The North Remembers (that cooperation strengthens their health systems)

The story of Nordic cooperation was written 1000 years ago. Like all stories from the medieval ages, this one begins with kingdoms. Many of them. Prosperous kingdoms, ambitious kingdoms, and kingdoms that wanted to conquer the world. One such kingdom was the Norwegian kingdom. The medieval Norwegians were an enterprising bunch. After ruling the Norwegian territory for a long time, it was time to expand. They wanted to go after the Danish throne now. That plan had some obstacles though in terms of dynastic claims over the throne. But the Norwegians were not going to take no for an answer. There was drama, there was action, and, more importantly, strategy behind getting a Norwegian elected to the Danish throne, thereby giving birth to the Danish - Norwegian Union. The kingdom then set its eyes on Sweden. Luckily for the Norwegians, the Swedish kingdom had some fault lines. Norwegians used all their might and diplomacy to exploit these fault lines in the hope of consolidating their position by bringing Sweden into its fold. They won. The three Scandinavian territories of Norway, Denmark, and Sweden now had a single Norwegian ruler.?

Now here’s the twist. The mastermind behind all this ambition, diplomacy, and strategy was not a King.

It was a Queen.?

‘A Golden Crown’

Margaret I, daughter of King Valdemar IV of Denmark, was a woman of conviction and authority. Strategic in her thinking, she understood power. Both the importance of it and how to acquire it. Think of her as someone who really understood both House of Cards and Game of Thrones. But life was not all sunshine and rainbows. Her husband and son passed away unexpectedly, both Kings at the time.?So while some would have caved, Queen Margaret decided to step up the game. She used force, tactic, diplomacy, and any tool she had at her disposal to realize her vision of bringing 3 Scandinavian kingdoms under her rule.?

Upon the passing of her husband, she not only ruled Norway herself but also managed to get her nephew Erik and her son Olaf elected as kings of Norway and Denmark, respectively. Given that her nephew and son were young, she was designated as regent of Norway and Denmark. Unfortunately, her son Olaf died unexpectedly. She deployed all diplomatic skills to keep power, consolidate her position, and keep Norway and Denmark under her control. She could not take Sweden out of her mind despite having two kingdoms under her direct supervision. Sweden was undergoing a rebellion with the Swedish nobles rising against the unpopular King Albert at the time. She saw this as a great opportunity, joined hands with the nobles, doubled down on the rebellion, and managed to take the Swedish King captive after defeating him. She released him only after six long years, only after she ensured peace prevailed.?

This brought all three kingdoms under her purview. The Danish - Norwegian union lasted from 1385 to 1814. And as you will soon read, the broader union lasted even longer. Queen Margaret is one of the essential names in Scandinavian history and, in my opinion, solely responsible for conceiving the idea of Nordic Cooperation. In a world where strategies do not seem to survive even a couple of years, this one did for centuries.?

‘What Is Dead May Never Die’

Source: blogs.loc.gov - "Nordic military men negotiating with Romans over gold, silver bowls and coins] (1910). Library of Congress Prints and Photographs Division, //loc.gov/pictures/resource/ppmsca.45639/."

Although Margaret I passed away in October 1412, her legacy lives on hundreds of years later. She set the foundation and got all the building blocks right for Nordic cooperation. She seeded the idea into the minds of independent kingdoms that cooperation ensures survival and, in most cases, prosperity. All realms were sold on the idea. But somewhere down the line, the plot was lost. The history of Nordic Cooperation is choppy. The same Nordic countries that cooperated during one era went to war with each other during another. But come the 20th century, sense prevailed. It all started with the governments of Finland, Denmark, Iceland, Sweden, and Norway signing the Helsinki Treaty on 23rd March 1962. This marks another inflection point in the history of Nordic Cooperation. The treaty has several articles relating to cultural cooperation, economic cooperation, social cooperation, etc. The collaboration between Nordic countries is the world’s oldest regional partnership. The treaty gave birth to the Nordic Council, the forum where all the cross-country policy discussion and learning happens.?

Source: Screengrab from TL;DR News EU YT channel

The idea that nations could cooperate and win caught on so much that several other logical groups emerged from what was originally a Nordic idea. Good or bad, you decide, but the above visual shows different groups in which many European and Northern nations cooperate. The Nordic cooperation paid rich dividends. The Danish Minister of Trade, Jen Otto Krag, who later became the Prime Minister, said -

“In my office in the ministry of trade in Copenhagen, I have a cupboard in which I store important documents. In it, I have a drawer marked ‘Studies and Minutes’ referring to Nordic economic cooperation. It is packed full. It is bulging with paper.”

