in the next 30 years the number
of people needing care will triple
in the Nordic region. longer life
expectancy, new medicines and
better treatments will improve
QUALITY OF LIFE and will pose
Nord­i c healthcare one essential
question. Who’s going to pay?
health 3.0
Includes a summary of the 2008 If year
start
tomorrow’s health and healthcare
who’s going
to pay?
H
ealthcare is one of society’s
most important issues. The
political decisions taken, discoveries made and new types of
treatments developed, all have
an immediate bearing on our
lives.
Enormous advances have been made in
these areas over the past 100 years. Life expectancy in the Nordic region has increased by
more than 20 years. A long list of deadly or very
serious diseases such as smallpox, polio and
diphtheria have been eradicated. And developments continue. New medicines and treatments mean that the prospects for surviving
cancer and other major widespread diseases
look good for the future.
nnn
At the same time health has become a difficult political issue. In 30 years the number
of elderly who may need healthcare will have
increased dramatically in the Nordic countries.
At the same time research is revolutionizing
care and medications. This means increased
costs. Public sector resources will not be able to
cover everything that is possible to achieve.
This will force us to make serious ethical
decisions. Who will have the right to new, often
expensive, treatments? And who will be forced
to forgo them?
ers compensation insurance and health insurance. I believe we are witnessing only the beginning of this development. In 20 or 30 years,
a significantly larger part of healthcare will in
all probability be financed through private or
employer-purchased insurance.
Some feel that this is a disturbing development and believe that it will lead to a society that favours those with most resources.
Others, such as I, look on private and
employer-related solutions as a way
to create better healthcare for all.
And it is in itself exciting that so
many seem interested in a discussion about using our prosperity for
better health rather than just more
material things.
nnn
The debate about tomorrow’s
healthcare has already begun, but it needs to be intensified and broadened,
and the aim of this publication is to contribute to that. Let’s start
now.
Torbjörn Magnusson,
CEO If P&C
nnn
One central issue is: What will society have
the means and the resolve to take responsibility for in the future, and what must we pay for
ourselves? The trend is toward more private
solutions. If and other insurance companies
already complement public healthcare in some
areas, e.g. through children’s insurance, work-
PS. At the end
of this publication
there is a section
that presents If
and our result for
2008. Be sure not
to miss it!
photo:
thron
ullberg
contents
chapter 1
new disease landscapes and an increased life expectancy
will create different healthcare needs, research will provide
new methods and medicines. an overstretched health sector
finds it increasingly difficult to make ends meet.
what will this cost you?
how we’ll fall ill
the next generation’s ill health ������������������������������� 6
n four diseases and their trends ������������������������������������ 9
n the future will make us healthier
– and less well� ���������������������������������������������������������������������������������� 10
n
chapter 2
how we’ll get help
chapter 3
0
who will pay?
at the sharp end of research ���������������������������������������� 14
n s
cience fiction or reality? � ��������������������������������������������� 18
n
n p
riorities in focus
as the north ages ������������������������������������������������������������������������ 22
n 2
4 replies: who pays for
tomorrow’s healthcare?����������������������������������������������������� 26
4
chapter 1
how we’ll
2009
The image shows a blood clot that could lead to a stroke or heart attack. Cardiovascular diseases are the
most common cause of death today. But the graph points steadily downwards. In Sweden the risk of dying
of coronary artery disease dropped by 40 per cent between 1987 and 2002. Preventive efforts and better
cardiac emergency care are the reasons.
5
fall ill
2025
Cancer is an increasingly common disease. The number of new cancer cases is rising by 1 to 1.5 per cent per
annum throughout the Nordic region. Nothing indicates that the upward trend will fall off. In 2025 around
700 in every 100,000 Nordic citizens will fall ill with cancer. The image shows a breast cancer cell, i.e. a
small part of a malign cancer tumour. Breast cancer is the most common form of cancer among women.
how we’ll fall ill
chapter 1
6
will we grow old, get sick and die the same
way our forefathers did? Hardly. New diseases
are on the increase, others on the decline.
you will very likely be older, healthier and
work longer than your parents.
the next
generation’s ill
health
B
etter medicines, vaccines and living
standards have helped the Nordic citizens increase their longevity by around
two years every decade over the past century. This trend shows no signs of falling
off. The very oldest will be older yet, and
more and more of us will experience old age.
The Nordic countries will have more elderly people, and more of them will be healthy. Statistics Norway has calculated that the “Senior Boom” will begin
around 2013, and as early as 2060 the number of
people 67 years old or older will be around double
that of today. In Norway, the proportion of people
over 80 will increase from around five per cent to nine
per cent – from 213,000 to over 440,000 people.
According to the report “Take part; take decisions!” prepared by the Swedish National Institute
of Public Health, around 44 per cent of Swedes will
be 50 or older by 2025 – either as pensioners or on
their way to pension. By 2050 as much as half the
Swedish population will be 50 or older, and those
leaving working life will outnumber those entering
it. Most likely fewer children will be born, which
will result in fewer employed people to provide for
pensioners.
The “Senior Boom” will not just sweep across
Norway and Sweden, but the rest of the Nordic
region and Europe too. And so our part of the
world will have a new human resource.
The Copenhagen Institute for Futures Studies (IFF) in Denmark has prepared a report
entitled “Behind the Facade”. In it tomorrow’s
text:
Vigdis Askjem Dahl
seniors are characterized as everyman romantics,
backpacking pensioners, scientific acrobats and local
heroes with time and money to spare. Future centenarians will be like today’s eighty-year-olds, and
eighty will be the new sixty. In other words, there
will soon be many more healthy old people enjoying
meaningful lives.
“Older people will probably be working longer as a
shortage of manpower will lead to an increase in
pensionable age in many countries. And what’s
more, they will have fewer strain injuries due to
the less physically demanding nature of their
work. They will quite simply last longer in the
job market,” says Kristina Laksáfoss Søgaard,
project manager at IFF.
In her opinion, old people of the future will
also be better off financially and thus have
more opportunities for spending money.
They will have much better prospects of meeting their needs
and living out their dreams,
depending on their interests.
New disease landscapes
A girl born today can expect
to live until she is at least
82 and a newborn boy until he is 78. But it was not
always like this.
“125 years ago Norway
7
was a poor corner of Europe. Bad diet and inadequate
hygiene allowed poverty-related illnesses such as
tuberculosis and leprosy to flourish,” says Geir SteneLarsen, Director of the Norwegian National Institute
of Public Health. Infant mortality was as high as 10
per cent and in 1880 epidemics of various kinds of
infectious diseases were dominant and widespread.
Of these, tuberculosis, smallpox and leprosy were the
most feared, surrounded by taboo and received the
greatest attention.
It was not until various antibiotics arrived on the
scene in the 1940s and 50s, and child vaccination
programmes began in the 50s, that we seriously came
to grips with the many deadly infectious diseases –
diseases we never give a second thought to today.
Stene-Larsen tells us that since World War II it is
cardiovascular diseases and cancer – and latterly
also type 2 diabetes and COPD (chronic obstructive pulmonary disease) – that constitute the biggest
widespread diseases. Since 1950 our longevity has
increased by almost ten years, but at the same time
illnesses such as cardiovascular disease and cancer
have become ever more common.
“Something will kill us in the end, and cardiovascular diseases are still a common cause of death,
but now at a later age. It is possible that these will
increase all the more if the population continues to
put on weight. Today, the obesity epidemic affects rich
and poor countries alike, but widespread illnesses
such as cancer and cardiovascular diseases are the
most common causes of death,” says Stene-Larsen.
He feels that it is difficult to foresee the type
of illnesses that will dominate in the future, but
believes that we will continue to suffer from
the most widespread “western” diseases. Also, mental
disorders will probably receive more attention.
“On average, one or two new infectious diseases
have shown up every year for the past 30 to 40 years,
most of these in poor countries. But illnesses such
as legionnaire’s disease and HIV/AIDS have also affected rich countries,” says Stene-Larsen, and points
out that it is not inconceivable for infectious diseases
to once again be the most serious endemic diseases
in rich countries. The difference between then and
9
factors
that affect
your health
1
Exercise
In order for us to
have the energy for
work and to protect
ourselves against illness, we need to be in
good shape. Stamina is
important for sustaining good health, and
it also guards against
strain injuries, cardiovascular disease and
type 2 diabetes.
The COPD
picture. Airways
become swollen,
tight and partially obstructed
leading to severe
breathing difficulties. It has
become one of
the major widespread diseases
since the Second
World War.
cardiovascular
diseases
are still
a common
cause of
death,
but now
at a later
age
Kristina Laksáfoss
Søgaard, project
manager at IFF in
Denmark.
Geir Stene-Larsen, Director of the Norwegian National Institute
of Public Health.
now, and between rich and poor, is that in the Nordic
region we live in welfare societies with world-class
hospitals and care.
Public care dominates
However, Kristina Laksáfoss Søgaard at IFF is of the
opinion that there will be much more emphasis on
service in hospitals and healthcare than today, and
that the elderly will place ever greater demands on
such service.
“Because the elderly of the future will enjoy better
personal finances they will also have the opportunity to buy healthcare to a far greater extent than is
usual today. And it is unlikely they will be content
with the standards the public sector has to offer,”
says Søgaard.
