare hospitalbedshave been population in2017, compared toanEUaverage of for thelastdecade(falling to3.1beds per 1000 The number ofhospitalbedshasbeendecreasing steadilyfallen over time The number ofhospital beds has Section 5.3). inpatient care tooutpatientandday care services(see Hospitals are increasingly shifting activities from Hospital serves asanaffiliatedteaching hospital. university hospitalinIceland. Akureyri Regional Akureyri Hospital. Regional Landspitaliistheonly at LandspitaliUniversity Hospital inReykjavík and of specialistcare varies. Tertiary care is provided and outpatientservices. However, theavailability including primary andsecondarycare, inpatient hospital,regional which provides generalservices Each ofIceland’s seven healthregions hasonemain on outpatient andday careservices careisentirelyHospital andfocused public Source: Eurostat Database (data refer to 2017 orthenearest year). around 30%inPortugal). InAustria andGreece, thenumberof nurses isunderestimated asitonlyincludes those workinginhospital. Note: InPortugal andGreece, data refer to alldoctors licensed to practise, resulting inalarge overestimation of thenumberof practising doctors (e.g. of Figure 10. Iceland hasmore doctors andnurses thantheEU average, butshortages remain Prctcn nurses per1000populton 20 10 18 14 16 12 0 8 4 6 2 2 Nurses Low Doctors Low Nurses H h Doctors Low 25 PL RO LU U SI 3 LV HU IE BE FR FI HR S EE 35 CZ NL EU EU vere 36 CY State of Healthin the EU ·Iceland ·Country HealthProfile 2019 ES IS 4 MT IT D SE care (IcelandicNational Audit Office, 2018). mechanismsaccountability tomonitorthequalityof increases in volumes of activity without adequate payments, leading tosupply-induced demand and the contracts are solely basedonfee-for-service from private specialisedclinics, onthe grounds that Agency ismanaging its growing purchases ofservices criticised the way theIcelandicHealthInsurance in public hospitals. The National Audit Officehas operationsthat were previouslyexclusively performed specialists increasingly performing more complex medical specialistmarket islargely unregulated, with are locatedintheCapital Region. Entrytothe can accessdirectly. Most private specialisedclinics services is provided outside hospitals, which patients A growing segmentof private medicalspecialist outpatient private specialists Patients have directaccess to BG DE 45 LT NO PT 5 Prctcn doctors per1000populton AT 55

EU vere 85 Doctors H h Doctors H h 6 Nurses H h Nurses Low EL 65 11

ICELAND 5 Performance of the health system ICELAND

conditions. However, while mortality rates from 5.1. Effectiveness ischaemic heart disease and cerebrovascular disease Preventable and treatable causes of are much lower in Iceland than the EU average, mortality are well below the EU average mortality rates from colorectal and breast cancer are similar to the EU average. Mortality from treatable causes of death in Iceland Iceland also has a relatively low rate of preventable was lower in 2016 than in any EU country (Figure 11). mortality overall, but some preventable causes This indicates that the health system is effective of death, such as lung cancer and chronic lower in saving the lives of people with life-threatening respiratory diseases, are relatively high.

Figure 11. Iceland has low rates of preventable and treatable causes of mortality

Preventble cuses of mortlt Tretble cuses of mortlt

Cprus 100 Icelnd 62 Itl 110 Norw 62 Mlt 115 Frnce 63 Spn 118 Itl 67 Sweden 121 Spn 67 Norw 129 Sweden 68 Frnce 133 Netherlnds 69 Netherlnds 134 Luxembour 71 Irelnd 138 Cprus 71 Icelnd 139 Belum 71 Luxembour 140 Denmr 76 Portul 140 Fnlnd 77 Greece 141 Austr 78 Unted ­ndom 154 Sloven 80 Belum 155 Irelnd 80 Germn 158 Germn 87 Denmr 161 Mlt 87 Austr 161 Portul 89 EU 161 Unted ­ndom 90 Fnlnd 166 EU 93 Sloven 184 Greece 95 Czech 195 Czech 128 Polnd 218 Polnd 130 Crot 232 Crot 140 Bulr 232 Eston 143 Slov 244 Slov 168 Eston 262 Hunr 176 Romn 310 Bulr 194 Hunr 325 Ltv 203 Ltv 332 Lthun 206 Lthun 336 Romn 208 0 50 100 150 200 250 300 350 0 50 100 150 200 250 Ae-stndrdsed mortlt rtes per 100 000 populton Ae-stndrdsed mortlt rtes per 100 000 populton