And it is not just countries cooperating. This cooperation has a trickle-down effect, as you may have realized. You see how Finland has taken this idea one level down and defined clear lines of cooperation. Look closely, and you will notice the specific areas where each startup cooperates with the larger ecosystem.?

Source: https://kuopio.neurocenterfinland.fi/kuopio-health-ecosystem-map/

Some may see this as an undue commitment in the backdrop of competition. For a startup to succeed, isn’t it important to first be successful and then go around helping and cooperating??

‘Breaker of Chains’?

In a world where the national interest comes before inter-national interest, Nordic countries realized this was a very constraining thought. This was the biggest chain of the several chains they had to break out of. The Helsinki Treaty of 1962 gave birth to The Nordic Council, responsible for inter-parliamentary cooperation, and the Nordic Council of Ministers, responsible for inter-governmental cooperation. And their vision was simple -

‘To make the Nordic Region the most sustainable and integrated region in the world.’

This paved way for a lot of cooperation. Then they broke the next chain, which was healthcare specific. They opened all of their electronic health policy documentation across all five countries and analyzed it with a magnifying glass. The ethos of this exercise is summarized in the introduction of the report -?‘The differences in eHealth policies, architectures, and implementation create a fruitful basis for benchmarking and learning from each other.’

Source: Screengrab from Policy Documentation

And this was an interesting exercise in terms of complexity. The Swedish, Norwegian, and Danish eHealth policies were written in their respective languages, and Icelandic and Finnish policies were written in English. In addition to this, there was no standard template in which policies were written. So all policies had to be translated into a common language and mapped to a standard template to make an apples-to-apples comparison. The working group deconstructed these policies using a text annotation tool and put them back together in a way that identified standard sections across all policies. All the policies you see in the visual below, were analyzed.?

Following areas were where most Nordic countries focussed when it comes to eHealth, in order of priority.?

1. Make services more available to citizens
2. Empower and activate citizens?
3. Improve the organization of digital services project?
4. Improve information security and privacy?

Whichever Nordic countries focused on the above areas got validation and whichever countries did not focus, learned from it.?

The report also analyzed governance systems for electronic health monitoring in Nordic countries. There were four questions on the table. All very fair and action-oriented.

1. What is the eHealth monitoring framework in the country’s eHealth strategy?
2. How is the eHealth indicator data collection organized?
3. How are the data collection and reporting funded?
4. How is eHealth monitoring data made available to policymakers and researchers?

The following table has a summary of answers across all questions and all countries. Again a learning opportunity for all Nordic countries.

In addition, the report has granular detail about how the survey questionnaire was designed across all the countries, how the reporting took place, what indicators were monitored, what each country learned from that monitoring, etc. You get the drift. The bottom line is that all Nordic nations left this exercise richer than when they started. They took back all the learnings and tweaked their protocols that basically enhanced their own health systems. And as you digest their policy play, it is important to understand that they are also leading the world in using technical standards. They use SNOMED, ICD-10, LOINC, FHIR, DICOM, and everything in between. And even here, they learned from each other cooperatively.?

Enough said? Not really.

One report that needs your undivided attention is by former Swedish minister Bo K?nberg. He takes a step back and looks at the 5 - 10 year horizon to focus on Nordic cooperation in healthcare. And I don’t know about you, but they are either too broad or vague whenever I have read such reports. That makes it non-actionable. But no Sir, Bo knew better. He laid out a list of 14 very concrete proposals that he envisioned Nordic nations cooperating on.?

1. Adopt robust measures against increasing antibiotic resistance
2. Boost co-operation on highly specialized treatments in the Nordic Region
3. Establish a Nordic network for rare diagnoses?
4. Establish a Nordic virtual center for registration-based research
5. Increase co-operation regarding measures to improve public health
6. Establish a Nordic public-health policy platform to reduce inequalities in health
7. Increase patient mobility in the Nordic Region
8. Strengthen co-operation on welfare technology
9. Increase co-operation on eHealth
10. Bolster Nordic cooperation in the field of psychiatry
11. Increase the mandate for co-operation within the field of health preparedness
12. Expand Nordic pharmaceutical co-operation to boost cost-efficiency and improve safety
13. Establish a new Nordic exchange of officials
14. Establish Nordic cooperation between national experts in the European Commission

And if you were wondering, this looks like all talk and no play; the Nordic Council discusses this list regularly to date. You can find the current status of each of these proposals here.?