2
diet
What we eat
affects our health,
but how? The experts
disagree. Some say we
should not eat fatty
foods, while others say
that fat is
just what
the body
needs.
3
sex
Men who ejaculate at least twice a
week have a 50 per
cent lower risk of
premature death than
those who have an
orgasm once a month.
According to a German
study, couples who
kiss each other every
morning live five years
longer than others.
4
education
Education has a
great influence on our
future living conditions,
standard of living,
finances and lifestyle.
A study has shown that
ambitious men in the
40 to 50 age group
suffer from Alzheimer’s
to a lesser extent than
those who remained at
the same place of work
for the larger part of
their lives.
chapter 1
8
how we’ll fall ill
Even today we can see that private healthcare has
achieved greater significance in the Nordic countries.
“Dental care is one example of this. And pharmacies have been privatized in every Nordic country
except Sweden. Now the Swedish pharmaceutical
market is also being de-regulated,” says Mika Gissler,
professor at the Nordic School of Public Health in
Sweden and Director of Development at the Finnish
Research and Development Centre for Health and
Welfare (Stakes).
But even though private healthcare has grown, it
is still public healthcare that dominates. Gissler tells
us that the provision of healthcare in the public sector
looks different depending on which Nordic country
a patient lives in.
Patients have no freedom of choice in Finland, while
in Sweden they are free to choose any hospital in their
county. There is also freedom of choice in Norway, and
in Denmark a patient may even select a hospital abroad
when waiting lists are longer than two months.
Today, the Swedish, Norwegian and Danish public
sectors cover 82 to 84 per cent of all costs pertaining
to healthcare. In Finland it is a little lower – there the
state pays 76 per cent of costs, and it is also the Nordic
country where the personal contribution is highest.
Healthcare is largely de-centralized, i.e. divided into
regions or municipalities.
“In Finland it is chiefly the municipalities that are
responsible for healthcare, especially primary care.
In the smallest municipalities there are only a couple
of hundred inhabitants, so it really is a case of local
democracy, for better or for worse,” says Gissler.
He says that the Finnish system will change in
time, and that a re-organization into larger health
districts is at the planning stage. In Denmark and
Sweden, regions and counties have a strong position,
while in Norway it is the state that is responsible for
hospital care via regional health companies.
patients
have no
freedom of
choice in
finland,
while in
sweden
they are
free to
choose
any hospital they
like
Vaccine development sluggish
At the same time as the hospital structure is changing, new medicines are being developed. For example, the World health Organization has a long list of
infectious diseases they want to develop vaccines for.
6
5
sleep
When we get too
little sleep it affects
our mood and quality
of life. Many traffic accidents and accidents
at work are probably
caused by a lack of
sleep.
Genetic
inheritance
If one of your parents
has a predisposition
for an illness, there is a
50 per cent probability
that you and your siblings inherited it. But
not everyone who inherits a predisposition
necessarily develops
the illness.
7
alcohol and
smoking
Beer, wine and spirits
contain quite a few
calories. Additionally, it is a fact that
too much alcohol can
have a very detrimental effect on health.
And it’s no news that
smoking causes lung
cancer, heart disease,
emphysema and other
serious illnesses.
However, in recent times the pharmaceutical industry
has been hesitant to invest large sums in the development of new vaccines, the reason being that vaccines
provide lower profits than medicines. Furthermore,
there have been a number of legal actions in which
pharmaceutical companies have been ordered to pay
large sums in compensation to patients who have
suffered side effects from vaccines.
“Therefore developments proceed more slowly than
we had hoped. But despite this, new, useful vaccines arrive all the time. A vaccine against the human papilloma
virus is the latest to be used in Norway. Vaccinations
begin in the autumn of 2009 and will include all girls
in the 11 to 12 age group. It is a vaccine that protects
against cervical cancer,” says Geir Stene-Larsen.
Will pharmaceutical developments lead to a further
increase in longevity?
“Yes, we believe so. In particular advances in the
treatment of cancer will prevent many premature
deaths. But also in a number of other areas there
are new medicines and new treatment methods that
prolong life. More and more of us will live to be a
hundred years old.
Calculations show that women born in 2060 will
have a life expectancy of 87 to 93 years, and men 83
to 88 years. n
8
happiness
Mirth and merriment lengthen life! And
according to humour
researcher Professor
Sven Svebak this is absolutely true – a sense
of humour makes life
easier, helps improve
health and can affect longevity.
9
globalization
Contagion follows
mankind on his travels.
There is no virus, bacterium or radioactive
and chemical pollutant
that respects national
boundaries. From a
health standpoint,
the Nordic region
is ever more dependent on international cooperation.
2025: cancer
increases but
hearts get better
fewer cardiovascular patients, the same unhappiness
and more cancer cases. In the worst case, tuberculosis makes a
comeback. This is the health situation in 2025 say the experts.
by: Madeleine Bäck
cancer
Thor Stenbeck
carries out the
world’s first successful radiotherapy in Stockholm.
This is only three
years after the discovery of X-rays.
1899
Understanding of cancer
development progresses.
A great step forward is the
discovery of oncogenes,
important for a cancer’s
growth, and tumour suppressor genes that have
the opposite effect.
1980s
The number of cancer cases in
Denmark is greater than in the
other Nordic countries. Since the
year 2000 the number of cancer
patients in Norway has also increased. Unhealthy lifestyles are
thought to be the reason, above
all smoking in Denmark.
2000
The number of new cancer
cases per year is rising by 1 to
1.5 per cent across the Nordic
countries. Nothing indicates
this upward trend will fall off. In
2025 around 700 per 100,000
Nordic citizens will fall ill with
cancer.
2025
Cardiovascular and strokes
The risk of falling ill and
dying of cardiovascular
disease fell dramatically
from the end of the 1980s.
There are several theories
regarding the cause. Two
are healthier lifestyles and
reduced smoking.
1980s
The number of deaths from ischaemic heart disease has halved
since the beginning of the 60s in
the Nordic region, for both men
and women. In Sweden the risk
of dying from coronary artery
disease dropped by 40% just in
the period from 1987 to 2002.
1990s
In contrast to other arterial diseases, strokes
have only dropped
marginally. However, the
risk of death one year
from a stroke shows a
reduction. From 47% in
1987 to 39% in 2001.
2001
“Hopefully the scenario will
be that heart and arterial diseases and mortality
will continue to fall. Our
lifestyles and preventive
treatments are decisive factors.” Urban Janlert, Umeå
University, Sweden.
2025
mental illness
“It’s a bit of a myth that mental
illness is on the rise in Nordic
countries. Finnish data shows that
the number of patients is around
10% of the population since the
1980s.” Kristian Wahlbeck, Professor of Psychiatry, Mental Health
Group, Stakes, Finland.
1980
The 10% figure still
applies. The exception
is in children and the
young where we see an
increase in mental illness
in that more and more
of them receive antidepressive treatment.
1990
Mental illness costs society large
sums every year. The cost of
depression alone is the equivalent
of 2,300 Swedish crowns per year
per person in Europe when all the
indirect costs such as unemployment, reduced capacity for work
and criminality are included.
Scientists
believe that the
number of mentally ill will be
the same in 30
years, i.e. 10%
of the Nordic
population.
2000
2025
The threat in Sweden seems to
be under control and vaccination
ends. Finland takes time to catch
up because of difficulties stemming from the civil war and World
War II. Today the country is ahead
and the Nordic region has the lowest number of cases in the world.
“The problem with antibiotic-resistant
TB in the Baltic states and Russia,
together with immigration to the
Nordic region, may cause a rise in TB.
However, new vaccines and treatments
are being developed, which may slow
up this development.” Gunnar Boman,
Uppsala University, Sweden.
tuberculosis
The disease accounts
for 25% of the total
mortality in Sweden.
The first sanatoria for
isolated treatment of
tuberculosis patients
are built.
1900
Universal vaccination against
the tubercle
bacterium is introduced using
the so-called
BCG vaccine
still in use today.
1940s
1975
2025
Sources: Wiman, Beskow, Swedish Medical Association Journal no. 15–16, vol. 103, 2006/Swedish Healthcare Advice Centre, Swedish Institute for Infectious Disease Control/Swedish Radio Science Association/
Swedish Cancer Society Periodical, no. 4, 2007/NOMESCO – Health Statistics in the Nordic Countries, 2006/Tuori, Gissler, Wahlbeck “Mental health in the nordic countries”, STAKES 2006/National Institute of Public
Health, Denmark, Public Health Report 2007/Swedish National Board of Health and Welfare, Public Health Report 2005/Urban Janlert, Professor of Epidemiology and Public Health Sciences at the Institute for Public
Health and Clinical Medicine, Umeå University, Sweden/Gunnar Boman, Professor Emeritus in Pulmonary Medicine and Allergology, Uppsala University/Carsten Rose, Clinical Director, Oncological Clinic, University
Hospital, Lund.
9
chapter 1
10
how we’ll fall ill
Anders Sandberg, Philosophy
Researcher at Oxford university
“The future
will make us
healthier – and
less well”
Tomorrow’s technology will increase our
chances of diagnosing and curing diseases. At the same time it will change
our view of ill health. In the future it will
be considered an “illness” to be forgetful
or to have a low stress threshold, asserts
Anders Sandberg, philosophy researcher
at Oxford.