Lun cncer Ischemc hert dseses Colorectl cncer Pneumon Chronc lower respŽ dseses Sucde Ischemc hert dseses Stroe Accdents (trnsport nd others) Others Brest cncer Others

Note: Preventable mortality is defined as death that can be mainly avoided through public health and primary prevention interventions. Mortality from treatable (or amenable) causes is defined as death that can be mainly avoided through health care interventions, including screening and treatment. Both indicators refer to premature mortality (under age 75). The data is based on the revised OECD/Eurostat lists. Source: Eurostat Database (data refer to 2016).

12 State of Health in the EU · Iceland · Country Health Profile 2019 The vaccination rate formeasleshasalsoremained 95 %coverage recommended by WHO (Figure 12). and pertussis: this was only 91%in2018–below the countries forchildren aged 2for diphtheria, tetanus one ofthelowest vaccination rates compared with EU regional primary care centre. Despite this, Icelandhas months, with each child monitored through their Recommended vaccinations atthree forinfantsbegin and recommended forchildren butnotmandatory. vaccination programmes, which are free ofcharge the vaccinations taking place undernational Epidemiologist hasbeenresponsible formonitoring vaccine-preventable diseases. Since2002, theChief public healthinterventions to prevent thespread of Immunisation isoneofthemostcost-effective and olderpeoplearelow Vaccination rates ofchildren policy drug priority onalcoholandillicit prevention enforcement ofdrink–driving laws. Iceland’s current advertising andsales promotions ofalcoholandstrict other restrictions onalcoholsales, regulations on high minimum age for purchasing alcohol(20)and control policies thatinclude hightaxesonalcohol, a consumption in Europe becauseofstrictalcohol Iceland hasoneofthelowest levels ofalcohol (Joossens &Raw, 2017). with themostcomprehensive tobaccocontrol policies 2016, Icelandranked third among European countries 0.9 %of gross tobaccosalesoncontrol. In obligesthe legislation government tospendatleast spending ontobacco control per capita inEurope, and those wanting toquit. Icelandhasthehighest public places and workplaces; andassistancefor and sponsorship; prohibitions onsmoking incertain packages; bansontobaccoadvertising, promotion 1960s, including health warning labelsontobacco comprehensive anti-smoking measures from thelate precipitated by theearly introduction of Lower tobaccoconsumption inIceland was policies have been effective Tobacco andalcoholcontrol the samefood group that donot fulfilthecriteria for more fibre andwholegrain compared to foods within contain less andhealthierfat, less saltand sugar, Denmark andNorway. Products bearingthelabel nutrition labelhassince beenadopted by Iceland, Originating inSweden in1989, theNordic keyhole Box 1. Iceland adopted theNordic keyhole nutritionlabel State of Healthin the EU ·Iceland ·Country HealthProfile 2019 impact inreducing overweight andobesity. measures donot yet appear tohave hadany major product group (Box 1;OECD, 2017). However, these which highlights thehealthieralternatives within a audience andusing the Nordic keyhole nutrition label, and radio during hours when children are themain fats, banning foodandbeverage advertising on TV nutritional standards forschools, regulation oftrans community and schools. These include mandatory and prevention measures insettings such asthe public healthissueby introducing health promotion countries. Icelandhasresponded tothis growing higher thaninotherNordic countriesandmostEU have increased over the past 15 years andare now rates among Icelandicadolescentsandadults As outlinedinSection3, overweight andobesity yet hadany majorimpact Actions to reduceobesityhave not services. ensuring thoseaddicted have accesstocoordinated consumption, reducing dangerous habitsand with goals including restricting access, preventing and vulnerablegroups,on young people focuses be explored. 75 %. The reasons forthislow rate ofuptake needto vaccinated in2017, well below the WHO target of less thanhalf(45%)of people inthatage group vaccination coverage for people above 65islow, with at greater riskofseriouscomplications. However, for people aged 60andover in Icelandasthey are Vaccination against influenzais recommended unvaccinated adults, as a precautionary measure. Regions, for6-to18-month-old children as well as vaccination formeaslesintheEasternandCapital regarding vaccination prioritisation andoffering free resulted intheChiefEpidemiologist issuing guidance 2019 (ChiefEpidemiologist ofIceland, 2019). This Icelanders were diagnosed with measlesinearly below the WHO recommendation since2009. Five 93 %trusted it(Maskina,2015). familiar withthelabeland 90 %of Icelanders were an Icelandic survey indicated by Iceland in2013, by 2015 the label.Whileonlyadopted 13