Needless to say - all this cooperation not only helped them lock down real, very tangible problems but also helped them sit on that symbol of excellence forged using the most challenging healthcare wins.

‘The Iron Throne’

‘In God, we trust; everybody else has to bring data to the table.’?

Data can help measure a health system’s performance objectively. So the question becomes, how do you really measure a health system?

Although there can be several (hundreds?) micro indicators, fewer and more impactful macro indicators can be used to assess the performance of a health system. I was digging around to see if the list goes beyond the usual infant mortality rate, maternal mortality rate, life expectancy, etc., and stumbled upon this comprehensive table of indicators in a research paper published in frontiers. Additionally, Harvard has some guidance on how to assess health systems.?

Antibiotic resistance is a worldwide problem, which is why Bo put it front and center on the 14-point proposal map. Nordic countries responded.?

Zooming out, Nordic countries have some of the best healthcare access numbers. Numbers don’t lie. But they have to be seen in context. And my way of making sense of, what I like to call, the health tech multiverse is by learning about how health systems function in various countries. Each article I write and research becomes a dot. The more dots I collect, the better the resolution of the overall picture. For this reason, I have written about health systems of Israel, Estonia, India, and France in my past articles, so I put them on some of the charts to see how they compare with the Nordic countries. Of course, one may not read these charts in isolation. In my opinion, several variables are at play here that are important to consider before jumping to conclusions, population being the biggest. But all said and done; the Nordic countries look pretty damn good on most charts.?

Source: https://ourworldindata.org/

Also, while you have trouble seeing all Nordic countries huddled below on the Y axis, you can’t miss the massive drop in my homeland India’s infant mortality rate. I mean, look at that drop!

Source: https://ourworldindata.org/

Nordic countries top the charts in life expectancy among the nations I compared.?

Source: https://ourworldindata.org/

Government spending is amongst the highest.?

Source: https://ourworldindata.org/

Maternal mortality is amongst the lowest.?

Source: https://ourworldindata.org/

Out-of-pocket expenditure rightly reflects government priorities.?

Source: https://ourworldindata.org/

The burden of diseases is the lowest.?

Source: https://ourworldindata.org/

And in case you were to actually need a physician, plenty of them to take care of you.?

Source: https://ourworldindata.org/

And a bit unrelated but ICYMI, the only company with an approved shot against the monkeypox virus, is a Nordic Company. In a World Economic Forum report that assesses digital health maturity across various countries, Nordic countries knocked it out of the park.?

So, where does this all bring us?

**************************************************************************

Napolean Hill famously said

“Whatever Your Mind Can Conceive and Believe, It Can Achieve.”

Queen Margaret conceived the idea of cooperation and believed in it. While it may have originated from a place of power, it works wonders for Nordic countries even 1000 years later. The learning I have from this research is that it is very important to keep ‘passing the ball’ once an idea is conceived. Anyone of those countries could have thought, well this is it - bye-bye Nordic cooperation, but they didn’t. They kept at it and ensured that the Helsinki Treaty did not just remain a piece of paper but evolved into a tangible cooperation exercise from which all countries benefit. In addition to that, they were also smart enough to put healthcare on that radar. And more importantly, it was all about defining a bold vision - which is now even bolder.?

‘The vision of the Nordic countries is to make the Nordic Region the most sustainable and integrated region globally by 2030. The vision will be realized by focusing on three strategic priorities: a green Nordic Region, a competitive Nordic Region, and a socially sustainable Nordic Region’.?

So while some countries may have trouble with those cold and chilly healthcare problems, in this part of the North, winter ain’t coming.?

**************************************************************************

References

1. History of Nordic Cooperation
2. The Helsinki Treaty of 1962
3. The Nordic Council
4. Nordic eHealth Benchmarking
5. eHealth Standardization in Nordic countries
6. The future of Nordic health cooperation
7. How to assess performance of a health system
8. How Israel beat the pandemic and continues to beat the world in healthtech
9. How to pull off a digital health utopia, the Estonia way
10. Ayushman Bharat Digital Mission (ABDM) - India's leapfrog moment
11. A different kind of Green Card (French Healthcare)