I
magine that you go to the doctor to check up
on a stubborn autumn cough. Instead of getting the diagnosis “chest cold” you leave with
a report stating exactly which virus you have,
together with an analysis of exactly how this
virus will affect your own, unique, medical constitution. And incidentally, you also find out you have
a nascent brain tumour and that you carry a genetic
mutation that predisposes you to sleeplessness and
memory lapses.
Science fiction, or soon reality?
The latter, at least if we are to believe Anders
Sandberg, who has a Ph.D. in computational neuroscience and is currently a philosophy researcher at
the Future of Humanity Institute at Oxford University in England. He is looking into how today’s rapid
technological development influences the way we
view our illnesses.
“One result of developments is that we have ill-
text:
Tobias Hammar
photo:
Anthony Oliver
nesses that are much more individualized than before. You no longer have a ‘cold’ but carry the ‘CV-A2’
virus. Maybe it doesn’t make you any healthier, but
your diagnosis is more specific,” he says, and adds:
“It’s the same thing when you are admitted to hospital. In 20 or 30 years hospital scans will be routine,
thanks to ever cheaper MRIs. The advantage of this is
that we will gain a good picture of each patient. The
disadvantage will be the discovery of a horrendous
number of trifling ailments. Even though we will actually be healthier, we will feel significantly worse because all of us will have a diagnosis of something.”
n n n
our
rapidly
changing
lifestyles
mean
that the
concept
of illness
will be
rethought
from top
to bottom
But improved diagnostics are only one result of tomorrow’s increasingly advanced technology. Another is
that the boundary between “ill” and “well” will shift.
“Traditional healthcare is aimed at curing, relieving
or preventing illness. But in the future we will have
new opportunities to ‘improve ourselves’ in various
ways with the aid of technology.”
This opens the door to new ethical dilemmas,
Sandberg asserts. Because even if we continue to
prioritize healthcare for whooping cough and cancer
for example, it will be significantly more difficult to
decide whether or not it is “good” to use medicinal
science to develop physically stronger bodies or biological super memories.
In the long run our rapidly changing lifestyles
11
“Most priorities will still be pretty simple. It’s
never going to be particularly difficult to choose between the common cold and severe liver damage, for
example. The problem is that people have ever better
knowledge of their conditions thanks to the internet.
In some cases they actually know more than their
doctors, and this also means they expect more care.
Doctors will have to get better at saying no.”
So in the years ahead you can count on a very noisy
battle over where the border between illness and normality is to be drawn. The debate is under way in
many countries right now. The UK, where Anders
Sandberg works, is well ahead in the discussion about
human enhancement medicine. The USA is hesitant
for religious reasons, while continental Europeans are
debating the judicial aspects. In the Nordic region we
have taken something of an in-between position.
n n n
mean that the entire concept of illness will be rethought from top to bottom. If forgetfulness, sleeplessness or being burdened with various dependencies were considered perfectly normal yesterday, these
traits will in future be seen as something abnormal
and unhealthy – and therefore suitable subjects for
medical treatment.
“This progress is ongoing. Caries, alcoholism and
obesity are examples of conditions that were regarded
as normal in the past, but which over time have come
to be looked on as diseases. And in Japan, body
odour is considered to be ‘unhealthy’,” says Anders
Sandberg, who adds:
“Many improvements will be directed at our lifestyles rather than our jobs. Perhaps it will interest us
more to manipulate our ability to sail boats or climb
mountains, for example. And with our new power
to switch various genes on and off, we might in time
also be able to medicate away the traumatic effects
of a troubled childhood.”
n n n
Essentially this value shift can be reduced to one
single meme: you the individual will bear increasing responsibility for not being in top form, regardless of whether your flaws are physical, emotional
or mental.
But then how will this new approach to disease
influence future ethical priorities?
Ill or
normal?
It all depends when.
Caries
A condition we have
had throughout the
ages, but now declared a disease.
Alcoholism
Previously we only
had moral objections, these days
we have begun to
see it as a mental
illness beyond the
alcoholic’s own
responsibility.
“staying
alert”
In the past we
thought forgetfulness and tiredness
to be natural in the
elderly. Today we
shoulder ever more
responsibility for
“staying alert”. Ginseng tablets, sudoku
and other forms of
stimuli cause us to
expect permanent
high performance.
The big question of course is all about … money.
“The fundamental rule is that we will happily pay
for someone else’s healthcare when it provides average
health, but no more. The state will presumably take
care of the ‘basics’ – at least in the Nordic countries –
while the individual will have to contribute privately
toward anything he wants over and above average
health. In other words, cosmetic surgery, memory
enhancement, brain doping and gene therapy will
continue to be private issues.”
But it is clear that healthcare will be increasingly
more expensive. Anders Sandberg talks of future
healthcare as being an “à la carte” menu, where the
patient will to an ever greater extent choose the health
status he or she would like. Doctors will form part
of an individual’s personal “health team” alongside
the dietician, health promotion consultant, masseur
and many others.
“In terms of social values, it is clear that patients
will become more like healthcare customers. They are
beginning to place demands on their doctors, they
travel to spas and they try out alternative treatments.
This is something entirely new compared to just a
decade or so ago. It will undoubtedly lead to those
with more money being able to buy better health in
the long term.”
But we might well ask: Is this fair?
“That’s always open to discussion. But it is obvious
that no matter how we solve the financing, those with
more money will always have better healthcare than
the majority. And it is not only about money, but has
also to do with the fact that people with a higher
socio-economic status are usually better at making
demands. They are just much better bellyachers than
the rest of us,” says Anders Sandberg. n
Anders Sandberg, 36 years old, from Solna, Sweden,
is a researcher at The Future of Humanity Institute at
Oxford University. He has a doctorate in computational
neuroscience from Stockholm University and is a
fellow founder of the Swedish think tank Eudoxa.
chapter 2
how
we’ll
get
help
Photo: Alcor Life Extension Foundation
12
An extraordinary
example of the hope
surrounding future
research is choosing
to freeze one’s dead
relatives so that they
can be cured in the
future. Here a surgeon
is seen preparing his
“patient” by injecting
a special fluid into the
circulatory system.
The fluid protects
tissue against freezing
injury. Location: Alcor
Life Extension Foundation, Arizona, USA.
13
Advances in research over the years have made the
impossible possible, and the vain dream of eternal life
no longer seems quite so unattainable. New discoveries continually contribute to new, advanced – and
costly – treatments and medicines. We bring a status
report from the sharp end of Nordic research.
chapter 2
14
how we’ll get help
at the sharp end
Five years have passed since the
human genetic code was mapped in its
entirety. For health researchers, the
map shows the way toward new, effective, but often expensive medicines.
BUT DISEASES are fighting back.
text: Mathias Luther, Patricia Bruun
R
esearchers are tremendously excited.
Genetic maps not only enable them
to foresee illnesses, but also to understand and predict how medicines will
work. They are able to create and dose
drugs extremely accurately. “Whereas
the shotgun principal used before brought down
whole flocks of pigeons, today we are able to snipe
the single grouse we’re hunting for,” says Research
Professor Sirpa Jalkanen. She leads the Academy of
Finland’s spearhead unit studying human defence
mechanisms.
New medications are made in a different way to
the old synthetic types.
“Biotechnical drugs are produced by cells from
bacteria or mammals that are genetically modified
especially for the purpose. The cells are able to produce substances that are much more complex than
those we can synthesize chemically in the test tube,”
says Jalkanen.
The new drugs are more expensive than the old,
often many times over. But doctors from every discipline argue that they are still worth the price to
society, if they can make a bed-ridden or wheelchairbound patient able-bodied again.
One example is Natalizumab, a promising medicine in the treatment of the severe neurological disease MS, which without treatment always leads to
invalidity. MS often advances during periods of rapid
deterioration, but Natalizumab halves the number of
such episodes compared to the best earlier medicines.
Its disadvantage is its high price, around 15,000 Euros per year. But in maintaining a patient’s ability to
work, it can still be worthwhile for society. Natalizumab is a medication based on monoclonal antibodies,
a growing family of advanced medicines.
Describing the differences
Genetic research has also meant that we can predict
differences in human reactions to medicines. We call
15
of research
it pharmacogenetics.
The first findings came along in the 1950s when
it was observed that Asians did not react to certain
medications in the same way Europeans did. Today,
now that the whole genetic map can be spread across
the table, we see that 35 to 50 million Europeans
lack the CYP2D6 gene – or have two – and that they
therefore risk overdosing, serious side effects or no
effects at all from around 15 per cent of medications
in use. Doctors must choose other drugs for these
people, or adapt doses individually.
This is just one example among many.
“Pharmacogenetics is an extremely important research avenue; it is the future,” says Mette Rosenkilde,
Professor of Molecular Pharmacology at Copenhagen
University, Denmark.
And it is one of the areas Denmark is investing
heavily in.
She is involved in molecular biology research centred on cell membrane receptors. They are literally
the keys to many illnesses and Rosenkilde expects
“many exciting things” to happen in the next few
years. Among others, the receptors that allow the
HIV virus to gain entry to cells are under study.