ICELAND It is expected that new funding for primary care Figure 12. Childhood vaccination rates are below the services will address vaccination rates, as financial WHO target and EU average incentives are offered to primary care centres for Icelnd EU ICELAND encouraging older people to be vaccinated, as well as encouraging parents to have their children vaccinated Dphther, tetnus, pertusss Amon chldren ed 2 (Chief Epidemiologist of Iceland, 2018). 91 % 94 % Hospitals provide high-quality treatment

to people requiring acute care

Hospitals in Iceland deal effectively with patients Mesles Amon chldren ed 2 requiring acute care following acute myocardial

93 % 94 % infarction (AMI) and stroke. Substantial progress was achieved over the past decade in reducing

mortality rates for people admitted to hospital for these life-threatening conditions, so that the 30-day mortality rate is now one of the lowest compared with

EU countries with available data for AMI (Figure 13). Influenz This results from streamlining emergency care Amon people ed 65 nd over

45 % 44 % processes and providing better treatments, although further progress may be achieved in providing more timely and effective treatments for ischaemic stroke.

Note: The data refer to the third dose for diphtheria, tetanus and pertussis, and the first dose for measles. Source: WHO/UNICEF Global Health Observatory Data Repository for children (data refer to 2018); OECD Health Statistics 2019 and Eurostat Database for people aged 65 and over (data refer to 2017 or nearest year).

Figure 13. Mortality rates following hospital admissions for AMI and stroke have dropped

Acute Mocrdl Infrcton Stro e

2007 (or nerest er) 2017 (or nerest er) 2007 (or nerest er) 2017 (or nerest er) 30-d mortl t rte per 100 hosp tl st ons 30-d mortl t rte per 100 hosp tl st ons 20 30 25 15 20 10 15 10 5 5 0 0

EU13 Itl Sp n EU11 Sp n Itl Ltv  Polnd Ltv  Eston  Czech  F nlnd SwedenIcelnd Norw Czech  Icelnd Sweden F nlndNorw L thun  Denmr Sloven  L thun Sloven  Denmr Luxembour Luxembour Un ted  ndom Un ted  ndom

Note: Figures are based on patient data and have been age-sex standardised to the 2010 OECD population aged 45+ admitted to hospital for AMI and ischaemic stroke. Source: OECD Health Statistics 2019.

14 State of Health in the EU · Iceland · Country Health Profile 2019 Ae-stndrdsed rte of vodble dmssons per100000populton ed 15+ 1 Source: OECD Health Statistics 2019 (data refer to 2017 ornearest year). Figure 15. Iceland haslow rates of avoidable admissions, for particularly diabetes Source: CONCORD programme, London Schoolof HygieneandTropical Medicine. Note: Data refer to people diagnosed between 2010 and2014. Figure 14. Iceland hashighersurvival rates following adiagnosis for cancer thantheEU average following adiagnosis forcoloncancerisalsohigherin recommended from 50 years. Nonetheless, survival in mostothercountries, where screening isoften minimum age threshold inIcelandishigherthan and women between theages of60and69. This recommended by theDirectorate ofHealthformen for colorectal cancer, althoughscreening hasbeen No nationalscreening programme is yet in place breast cancerthan theEUaverage (Figure 14). has ahighersurvival rate five years afterdiagnosis for Despite having arelatively low screening rate, Iceland recommendation in2016, down from 62%in2008. 55 %of women inthatage group followed this enable diagnosis atan early stage. However, only screening forbreast cancerevery two years to In Iceland, all women aged 40-69 years are offered average inEurope, but screening rates arelow Cancer survival rates arehigher than the