Cancer fighting back
Much of what seemed impossible 20 years ago is now
a reality. At the same time, researchers are forced to
acknowledge one fact: for every question that finds an
answer, new questions arise. Biology is dynamic. Viruses and cancer cells are often smarter than man.
“It happens time after time,” says Professor Lea
Sistonen, who researches cell stress in Åbo, Finland.
Her colleague and husband Professor John Eriksson
researches cell survival signals.
A cancer cell being treated with a cytotoxin tasked
with killing it, is able to “addict” itself, i.e. the cell
mutates so that it instead becomes dependent on
that particular toxin.
“This is relatively recent knowledge,” informs
5
MAJOR
future
CHALLENGES
How will we
survive the
great widespread
diseases? Cancer,
cardiovascular
disease, neurological and mental
illnesses all require
continual research
advances.
1
Sirpa Jalkanen leads
the Academy of
Finland’s spearhead
unit studying our defence mechanisms.
Mette Rosenkilde,
Professor of Molecular Pharmacology at Copenhagen
University, Denmark.
Lea Sistonen,
researcher in cell
stress, Åbo, Finland.
John Eriksson,
researcher in cell
survival signals,
Åbo, Finland.
How can
we get our
lifestyles to take a
healthier direction?
2
How do we
maintain the
privacy of the individual in healthcare
and research?
3
How can we
attract doctors and medical
students to continue research?
4
How do we
replace animal
testing without
impairing results?
5
Sistonen. Researchers have been able to observe that
cancer cells that are fought by stopping the supply of
nutrients via the circulatory system learn to live even
in these straitened circumstances.
Lack of doctors in the lab
Eriksson and Sistonen are doctors of philosophy and
as cancer researchers they stand at the front line of
SHORT MEDICAL GLOSSARY
BIOTECHNICAL
MEDICINES:
Medicines made from
genetically-modified
cells that produce a
specific molecule.
CELL:
CELL STRESS:
We can compare a cell
to a library. If we step
into the cell’s nucleus
we see shelves; they are
chromosomes. There are
books on the shelves;
they are genes.
A cell’s ability to survive
depends on how well it
can handle stress. Inside
the cell’s nucleus there
are also stress genes;
they’ve been around for
millions of years.
PHARMACOGENETICS:
An assessment of how
one and the same drug
has different effects on
different people depending on their hereditary
predispositions – genes.
GENETIC RESEARCH:
Mapping the role played
by each single identified
gene (there are about
20,000–25,000 in man)
in how a person looks
and functions.
chapter 2
16
how we’ll get help
medical research. In 2006 medical doctors formed less
than one third of the doctoral candidates at medical
faculties in Sweden, a proportion that is falling. The
situation is similar in the other Nordic countries.
Medical doctors are simply unwilling to do the
research work that progress demands. The vacuum
is filled today by researchers from other scientific
disciplines.
“During the past ten years we have seen that an
increasingly large proportion of researchers at medical faculties come from disciplines other than medical studies. It is other healthcare personnel, chemists, biologists and engineers,” says Professor Steinar
Hunskår, who heads the medical faculty research
programme at the University of Bergen in Norway.
“This has enriched medical research. They have
brought with them other angles of approach and know­
ledge, especially technological, that is of great value.”
But we also need the perspective and feeling for a
patient’s problems and needs that can only be picked up
in an operating theatre, the ward or a doctor’s surgery.
“Unfortunately, research isn’t an attractive career
opportunity for doctors,” continues Hunskår. “The
pay structure is such that even the youngest doctor in a Norwegian hospital earns more than a wellqualified professor at a university.”
Because it is difficult to attract doctors to research
everywhere in the Nordic region, it has also become
difficult to develop clinical research, which in one way
or another takes place inside the health services.
Often, but not always, it is clinical research that
prevails, i.e. research that sets out to solve a given
problem or create a certain product. Its counterpart
is basic research that should properly only be carried
out for the sake of scientific curiosity, regardless of
what the knowledge will be used for.
In the research strategies drawn up by among others the EU and the World Health Organization, a lot
is said about putting knowledge to work to improve
healthcare. The idea is that there is a lot of knowledge
floating around out there that is not exploited.
Many links in the chain
The Finns Sistonen and Eriksson demand substantial
investment in basic research. We have to pay for the
entire knowledge chain, they say.
They feel Finland is cheating on this. Sweden and
GENETIC
RESEARCH
RAISES
MANY
ETHICAL
QUESTIONS
AND PHILOSOPHICAL
MISGIVINGS
Denmark make significant investments in basic research, and will also harvest useful applications by
and by.
The conventional wisdom that adult brain cells
cannot renew themselves was shattered at the
Karolinska Institute. It was able to show that there
are neural stem cells that can divide and create new
nerve cells. The discovery is of importance for treating
among other things Parkinson’s disease.
It was basic research in Denmark that led to modern antidepressant medications – happy pills such as
Prozac and Cipramil.
But Professor Olle Stendahl from Linköping,
Sweden, who works with national evaluations of both
Swedish and Finnish clinical research, even has examples of trail-blazing discoveries within clinical
research.
“The bacterium that causes stomach ulcers was
discovered clinically by surgeons and this led to radically changed ulcer treatment – and thereby ended
ulcer surgery, ironically enough.
“Advances in anti-rheumatic medications, new
medicines based on monoclonal antibodies, were
made in collaboration between basic research and
clinical research. They have revolutionized treatment.
Some patients are literally able to take up their beds
and walk,” says Stendahl.
Ethical boundaries
Olle Stendahl,
Professor,
Linköping
University,
Sweden.
Steinar Hunskår, Professor
Faculty of Medicine in Bergen,
Norway.
Treatments that cause new blood vessels to grow in
the heart are being performed at the Karolinska Institute. It is known as regenerative medicine and the
possibilities seem limitless.
Recently a Finnish patient received a new upper
jaw that had been grown beneath the patient’s skin,
on the stomach. This was made possible thanks to
stem cells, a technique that in turn results from genetic research.
Genetic research and the use of stem cells that in
certain cases have been extracted from human embryos, raises ethical questions and philosophical misgivings. The European Convention on Human Rights
and Biomedicine forbids researchers from creating
human embryos solely for the purpose of research. It
is forbidden in many Catholic countries. Those Nordic
countries that wish to continue with the research must
reserve the right to do against the convention.
SHORT MEDICAL GLOSSARY
CLINICAL RESEARCH:
Research that is not only
conducted in the laboratory, but also partly
around patients who are
under treatment or who
are taking part in medical tests.
MOLECULAR
PHARMACOLOGY:
MONOCLONAL
ANTIBODIES:
The development of
drugs based on an
understanding of how
molecules affect cells.
Antibodies that have
been made using cloning technology and that
have shown themselves to be effective
against certain kinds of
rheumatism, cancer and
leukaemia.
NERVE CELL:
NEURAL STEM CELL:
A nerve cell, or neuron, is the type of cell
in the nervous system
responsible for receiving
and passing on nerve
impulses. Nerve cells
are the nervous system’s
building blocks.
The central nervous
system’s stem cells.
Animal testing indicates
that stem cell transplants
may be able to be used
to treat injuries to the
central nervous system.
17
The EU has also stopped subsidizing research
programmes that create new stem cell cultivations
from human embryos, but cultivations begun before
2003 may continue.
From an individual’s standpoint, having one’s hereditary dispositions mapped in detail is not entirely
agreeable.
In 2007, when the head of a gene laboratory in
California paid his respects to James D Watson, the
Nobel Prize winner and co-discoverer of the structure
of DNA, he presented Watson with the latter’s genetic
map, describing it as “the ultimate self-knowledge”.
Watson was impressed by this effort and the great
advances in technology. But the gene that predisposes
its host to fall ill with Alzheimer’s disease, Watson did
not want to see. n
new nordic discoveries
back problems no matter what
friends make us healthier
The significance of working life in back
problems is overestimated, assert researchers at the University of Southern Denmark.
They have found that people have roughly
the same amount of back problems from
their teens up to the age of 100.
Researchers recommend that we
discriminate between various types of
back problem more carefully than before
in order to observe their causes. Certain
problems are clearly the result of work
that e.g. involves a lot of lifting. In 2009,
an international group of experts will
study ways to reduce the problem.
Health is not just molecules. In some cases it would also appear to
be a question of language. National health researchers in Finland
have discovered that Swedish-speaking Finns are healthier than the
others. This also applies when comparing people belonging to the
same social class, the same age group and living in the same town.
The difference is attributed to something known as social capital.
Swedish-speaking Finns seem to have a network of friends and relatives that functions better than the others’. Another difference may be
that childhood conditions in Swedish-speaking Finnish homes in some
way provide a better start in life.
But how does this affect the body? Researcher Markku T. Hyyppä
in Åbo, Finland, speculates in an article in the Finnish medical journal about the possibility of a secure social network enabling people
to sleep better.
hypochondriacs
really are ill
Even hypochondria may
have a physical explanation. So suggests a survey of a small number of
patients with a long history of hard-to-interpret
symptoms and problems.