000 800 600 400 200

Portul 0

Itl EU26 83% Brest cncer Icelnd Spn

Icelnd  Netherlnds 89 %

Unted ‹ndomSloven

Eston EU26 87% Prostte cncer Icelnd

Sweden  91

Norw % State of Healthin the EU ·Iceland ·Country HealthProfile 2019 Irelnd

Denmr

Frnce establish anew standard ofcare. incorporating training intoformaleducationtohelp level, published in2009, as well astheresult of to supportdiabetescare delivery atthe primary the implementation offormalclinical guidelines lowest rates inEurope (Figure 15). This may reflect particularly diabetes, for which Icelandhasthe than inmostEUcountriesformany conditions– admissions forchronic diseasesinIcelandislower The rate of potentially avoidable hospital seems to have improved Quality ofcareforchronic diseases (Alþingi, 2019). policy for2030approved by parliament inJune 2019 screening berevised.will This is part ofanew health of Welfare, 2016)in which theorganisation ofcancer A new cancer plan isbeing implemented (Ministry Iceland (68%)thantheEUaverage (60%). Asthm ndCOPD EU26 60% Colon cncer Icelnd Fnlnd

Belum  68 %

EU21

Austr

Czech Conestve flure hert

Mlt EU26 15% Icelnd Lun cncer

Germn 

Slov  20 %

Polnd

Hunr

Lthun Dbetes 15

ICELAND Unmet needs are greater for services that are covered 5.2. Accessibility to a lesser extent under the public scheme, such as dental care. General dental and orthodontic treatment

ICELAND Unmet medical care needs are generally low, but higher for low-income groups for adults between 18 and 66 years is generally not covered by the national health insurance, with Everyone who has been legally resident in Iceland private dentists charging according to their own fee for six months automatically becomes a member of schedules, although exceptions exist. In 2016, 8 % of the Icelandic health insurance system. Nonetheless, the population reported unmet needs for dental care, some people report unmet needs for care for financial but there was a more than a fourfold difference in reasons or from other barriers. The proportion of unmet needs by income group: almost 15 % of people people who reported unmet needs for medical care in the lowest income quintile reported some unmet due to cost, distance or waiting times was about 3 % needs for dental care compared with only 3 % for in 2016. However, the rate of unmet needs among people in the highest. This proportion of unmet needs those in the lowest income quintile reached about among people on low incomes is far greater than in 5 %, more than double the rate among those in the any other Nordic country. highest (2 %). This disparity by income group is wider than in any other Nordic country (Figure 16).

Figure 16. Unmet medical and dental care needs are higher among people on low incomes

Unmet medical care needs Unmet dental care needs

Hh ncome Totl populton Low ncome Hh ncome Totl populton Low ncome

Fnlnd Icelnd

Icelnd Fnlnd

EU Norw

Sweden Denmr

Norw EU

Denmr
Sweden

0 1 2 3 4 5 6 0 5 10 15 20 % reportn unmet medcl needs % reportn unmet dentl needs

Note: Data refer to unmet needs for a medical or dental examination or treatment due to costs, distance to travel or waiting times. Source: Eurostat Database based on EU-SILC (data refer to 2017, except for Iceland 2016).

Ceilings exist to protect vulnerable groups A new ceiling for OOP spending, although not against high out-of-pocket spending including prescriptions and dental care, was introduced in May 2017, aiming to lower the expenses As noted in Section 4, the share of OOP spending in of those who require a considerable amount of Iceland is slightly higher than the average in the EU, health care. In 2019, the maximum amount of money with private households directly financing almost an individual pays each month is 17 400 Icelandic 17 % of all health spending in 2017. More than króna (about EUR 131) for pensioners, people with two-thirds of direct household payments are for disabilities and children; 26 100 Icelandic króna dental care and pharmaceuticals (Figure 17). (about EUR 196) for others. When this ceiling is reached, the individual only pays a low fixed amount of user fees. Prescriptions, dental care and some other services fall under separate cost-sharing systems.

16 State of Health in the EU · Iceland · Country Health Profile 2019

Not OOP Not OOP Sources: Alþingi(2018) for doctor numbers;Statistics Iceland (2019) for population numbers(data refer to 2018). Figure 18. Thedensityof doctors inprimarycare centres varies across regions inIceland to improve after-hours services. The proportion of centre networks inrural andisolatedcommunities, encouraged tosupportthedevelopment ofhealth centres decentralised toregional levels. are Regions national level, andmanagement of primary care being decentralised. Budgetsare establishedatthe The primary care governance systemisslowly across regions, including for primary care doctors. to 3.9in2018, butthere continue tobe variations the past decade, from 3.6 per 1000 population in2007 The number ofdoctorsinIcelandhasincreased over but regionaldisparitiesremain The number ofdoctorshasincreased, Source: OECD Health Statistics 2019 (data refer to 2017). Figure 17. Most out-of-pocket payments go onpharmaceuticals, dentalandoutpatient medical care Icelnd Overll shreof helth spendn South-westReon Cptl Reon 165% OOP 059 Western Reon 053 Westfords 090 090 Dstrbuton ofOOPspendn b tpeofctvtes Others 06% Dentl cre 49 Phrmceutcls 65% medcl cr Outptent Inptent 02% Southern Reon 095 e 42% Northern Reons State of Healthin the EU ·Iceland ·Country HealthProfile 2019 089 Not OOP first pointofcontact, particularly intheCapital and Icelanders seeking private medicalspecialistsasthe choose to practice inrural regions, resulting in explained by thefactthat very few specialistdoctors the Capital and South-West Regions. This may be care centres intheEasternRegion, incontrast to (Figure 18):ahigher densityofGPs work in primary and GPsare unevenly across distributed theregions GPs compared tospecialistsislow (seeSection4), guidance (Box 2). is increasingly usedby GPsforconsultationsand of theNorthernandSouthernRegions, eHealth Due tothesparse population andlarge servicearea South-West regions. OOP EU Overll shreof helth spendn Estern Reons 116 158% OOP Dstrbuton ofOOPspendn per 100000populton,2018 Phscns nhelth-crecentres > 1 06 -1 < 06 b tpeofctvtes Others 33% Dentl cre 25% Phrmceutcls 55% medcl cr Outptent Inptent 14% e 31% 17 Inptent Outptent medclcre phrmceutcls Dentl cre Others

ICELAND Box 2. The growing use of eHealth in rural Iceland

ICELAND Since 2013, the Klaustur project has provided a In north Iceland, the Life-line project by the Icelandic telemedicine service for consultations and guidance telecommunication company Siminn has tested in southern Iceland. A doctor visits a telemedicine telemedicine solutions for patients at sea. To provide clinic in Klaustur, a rural village in the Southern advice and treatment to these patients, health care Region, twice a month. When the doctor is not professionals log into a patient’s electronic health present, a nurse manages all primary care cases record, connect remotely with the patient and input with the support of the same doctor via telephone the data directly into the record. or computer. The Klaustur project has expanded to include four additional telemedicine clinics in the Southern Region and four in the Eastern Regions.

Waiting times for elective surgery In 2016, the Minister of Health introduced a have been reduced in recent years government plan for extra funding between 2016 and 2018 to reduce waiting lists for hip and knee As in many other national health service systems, replacements, cataract surgery and coronary waiting times have been a longstanding feature of angioplasty, with a view to meeting the three-month the Icelandic health system and the problem has waiting time target (Government of Iceland, 2016). been subject to numerous policy initiatives. This was The waiting time for some of these operations exacerbated by the economic crisis and the resulting was substantially lowered by 2018, particularly for cuts in health spending, as well as by population cataract surgery and coronary angioplasty, while ageing, which results in growing care needs. Long waiting times for hip replacement were reduced but strikes among doctors, nurses and other health remained high (Figure 19). care workers in 2014 and 2015 further deepened the problem.

Figure 19. Waiting times for elective surgery have been reduced, but remain high

Cataract surgery Hip replacement

2012 2015 2018 2012 2015 2018 % of ptents wtn more thn 3 months % of ptents wtn more thn 3 months 2018 78 100 89 80 2015 68 2018 78 65 62 65 80 73 70 60 58 59 2015 65 60 2012 47 45 2012 60 51 42 37 43 40 42 40 40 35 26 23 18 19 20 20

0 0 Sweden Spn Icelnd Portul Irelnd Sweden Spn Portul Irelnd Icelnd

Source: OECD Health Statistics 2019.