There are minute differences in these patients’
brains that can be seen
with a so-called PET
imager, discovered a researcher in Åbo, Finland.
He suspects that the patients’ nervous systems
all-too-easily pass on
pain impulses.
PREDISPOSE:
Increase the risk or
chance of a given event
happening.
autopsies
merely a
memory
brain discovery may help stroke patients
Advanced
medical
imaging
technology
can be used to solve crimes.
Linköping University in Sweden
has developed a method using
a combination of a CT scanner
and an MRI camera to scan 3D
images of deceased victims of
crime. The images are examined
in a computer and processed so
that it is possible to clearly see
internal injuries. The method is
able to replace autopsies and is
in many cases better.
Brain cells that have been hit by a stroke have a
mechanism for protecting themselves against
what otherwise would be a threat of poisoning
from calcium ions in cerebral fluid. The cells are
able to rapidly shut off the calcium intake that
normally forms part of the brain’s signaling
system. This was discovered by researchers
at the University of Oslo, in Norway.
Calcium levels in brain cells should normally only be a fraction of the concentration
in the fluid outside. But the cells need energy and oxygen in order to pump out excess
calcium again. If blood circulation is disturbed
the cells suffer a lack of energy and would be
under threat of being swamped by calcium ions
if they did not have a rapid shut-off valve. The discovery may be significant in the treatment of stokes
and epilepsy.
CELL MEMBRANE
RECEPTORS :
ANTI-RHEUMATIC
MEDICATIONS:
REGENERATIVE
MEDICINE:
Molecules that pass right
through a cell’s outer
wall in the manner of
a door handle or key.
They pass on different
substances and signals
to the cell.
Combat rheumatic
diseases, e.g. rheumatism. New medicines are
available that interfere
with the disease itself,
not just the symptoms.
They are promising, but
extremely expensive.
Replaces injured or
diseased body parts with
new, permanent parts
that eliminate or reduce
disease symptoms.
STEM CELLS:
Immature cells that are
present in all multicellular
organisms. They have two
characteristics that distinguish them from other cell
types: they are able to undergo a limitless number
of cell divisions, and they
can mature into several
different cell types.
chapter 2
18
how we’ll get help
science fiction
or reality?
a good question
1
Cloning a
human
It is already technically possible to clone a human today,
but we refrain from doing so
for ethical reasons. But it cannot be ruled out that the first
cloned human will be created
within the next 30 years –
there are in fact scientists who
are willing to defy the general
prohibition against human
cloning.
3
Designer
babies
Are we on the way to a
world of supermen with
computer-linked brains,
technically improved
consciousness and robots in the bloodstream
that make sure we are always well? We asked researchers which sciencefiction-like treatments
are merely a myth, which
ones we will experience
in the future and what
falls in between.
text: Søren Rathje
Because it is possible to genetically modify animals, it is
in principal also possible to
break into an unborn child’s
DNA and alter its genes. We do
not do this today because it is
regarded as ethically indefensible. But there are already
certain ways of having one’s
own “designer baby”. It is not
unheard of for childless couples
to seek out especially goodlooking donors, and Nobel Prize
winners have created their own
sperm bank for those who want
a clever baby …
2
Eternal life
“The idea of an average life
expectancy of 150 years, not
to mention immortality, is
pure science fiction,” says
Sissel Rogne, Head of the Norwegian Biotechnology Commission. “For example, we are
unable to predict future diseases; new ones will crop up,
old ones will mutate.” On the
other hand she has no doubt
that the health gap will widen
so that in future the well-off
will live significantly longer
than the less privileged.
19
4
A human
machine
“It is already possible today to substitute many body parts
with high-tech replacements. And we will see much more
of this in the future,” says author and ethics scholar Klavs
Birkholm. However, one crucial issue is whether technology should solely be used to heal the sick, or also be used
to make healthy people sharper and faster. This is where
Birkholm sees ethical problems. “We will lose the mystique
surrounding how far human skill and talent can take us. And
the gap between rich and poor will also widen, because it
will to a great extent be private individuals who would pay
for this,” says Birkholm.
7
Medicine
from DNA
5
Genetic
testing
So-called biomarkers give
a hint about the diseases of
tomorrow. They are already
making a small appearance in
healthcare, and they will have
much greater significance in
future. By using markers it is
possible to get an indication of
bodily health from quite small
amounts of biological material. The market for tests and
screening will on the whole
grow markedly. “This will lead
to a great deal of pressure
being put on public healthcare, because everyone will be
insisting on their rights,” says
Sissel Rogne, head of the Norwegian Biotechnical Commission. Which is why she believes
that this type of test will be
much more common in the private sector, where people will
pay for tests themselves.
8
Robot
surgeons
6
Nanobots
in the blood
The development of nano robots is already in full
swing all over the world, but we have only seen a
tiny part of what will happen in this area. So thinks
Ilpo Vattulainen, Professor of Biophysics. In the best
case, these small robots that move through the blood,
will not only be able to identify cancer cells, but also
destroy them before they have time to spread. Vattulainen believes that this treatment will benefit many:
“The lion’s share of all research comes from public
resources, so I feel that this is something that will be
for the good of all.”
Operating theatre robots are in no uncertain terms already a reality. At the Karolinska Hospital in Stockholm,
Sweden, two robots equipped with gripping claws are
used chiefly in operations on cancer patients. But they
do not operate entirely alone. The arms are controlled by
the surgeon using two joysticks. Urologist Peter Wiklund
expects that the future will see robots that can perform
certain tasks autonomously. It is also theoretically possible
today for the surgeon to be in a different place to the
robot and patient. When the price of robots falls this may
be a good way to economize on manpower resources, but
right now it is still an expensive spearhead technology.
Photo: Intuitive Surgical, Inc.
It is highly likely that several
global epidemics that would
have disastrous consequences
if allowed to spread unchecked
will emerge in the future. In
which case, DNA vaccine,
made from DNA hosting a
specific disease, will be an
effective weapon. Today DNA
vaccine is under development
– tests are being carried out
with HIV, malaria, tuberculosis,
several types of cancer and a
range of other diseases.
20
chapter 3
photo: anders hansson
21
who will
pay?
Carl-Axel is 65. He has been fat
since he was 4. Neither he nor researchers
know why. He has sought help for RLS (restless
leg syndrome), sleep apnoea and carpal tunnel syndrome (his hands go to sleep because
the nerves in his wrists are compressed), but
he has never received timely, satisfactory help –
“his condition depends entirely on his obesity”.
He has had type 2 diabetes for a few years.
The overweight will be one of the groups
under threat when healthcare is forced to
make tougher priorities.
Carl-Axel Wildt does charity work in health and healthcare issues for the Swedish National Association for the
Overweight. “It’s all too easy for the health service to blame obesity. It’s probably only a matter of time before
cancer and type 2 diabetes. which are largely exercise and diet-related illnesses, end up in the same situation. Research and priorities are too focused on medications. Preventive healthcare should be the priority,” is his opinion.
chapter 3
22
who’ will pay?
the senior boom and the rise of new, more
expensive medicines and treatments will stretch
Nordic health service finances. the need to
prioritize will be greater than ever.
priorities in
focus as
the north ages
text: Tobias Hammar
23
T
hings look pretty grim.
The words are Paul Lillrank’s, Professor of Production Economics at Helsinki
University of Technology, Finland, when
he was asked to sum up the condition
of the health services in the four Nordic
countries.
“It’s not catastrophic, but close,” he adds, as if to
emphasize that the patient is still with us, despite
weak signs of life and poor future prospects.
The reason for Lillrank’s gloom is easy to understand. The Nordic health services, established when
populations were young, wallets full and optimism for
the future great, are fast approaching a point where
they must either be reformed from the bottom up, or
suffer a long, agonizing disintegration.
Changes in the demographic structure are placing health service finances under devastating pressure. Increasing life expectancies and an ever larger
proportion of pensioners means that the number of
people requiring care will triple in Nordic countries
over the coming three decades, at the same time as
financing opportunities via taxes become limited.
The economic dependency ratio – the ratio between
the numbers of gainfully employed in a country and
those, who because of age, are outside the labour
market – will increase by 20 per cent in 30 years as
fewer and fewer must provide for more and more.
Considering the traditionally low wages and strenuous working environment in healthcare it is easy to
understand the economists’ dilemma: will there be
people and money enough to handle the healthcare
needs of the future?
“From a public health perspective the Nordic
countries are at the top in the Western world. We
are healthier than most. But the macro-economic
challenges are all the greater. Nordic healthcare
budgets may well be increasing faster than in other
countries, but nothing points to this being enough.
Rather, the world trend is toward a falling tax burden,” says Lillrank.
Dearer healthcare ahead
The problem is made worse by more expensive drugs
and forms of treatment – a trend that is also making
present-day care more costly. According to a survey
from the American pensioners’ organization AARP,
prices for 140 of the most important specialized medications against cancer and other common age-related
illnesses have risen more than three times faster than
inflation over the past few years. The most expensive
cost far more than $10,000 per patient per year.
And as if this wasn’t enough, the political trend is
also on a collision course with economic graphs. State
healthcare commitments that guarantee patients the
right to treatment within given maximum times is a
phenomenon that has emerged in the Nordic countries during the last decade.