18 State of Health in the EU · Iceland · Country Health Profile 2019 -8% -4% -6% 10% 2: Resilience refers2: Resilience tohealthsystem’s capacitytoadapteffectively tochanging environments, suddenshocks andcrises. Source: UNPopulation Projections. per personaged 65+ (numerator). Note: Thisgraphic shows thenumber of people aged 20-64 (denominator) person aged over 65 willbereduced by two by 2050 Figure 21.Thenumberof working-age peopleper Source: OECD Health Statistics 2019; Eurostat Database. Figure 20. Healthspending inIceland hasgrown at aboutthesamerate asGDPsince 2012 spending inthe coming decades. Population ageing progress are expectedto put pressures onhealth Looking ahead, population ageing andtechnological in 2007and2008. accounted for8.3%in2017, slightly down from 8.6% than GDP growth (Figure 20). Overall healthspending health rose again from 2013, atarate slightly higher after theeconomiccrisisin2008, public spending on Following themarked reduction inhealthspending has declined over the pastdecade Health spending as ashareofGDP 5.3 2015 -2% 8% Annul chne nrel terms 0% 4% 6% 2% Resilience 2006 2007 2

2008 2050 2009 2010 State of Healthin the EU ·Iceland ·Country HealthProfile 2019 2011 (Lorenzoni etal., 2019). of GDPin2030underthecurrent setof policies expected to grow from 8.3%ofGDPin2015to10.4 projections, thehealthspending share ofGDPis and establishing new nursing homes. BasedonOECD already increasing resources inhomehealthcare to respond tothese needs(Figure 21). Icelandis care,fewerbe working-agethere will people while increasewill theneedsforhealthandlong-term been greater thanintheEUasa whole. of hospitalbedsinIceland per 1000 population has Between 2007and2017, thereduction inthenumber to anEUaverage ofseven days (OECD/EU, 2018). an AMI was lessthanfive days in2017, compared For cardiac care, theaverage length of stay following slightly more thanthree days onaverage intheEU. a normaldelivery islessthantwo days, compared to (Figure 22). For example, theaverage length ofstay for average length ofstay are well below theEUaverage Both thenumber ofhospitalbeds per population and more efficiently The systemisfunctioning hospital 2012 2013 2014 GDP 2015 Publc spendn onhelth 2016 2017 19

ICELAND Figure 22. The number of hospital beds and average length of stay are below the EU average

ICELAND Icelnd Beds ALOS EU Beds ALOS Beds per 1 000 populton ALOS (ds) 7 10

6 8 5

4 6 3

2 4 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Source: Eurostat Database.

The Icelandic primary care system faces In response to concerns about shortages of GPs, the challenge of responding to greater demand government increased the number of training places in primary care medicine from 33 in 2000 to 53 in 2016 The Health Care Act stipulates that services should and put in place incentives to encourage more doctors be provided at the most appropriate level of care, to choose primary care, as part of a wider plan to and that PCCs should be the first point of contact for strengthen the primary care system. Nurses have also patients. However, given the low number of GPs and begun to play a bigger role in primary care, although the absence of a gatekeeping function and referral these new roles remain limited and the number of system, a significant proportion of primary care is nurses involved in more advanced practice is still provided by private specialists. relatively small (Box 3).

Box 3. The role of nurses could be expanded across the health care system

The relatively large proportion of nurses compared providers of care for older patients in the emergency to doctors in Iceland, combined with the high department, while others lead advanced pain and quality of nursing education and training, provides wound care services. opportunities for greater task sharing between nurses and doctors in most fields. Some examples of more However, Iceland remains at an early stage in advanced practice nursing already exist. For instance, developing new advanced roles for nurses in primary in primary care some nurse-led ambulatory clinics care and in hospitals. A Master’s degree programme are responsible for patients with lung problems, has been put in place to train clinical nurse for children and adolescents with diabetes, and specialists, but the number of students enrolled in for pre-dialysis patients. At Landspitali University this programme is limited. Hospital, nurses with geriatric expertise are lead

Source: Gunnarsdóttir (2017).

In 2017, a new funding scheme for primary care following the patient. Two new private centres centres was introduced in the Capital Region, which started operating in the Capital Region in 2018 based applies to both public and private centres. It is based on service agreements with the Icelandic Health on a mixed funding scheme, including a capitation Insurance Agency. formula, with financial incentives for providing certain types of services such as vaccination, as well as bonuses for displaying good results on pre-defined quality indicators. In addition, competition was introduced between primary care centres, enabling patients to choose their GP and centre, with funding