Nordic
healthcare budgets are
increasing, but
nothing
points to
this being
enough
The 9 most
resourceconsuming
disease
groups
2 1
Cardiovascular
diseases.
Diseases of
the liver, gall
bladder and pancreas.
4 3
Skin diseases.
Kidney and
urinary diseases.
6 7 8 9 5
Birth etc.
Neurological
diseases.
Gastrointestinal diseases.
“It is yet another powerful cost driver. Guarantees put
the entire system under pressure because the promises
are made at the same time as many governments have
pledged to balance their budgets,” says Kjeld Møller
Pedersen, Professor of Health Economics at the University of Southern Denmark. He continues:
“This certainly begs some interesting questions.
How great is the political will to pay? Will we allow
healthcare budgets to grow at the expense of other
areas? I believe the debate around these issues will
be pretty tough in the years ahead.”
Public healthcare unable to cope
One obvious change that many are counting on is
a continued expansion of the private sector in step
with a health service that is burdened more and more.
Björn Lindgren, Professor of Health Economics at
the University of Lund in Sweden, reckons that the
whole Nordic welfare concept should be overhauled
from top to bottom.
“We will see an increased penetration by private
health insurance, or alternatively, means-tested
subscription systems. Either way, more and more
healthcare will be private in future. The fundamental welfare state concept of publicly-financed and
publicly-delivered healthcare quite simply cannot
Pulmonary
diseases.
Bone and tissue diseases.
Source: Ministry of
Health, Denmark,
2006.
Paul Lillrank, Professor of Production Economics at
Helsinki University of
Technology, Finland.
Kjeld Møller
Pedersen, Professor
of Health Economics
at the University of
Southern Denmark.
chapter 3
24
who will pay?
cope with developments.”
This trend is already well on its way in Denmark.
Today, more than three million Danes have some
form of private health insurance – a number that is
steadily growing. The other Nordic countries are by
tradition more sceptical to private elements in healthcare, even though private health insurance is making
significant inroads in Sweden and Finland.
Only Norway, with its exceptionally strong public
finances seems to be bucking the trend.
“Our financial position means that most Norwegians can count on continued public healthcare financing in the future. We also have higher incomes here,
which makes the recruitment of above all doctors and
specialists easier. But we have the same problems as
our neighbours when it comes to care of the elderly and
handicapped,” says Terje Hagen, Professor of Health
Economics at the University of Oslo in Norway.
However, not all experts are equally sure that private healthcare will be a must in the future. Inger
Ekman, Professor at the Department of Health Care
Sciences and Health at the Sahlgrenska Academy in
Gothenburg, Sweden, believes that public healthcare
can survive with a different modus operandi. She
talks about “patient or person-centred healthcare”.
“Today, healthcare is founded on big, resourceconsuming accident and emergency centres. But as
the population ages, it will move increasingly toward
chronic diseases. There will no longer be a need for
the same type of health service directed toward acute
illnesses. By changing perspective and adapting
healthcare to the individual patient we will be able to
save significant resources,” she says, and explains:
“Something we always begin with when a patient is
admitted is to try to find some form of disease process, a diagnosis. But there are plenty of conditions
where we cannot find a pathology. It’s often a matter
of inexplicable symptoms, and then the whole treatment becomes ineffective. By simply listening to the
patient, we will be able to adapt care and support to
each individual’s needs and resources which will make
entire treatment procedures markedly cheaper.”
Nevertheless, most indications show that we are
moving toward a future where healthcare needs will
exceed public resources. The question is what we do
with the healthcare’s actual content. Will we need to
change healthcare priorities?
We need
clearer
insight
into what
our priorities will
be, not
least so
that our
citizens
know what
kind of insurance to
buy
Terje Hagen, Professor of Health
Economics at the
University of Oslo,
Norway.
Inger Ekman, Professor at the Department of Health Care
Sciences and Health
at the Sahlgrenska
Academy in Gothenburg, Sweden.
Clearer priorities
Hitherto the healthcare systems of all the Nordic
countries have succeeded in managing their priorities
more or less behind closed doors. Choices were made
either locally or at an overarching central level, and
without being preceded by any noticeable discussion.
In the future, however, politicians will no longer be
able to sweep problems under the carpet. This issue
must be taken up for debate.
“It is a question of rights. We need clearer insight
Björn Lindgren,
Professor of Health
Economics at the
University of Lund,
Sweden.
into what our priorities will be, not least so that our
citizens know what kind of insurance to buy,” says
Lindgren.
He and his colleagues agree that many of today’s illnesses will fall outside the public
remit tomorrow.
“Much of what is lifestyle dependent will disappear. There are medications that enhance one’s quality of
life, but that are not directly justifiable
by an illness,” he says.
Whatever we do, the dilemma raises many issues.
For example, should geriatric care be allowed to expand at the expense of other forms of care as our
populations age? Should fertility and obesity treatments be handed over to private players?
“The public sector will clearly still be responsible
for basic healthcare in society, but otherwise things
bode well for privatizations. At the same time I believe that demands placed on individual responsibility will increase. Many illnesses are lifestyle related. I
won’t be surprised if tax incentives for taking care of
personal health are introduced,” says Lindgren, and
gives as examples the taxes and duties on tobacco and
alcohol. In the same way, tax subsidies have long been
used to encourage occupational health contributions
from companies and employers.
Leaner processes increase productivity
But reprioritization will also affect the very infrastructure of healthcare. Aging brings with it a growing
urbanization which will mean that the need for large,
central general hospitals will rise in the future.
“Smaller hospitals out in the country will be closed
to make room for larger hospitals that bring together
expertise and exploit the economies of scale,” says
Møller Pedersen.
Luxuries
preventive
care
cosmetic
medicine
You will be expected
to invest in your own
health, and preventive
care will presumably
be managed by the
individual. Similarly,
you will be expected
to seek out health
information yourself.
This will lead to a proliferation of services
for healthier lifestyles,
sponsored by employers and authorities.
Cosmetic medicine
will most likely be
private, and will include conditions such
as warts and squints.
Even conditions such
as Bogart-Bacall Syndrome, or dysphonia
(a medical term for a
type of hoarseness)
will be “cosmetic”
because they are not
significant for basic
health, so they will be
private supplements.
25
there are medications that
enhance one’s quality of life,
but that are not directly
justifiable by an illness
But in the short term the most significant cost savings are expected to come from another direction –
rationalizations. By tradition, all four Nordic countries
have big, resource-consuming national health services.
According to Lillrank there is a huge potential to make
healthcare production processes more efficient.
“Studies from all the Nordic countries show that
as much as one third of all surgical operations are
unnecessary or harmful. There is a great deal of slack
in the system that can be hauled in without hurting
anyone,” he says, and goes on:
“If we apply the same kind of industrial flows and
processes that the best companies in the private sector already use today, we would be able to improve
healthcare productivity by up to 30 per cent. Add to
that new innovations and the figure could be even
higher. I think it is here we will see the fastest changes
in the short term.” n
– Future priorities
chronic pain
circumcision
Chronic illnesses such
as stomach pains,
backache and neck
pain that have unclear
causes and that are
largely psychosomatic
will not be prioritized in
the future, if the patient
has not previously received treatment that is
demonstrably effective.
In order to avoid
controversy and to
save money, circumcision will be referred
to private, cosmetic
surgery.
unnecessary
tests
unusual
diseases
ineffective
treatments
Diffuse symptoms
are costly, and they
will lead to a hunt for
more effective tests
at the same time as
health services will
be striving to minimize “unnecessary”
tests. Examinations
will become cheaper
and simpler.
Unusual diseases
are becoming quite
common, primarily
through improved
diagnostic methods
and because we are
able to distinguish
between different
causes of e.g. breast
cancer. Some variants
will be treated while
others will receive
less support.
The focus will continue
to be on those in most
need and those who
draw most benefit from
a treatment. Healthcare will become less
interested in stubbornly
administering treatments
that do not “take”, which
will lead to an increased
interest in finding efficient ways to measure
what functions individually and universally.
Source: Anders Sandberg, philosophy researcher at Oxford University
chapter 3
26
who will pay?
24
Replies
who pays for
healthcare?
nordic opinions on the future of healthcare
USA, where some cannot
afford healthcare.”
Arne Refsum, Doctor and
Fellow of the Norwegian
Medical Association:
“Private elements will
become much more
common. But this will apply above all to supplementary services such as
cosmetic surgery. Hopefully, the private sector
will inspire the public
sector to do better.”
Kristina Laksáfoss Søgaard,
Project Manager at the
Copenhagen Institute
for Future Studies (IFF),
Denmark:
“The healthcare sector
will be privatized to an
increasing extent, because
the elderly will in future
have more money and will
not content themselves
with public healthcare
standards. Another reason
is that public healthcare
finds it hard to do patient
follow-up in many circumstances, due to recruiting
problems and long hospital waiting lists.”
Urban Janlert, Professor of
Public Health Sciences at the
Institute for Public Health
and Clinical Medicine at
Umeå University in Sweden:
“The state or the county:
publicly-financed healthcare is the model. In my
opinion there should be
a public safety net in a
welfare society, otherwise
there is a risk that things
will be as they are in the
more as customers who
demand good, efficient
service. One of many
small changes could be
to send SMS messages
to patients to confirm
that referrals have been
received, for example.”