20 State of Health in the EU · Iceland · Country Health Profile 2019 reimbursement authorities. informal collaboration between national pricing and the Nordic Pricing andReimbursementGroup, an The Nordic PharmaceuticalForum also works with authorisations are physically available inthecountry. availability, asonly halfof valid medicinemarket of pharmaceutical budgets. This hampers medicine limited competition oftenresults inoverspending interest toIcelandas, market duetoitssmall size, pharmaceutical products. Thisof particular projectis products, increasing availability andaffordability of aims tolower prices andimprove supply securityfor is theJoint Nordic Procurement pilot project, which countries. Oneofthemajor activities oftheForum to supply pharmaceuticals jointly tothefive Nordic undertaking shared projects tomake itattractive 2015 with theaimofidentifying opportunitiesand Lægemiddelforum), establishedin analliance of theNordic PharmaceuticalForum (Nordisk procurement, organisations from Icelandare part Concerning access tonew medicinesand public to private expenditure. cost-sharing arrangements, resulting inashiftfrom with generics when available andchanges in mandatory substitutionoforiginator pharmaceuticals achieved notably by useofexternalreference pricing, increased. These price reductions have been volume ofconsumption of pharmaceutical products achieved mainly through price reductions, asthe pharmaceutical spending since 2010hasbeen 16 %in2010to112017. The reduction in to allocated pharmaceuticals declined from almost As notedinSection4, theshare ofhealthspending pharmaceutical costs Initiatives areunderway to control State of Healthin the EU ·Iceland ·Country HealthProfile 2019 (Icelandic Directorate ofHealth, 2016). to enhanceelectronic healthrecord dataretrieval health informationinelectronic healthrecords; and health information;toensure securityandqualityof to patient information andfor patients totheirown to secure seamless accessforhealth professionals as part ofitseHealth strategies, theDirectorate aims eHealth projects inIceland. Between 2016and2020, The Directorate ofHealthoversees national all sector clinics has not yet beenachieved. seven healthregions andbetween public and private use electronic medical records, integration across the sectors. hospitalsand all While primary care clinics information more effectively across institutionsand information systemstoshare medicalandhealth to establishintegrated and interconnected health Since 1996, theIcelandic government hassought fully integrated across regionsandsectors The Icelandicinformation infrastructure isnot 21

ICELAND 6 Key findings ICELAND

• Life expectancy in Iceland is above the EU • Iceland has a relatively high number of average, although recent gains have been doctors and nurses compared with most EU small compared to EU countries. The gap countries, but there are persisting issues in longevity between those most and least regarding the composition and geographical educated has widened since 2011, as the life distribution of the medical workforce, as expectancy of the most educated continued to well as growing concerns about shortages of increase while there was no gain among the nurses. Only one in six doctors is a general least educated. Women still live a few years practitioner, and availability is particularly more than men do, but the gender gap in the low in the Capital and South-west Regions. number of healthy years is in favour of men, While primary care clinics should be the as Icelandic women tend to live a greater first point of contact for patients, specialists proportion of their lives with chronic diseases provide a significant proportion of first and disabilities. contacts, as general practitioners do not provide a gatekeeping function. Nurses have started to play a greater role in primary care • Tobacco and alcohol consumption are and in emergency departments in hospitals, substantially lower than in most other but these new roles are rare, and the number European countries, which is credited to of advanced practice nurses is still limited. longstanding and comprehensive efforts to combat their use. However, the rising rate of overweight and obesity is a growing public • Long waiting times for some health services health issue, with one in five adolescents now are a persistent issue in Iceland, which being overweight or obese, and one in four became more pronounced following the adults obese. Iceland has begun to respond economic crisis and a series of strikes among to this public health concern by issuing health professionals. A 2016 government guidelines on nutrition and physical activity, plan that defined waiting time targets and as well as restricting marketing of certain allocated additional funding has resulted foods towards children. The results so far in shorter waiting times for operations like appear modest, however. cataract surgery and cardiac angioplasty. However, waiting times for hip and knee replacements still exceed the targets. • Health expenditure per capita in Iceland is above the EU average, yet as a percentage of GDP it is below the EU average (8.3 % • Iceland continues to work towards compared with an EU average of 9.8 %). Most the creation of a more integrated and expenditure is publicly funded (82 %), interconnected health information system. with out-of-pocket payments accounting The overall aim is to be able to share for most of the remaining expenditure, information with patients and across as private health insurance only plays a institutions, the public and private sector, and marginal role. More than two-thirds of out-of- the seven health regions, in order to improve pocket payments are for dental care and care coordination and reduce duplication of pharmaceuticals, with these services and tests and procedures. goods covered to a lesser extent by health insurance. This results in higher unmet needs for dental care than for other care, particularly among people on low incomes.

22 State of Health in the EU · Iceland · Country Health Profile 2019 Key sources

OECD/EU (2018), Health at a Glance: Europe 2018: State Sigurgeirsdóttir S, Waagfjörð J, Maresso A (2014), Iceland: of Health in the EU Cycle. OECD Publishing, Paris, https:// Health System Review. Health Systems in Transition, doi.org/10.1787/23056088. 16(6):1–182.

References

Alþingi (2019), Þingsályktun um heilbrigðisstefnu til ársins Joossens L, Raw M (2017), The Tobacco Control Scale 2030 [A Parliamentary Resolution on a New Health 2016 in Europe. Association of European Cancer Leagues, Policy 2030]. Reykjavík. Brussels.

Chief Epidemiologist of Iceland (2018), Participation Kristjansson AL et al. (2016), Population Trends in in General Vaccination for Children in Iceland 2018. Smoking, Alcohol Use and Primary Prevention Variables Reykjavík. among Adolescents in Iceland, 1997-2014. Addiction, 645-652. Chief Epidemiologist of Iceland (2019), Five Cases of Measles. Reykjavík. Lorenzoni L et al. (2019), Health spending projections to 2030: new results based on a revised OECD methodology. Government of Iceland (2016), Átak til að stytta biðlista OECD Health Working Papers N° 110, Paris. [Government initiative to cut down waiting lists]. Reykjavík. Maskina (2015), Keyhole: a Survey of Beliefs and Knowledge. Icelandic Directorate of Health, Reykjavík. Gunnarsdóttir S (2017), Care Empowered by Nursing Research. SSN/NNF Conference 2017 – Research in Ministry of Welfare (2016), Tillaga að íslenskri Nursing, 35. Krabbameinsáætlun til ársins 2020 [Proposal for the Icelandic Cancer Programme for 2020]. Reykjavík. Icelandic Directorate of Health (2016), National eHealth Strategy 2016-2020. Reykjavik. OECD (2017), Obesity Update 2017. OECD Publishing, Paris, http://www.oecd.org/health/health-systems/ Icelandic National Audit Office (2017), Obesity-Update-2017.pdf Hjúkrunarfræðingar Mönnun, menntun og starfsumhverfi [Nurses, staffing, education and working conditions]. Statistics Iceland (2019), Life Expectancy in Iceland is One Reykjavík. of the Highest in Europe. Reykjavík.

Icelandic National Audit Office (2018), Sjúkratryggingar Íslands sem kaupandi heilbrigðisþjónustu [The Icelandic Health Insurance as a purchaser of health care services]. Reykjavík.

Country abbreviations

Austria AT Denmark DK Hungary HU Luxembourg LU Romania RO Belgium BE Estonia EE Iceland IS Malta MT Slovakia SK Bulgaria BG Finland FI Ireland IE Netherlands NL Slovenia SI Croatia HR France FR Italy IT Norway NO Spain ES Cyprus CY Germany DE Latvia LV Poland PL Sweden SE Czechia CZ Greece EL Lithuania LT Portugal PT United Kingdom UK

State of Health in the EU · Iceland · Country Health Profile 2019 23 State of Health in the EU Country Health Profile 2019

The Country Health Profiles are an important step in Each country profile provides a short synthesis of: the European Commission’s ongoing State of Health in the EU cycle of knowledge brokering, produced with the ·· health status in the country financial assistance of the European Union. The profiles ·· the determinants of health, focussing on behavioural are the result of joint work between the Organisation risk factors for Economic Co-operation and Development (OECD) and the European Observatory on Health Systems and ·· the organisation of the health system Policies, in cooperation with the European Commission. ·· the effectiveness, accessibility and resilience of the The concise, policy-relevant profiles are based on health system a transparent, consistent methodology, using both quantitative and qualitative data, yet flexibly adapted The Commission is complementing the key findings of to the context of each EU/EEA country. The aim is these country profiles with a Companion Report. to create a means for mutual learning and voluntary For more information see: ec.europa.eu/health/state exchange that can be used by policymakers and policy influencers alike.

Please cite this publication as: OECD/European Observatory on Health Systems and Policies (2019), Iceland: Country Health Profile 2019, State of Health in the EU, OECD Publishing, Paris/European Observatory on Health Systems and Policies, Brussels.

ISBN 9789264771772 (PDF) Series: State of Health in the EU SSN 25227041 (online)