Marianne Falk, Nurses Association Chairwoman, Finland:
“Because resources are
becoming increasingly
scarce, more will be paid
for by patients themselves
in future. But at the same
time, I believe that the
major part of healthcare
will continue to be public.”
Torben Fridberg, Researcher
in social politics and welfare
at the Danish National
Centre for Social Research
in Copenhagen:
“In Denmark healthcare
will be financed privately
to an increasing extent.
The risk is that individuals
will have to pay privately
in order to get good quality. The nightmare scenario would be if healthcare
were to be based entirely
on private insurance, but
I don’t believe it will ever
go that far in the Nordic
countries.”
Ingrid Kössler, Chairwoman
for the Swedish National
Breast Cancer Association:
“Major parts of healthcare will continue to be
publicly financed, but
because we now live so
much longer we will need
care much later in life.
Healthcare must become
more efficient to cope.
We must look on patients
of average. Cosmetic
surgery, i.e. straightforward “enhancements” are
things people will have
to pay for themselves.
A basic portion will be
handled by national insurance, but more and more
will be paid for privately.
One way to counterbalance this debate would
be to bring automation
to healthcare – to make it
more efficient.”
Kalervo Väänänen, Professor of Cellular Biology in
Åbo, and chairman of the
committee that disburses
Finnish Academy finances to
medical research:
“It is the responsibility
of society to ensure that
healthcare is available
for the entire population.
There are several ways to
organize this in practice.
We can envisage municipalities taking responsibility for basic healthcare
(as is the case today in
Finland) while specialized
care could be transferred
to the state (in Finland it
is managed by municipal
syndicates). This would
provide economic equality among the municipalities. Both the state and
municipalities could then
purchase services from
private companies.”
Anders Sandberg, Philosophy Researcher at Oxford
University in England:
“More and more fields
are seen as conditions we
want to take care of. This
foretells of healthcare becoming a pretty expensive
affair. In purely general
terms I don’t think people
are willing to pay for the
health of others if we are
talking about their getting
healthier than some sort
Jakob Axel Nielsen, Minister
of Health, Denmark:
“Even in the future the
public sector should pay
when people fall ill and
need treatment. In Danish healthcare, free and
equal access applies, and
this is how it should be
in the years to come. But
we must absolutely draw
advantage from private
hospitals, both by buying
in extra capacity and allowing them to pressure
public hospitals into providing the best care possible. Both patients and
society as a whole benefit
from healthy competition.”
Inger Ekman, Head of Health
Care Sciences and Health at
the Sahlgrenska Academy in
Gothenburg, Sweden:
“We will continue to pay
for healthcare via our
taxes, but we will need
to do it differently. The
focus will be more on
what resources we have,
and how we can best use
them. Today we tend to
create a disease out of
everything, which often
leads to oversimplified
solutions to fundamentally complex issues.”
Paul Lillrank, Professor of
Production Economics at
Helsinki University of Technology, Finland:
“Insurance copays will
be raised. Citizens will
have to pay more for
normal basic healthcare;
going to the doctor will
be a bit like going to the
hairdresser. The chronic­
ally ill will continue to
have guaranteed public
support and subsidies. In
other words, you are on
your own up to a certain
level, beyond that there
will still be some kind
of ‘catastrophe insurance’. Overall, the flow
of money will come to
bypass the tax system
more and more. We will
have a larger element of
private health insurance even though public
healthcare will continue
to ensure that no one
ends up entirely outside
the healthcare system.”
Lisbeth Löpare-Johansson,
Nurse and Vice-Chairwoman
of The Swedish Association
of Health Professionals:
“Healthcare will continue
to be financed through
public funds, while various
supplementary services
will be increasingly in the
hands of the private sector. We need a proper discussion about where the
public boundary should
be drawn. It is extremely
important that we get our
healthcare priorities right.”
27
tomorrow’s
financing
Trond Egil Hansen, Doctor,
Nesttun, Norway:
“Healthcare in Norway
will see private financing
increase. Those who can
afford it will be able to
pay for services themselves. There’s no way to
prevent this. Problems
will occur if the range of
publicly-financed services dwindles because of
private alternatives.”
Anna Ortner, Clergywoman,
Sollentuna Parish, Sweden:
“We are headed toward
a poorer Sweden where
those who can afford
to will take out private
health insurance. It is a
deplorable development
when everyone does not
have access to the same
healthcare. We can only
hope that profit-oriented
companies take care of
their employees’ health
and that we try to hang
on to welfare as best
we can. The church will
become an all-the-more
important welfare player.”
Mika Gissler, Professor
at the Nordic School of
Public Health in Sweden and
Director of Development at
Stakes in Finland:
“The private sector will
increase its business
activities and cooperation between the public
and private sectors will
be increasingly common.
Freedom of choice for
patients will improve,
especially in Finland. But
public treatment and
care will continue to be
the most common form
of organizing primary
and specialist services in
the Nordic countries.”
ance. When we also add
private insurance and copay fees from the patient,
we end up with a very
unwieldy whole. The result
is that healthcare access
is sometimes inadequate.
The government has
pledged to analyze these
challenges in depth.”
that we never need to prioritize between different
health treatments.”
transferred to the private
sector and these will be
financed by private health
insurance. Today, almost
three million Danes already
have private health insurance, of whom 1.8 million
have policies that provide
access to surgery in private hospitals.”
Steinar Hunskår, researcher
at the Faculty of Medicine in
Bergen, Norway:
Terje Hagen, Professor of
Health Economics at the
University of Oslo, Norway:
“In Norway we pay for
healthcare through our
taxes, via the public
budget. Norway’s exceptionally favourable state
finances mean that it is
unlikely that this situation
will change in the years
ahead. The scenario in
which financing is transferred to private health
insurance or increased
personal copay is of less
immediate concern for
Norway than it is for the
other Nordic countries.”
Björn Lindgren, Professor
of Health Economics at the
University of Lund, Sweden:
“We will see a larger proportion of private elements
when it comes to both
healthcare production and
financing in the future. The
public model will remain
as the basis, but fees and
premiums will probably
be significantly more risk
related. In the same way
as the subscriber system
was introduced for dental
care, where the patient
binds himself to take good
care of his teeth, we will
see healthcare that places
emphasis on the patient’s
own responsibility for his
health.”
Päivi Sillanaukee MD, Director
General, Ministry of Social Affairs and Health, Finland:
“Who’s going to pay is not
the most essential question. Healthcare services
belong to the most fundamental of universal rights.
The rules of the game
must be fair, both when it
comes to the collection of
resources and the financing of care. Then everyone
will receive services
according to their needs,
regardless of who pays.
Today, Finnish healthcare
is financed through taxes,
statutory health insurance
and income-related insur-
Mette Rosenkilde, Professor
of Molecular Pharmacology
at Copenhagen University,
Denmark:
“The state must finance
healthcare with the taxes
our citizens have paid.
Only in this way can we
safeguard equal acess to
good healthcare for all,
regardless of income, age
and state of health. This
is the easy answer in a
perfect world where there
is no lack of doctors or
nurses, and where there
are such vast resources
“We must invest in
strong public healthcare
to safeguard the most
important healthcare
services for us all. Healthcare should be free and
financed through taxes.
Increasing demands for
treatment and care in the
future will be a challenge
for public finances. I
think purchasing additional services, either
directly or through insurance arrangements, will
become more common.”
Lisbeth Schultz, Nurse,
Åland, Finland:
“There will be more and
more private healthcare
alternatives. One hopes
that they are able to pressure municipal healthcare
into becoming better. But
I believe the tax payer will
continue to pay for the
larger part of healthcare.”
Kjeld Møller Pedersen,
Professor of Health Economics at the University of
Southern Denmark:
“Healthcare will continue
to be financed through
taxes in Denmark even in
the future. Some treatments will however be
Ursula Tenglin, General Secretary, Swedish Cancer Society:
“When it comes to cancer
treatment I have difficulty
in seeing anything but
social financing. However, there will be greater
diversity among those who
carry out healthcare. It is
important that there be
mechanisms to ensure that
everyone has the right to
equal care.”
Hannu Hanhijärvi, Programme
Director at Sitra, the Finnish
Innovation Fund:
“The proportion of elderly
is growing fast in comparison to the gainfully
employed, and so we need
new methods of approach to maintain today’s
healthcare standards.
Studies show that there is
reason for optimism if we
move away from current
activity-based healthcare
toward a result-oriented
health service. Using the
best methods and quality
assessments there would
seem to be scope for cost
increases of around 20 per
cent. In this case current
fiscal financing appears to
be sufficient. But a good
private sector is necessary
to keep up the necessary
competition.”
28
6
key questions
Nordic healthcare is faced with great future challenges. The number
of people who will need care is growing. New medicines and treatments will come along that are better but more expensive than the
old alternatives. Public sector resources will not be able to cover
everything possible. Here are six key questions about the destiny of
health and healthcare that must form part of a broad debate.
1
which diseases should society take responsibility for – and which ones not?
2
How shall we prioritize who should
get care when more costly, better
treatments come along?
3
what will the new epidemics be and
how shall we stop them?
4
how shall we attract enough
personnel for healthcare?
5
is it ok to pay our way to
better care?
6
what must we do to live
healthier?
29
If 2008
If is the leading Property and Casualty (P&C) insurance
company in the Nordic area with around 3.6 million customers in the Nordic and Baltic countries and Russia. If has
around 6,900 employees and offers the whole breadth of
P&C insurance solutions and services, for everyone from
private individuals to global industrial companies.
2008 was yet another
successful year for If. De-
spite the financial crisis the company exceeded its profitability
goals for the fifth year running. Technical profit amounted to
MSEK 5,273. The combined ratio was 91,8 per cent, decidedly
better than the long-term goal of staying below 95 per cent.
These successes are the result of systematic and long-term
efforts in which strong customer focus, selective growth strategy and operational excellence form the main elements.
If ’s business activities are pursued in the business areas
Private, Commercial, Industrial, and Baltic & Russia.
30
Business Idea, Strategy and Financial Targets
If’s vision is to be the leading property and casualty insurance company in the Nordic
and Baltic Region with the most satisfied customers, leading edge insurance expertise
and superior profitability.
Business Idea
If offers attractively priced insurance solutions that provide
customers security and stability in their business operations,
housing and daily life.
Combined ratio
2008
91,8 %
2007
90,6 %
0
Strategic Goals
20
40
60
If’s goal is to establish better profitability and customer satisfaction in the long term compared to our competitors, coupled
with high creditworthiness.
Technical results
Strategic Direction
2008
5 273
2007
5 226
Customer Value
If will exceed customer expectations through superior insurance solutions, fast and accurate claims management and
sympathetic behaviour.
Focused Insurance Expertise
If will purposefully strengthen the organization’s skills in developing, pricing and distributing insurance products, as well
as in the areas of claims management and prevention.
Nordic Business Platform
If will create competitive advantage through economies of
scale and know-how transfer through an integrated Nordic
and Baltic platform.
Investment Strategy with Balanced Risk
If has adopted a low risk strategy in investments by maintaining a balance between insurance commitments and investment
assets in terms of currency and duration. Surplus capital is
invested to enhance total returns.
0
2 000
Easy to Reach and Relate to
If is easy to make contact with, and its staff, products and
services are easy to understand.
Dedicated
If takes initiative and cares about me.
2008
Forward Thinking
If is always in the forefront with new ideas and products.
If’s Annual Report 2008
%
6 000
8 000
MSEK
6 000
8 000
MSEK
5 337
2007
5 009
0
2 000
4 000
Average number group employees 2008
Denmark
464
Estonia
356
Finland
1,805
142
Lithuania
191
Norway
1,644
Russia
422
Sweden
1,875
Others
25
0
Reliable
If keeps its promises and is there to help when needed.
100
Operating profit/loss
Latvia
Core values
4 000
80
500
Total number employees 6,924
1,000
1,500
2,000
31
Market and Competitors
The Nordic region is the seventh largest P&C insurance market in Europe, with an estimated premium value of around SEK 200 billion. Europe has a total premium value of
SEK 3,900 billion. In the total European P&C insurance market, If is the Nordic region’s
largest and one of Europe’s 15 largest listed P&C insurance companies.
The Nordic Region
If is a pure P&C insurance company with an integrated Nordic
business organization. In total, If’s market share is equivalent
to around one fifth of the Nordic market. In Sweden, Norway
and Finland If is one of the leading insurance companies with
market shares of 20, 29 and 27 per cent respectively. In the
Danish market, which is more fragmented, If is the fifth largest
company with a market share of five per cent.
The Nordic insurance market is relatively consolidated. The
five largest companies have almost two thirds of the market
and the four largest companies are established in more than
one Nordic country. The largest companies’ market shares
have increased since the middle of the 1990s.
Competition in the Nordic insurance market has been intense over the past few years. For example, several players
have displayed high levels of activity in strengthening their
distribution capability via alliance partners and the internet.
The market has also seen establishments from leading foreign
companies primarily within the industrial sector, and banks
that have expanded their product range with P&C insurance
products, in some cases as actual insurers.
The financial crisis and the subsequent economic slowdown has also affected the P&C insurance industry. Most
important were the effects felt in every company on returns on
equity, and also, indirectly, on the solvency situation as result
of falling market values of investments. The P&C market as a
whole, in the form of premiums earned, continues to be stable
even though growth in certain product areas came to somewhat of a standstill during the second half of the year owing to
lower economic activity. Concerning claims costs, inflationary
pressure is expected to diminish slightly in the period ahead
as capacity utilization falls. However, this decline will be from
a relatively high level even during 2008. Turbulent developments on the financial markets will also increase demands on
insurance companies to run healthy, efficient businesses.
Market shares in Sweden
Others 19%
Länsförsäkringar 30%
Folksam 14%
Trygg-Hansa 17%
Market shares in Norway
Others 13%
Sparebank 1 10%
Gjensidige 30%
TrygVesta 18%
If 29%
Market shares in Finland1)
Others 16%
Pohjola 27%
Fennia 11%
Tapiola 19%
If 27%
Market shares in Denmark1)
TrygVesta 21%
Others 31%
If 5%
The Baltic Region
If is the largest player in the relatively consolidated Estonian
P&C insurance market with a market share of 32 per cent.
In the more fragmented Latvian and Lithuanian markets, If
is the fourth and fifth largest player respectively. In 2008 If
had a market share of 9 per cent in Latvia and 10 per cent in
Lithuania.
If 20%
Alm. Brand 10%
TopDanmark 19%
Codan 14%
Market shares Baltic Region
Codan 22%
Others 30%
Gjensidige 7%
BTA 13%
If 14%
Ergo 14%
Applies to 2007.
1) If’s Annual Report 2008
32
If’s business areas
If’s business activities are run from a Nordic perspective. Activities
are divided into customer segments within the business areas Private,
Commercial and Industrial. Baltic & Russia, with their special market
circumstances, form a separate business area.
Private
Commercial
If is the leading insurance company for private individuals in the Nordic
region. Business Area Private has three million customers in
Norway, Sweden, Finland and Denmark. The 2008 technical result was
MSEK 2,807. Total combined ratio was 91,3 per cent.
Business Area Commercial target group is companies with up to 500
employees. The business area is Nordic market leader and has around
330,000 companies as customers. The 2008 technical result was
MSEK 1,562. Total combined ratio was 92,4 per cent.
How was 2008 in your business area?
“2008 went well! Profits were strong with a good combined ratio, lower
cost ratio and increased sales. And we had successes in the market. For
example, in Finland large investments such as our collaboration with
the S Group, the introduction of a new advantage programme and our
internet initiatives were great successes. In 2008 we passed the 100,000
mark in the number of child insurance policies sold in Norway, remarkable considering we have only provided child insurance for four years.
In Sweden demand for the new StorHem policy,
the country’s best household insurance, exceeded all
expectations. And in Denmark, where If is otherwise
a small player in the private market, we now insure
every tenth new car thanks to a business model we
imported from If in Sweden.”
How was 2008 in your business area?
“Once again we showed a really good profit. We have had a strong and
anticipated improvement in profitability for a number of years now
and this creates security for our customers, owners and staff. And that’s
important, particularly now when the world is as turbulent as it is.”
How will you be affected by the financial crisis?
“If is a reliable partner even in stormy weather. We
have been around for a hundred years and we will
still be around in another hundred. And we will help our customers and
our partners through this crisis, too. But obviously, If has not been left
unaffected by the decline in national economies. A reduction in new
car sales and fewer new buildings naturally limit our opportunities to
be on the offensive, and it increases competition between insurance
companies.”
Line Hestvik,
Business Area
Private.
What will you invest in during 2009?
“Among other things we will launch our new website. The goal is to be the
best insurance company on the internet when it comes to customer contact,
service and sales. We will also automate and simplify claims handling so
that our customers will have even faster service. And in Denmark we will
exploit our position as challenger and really go on the offensive.”
Premiums written,
gross, by country
How will you be affected by the financial crisis?
“If stands on stable ground in this economic storm. But industry has
been hurt and therefore so have our customers.
Unfortunately we will probably see a number of
business failures. And there are fewer new investments, so the insurance market will barely grow as
a whole. But on the other hand it will not shrink
either, at least not to any great extent. Companies
will still have to insure existing buildings, vehicles,
and staff etc. in the period ahead.
Ivar Martinsen,
“Our experience from previous recessions shows
Business Area
that companies are more careful with their assets, which
Commercial.
may lead to a reduction in the number of losses.”
What will you invest in during 2009?
“Many customers are facing major traumatic challenges now that the
world is so financially insecure. If has the financial strength to be a
reliable partner to those living through the full blast of the storm.
This, together with our high-quality products and services means that
we have every opportunity of strengthening our market position in
the coming year.
“We will develop a range of new customer benefits and be even more
active in the market, despite these gloomy times. At the same time,
we will make major IT investments with the aim of reinforcing our
products and making things simple for our customers. 2009 will be a
year for If to go on the offensive in the business market.”
Premiums written,
gross, by country
Denmark 6%
Denmark 10%
Sweden 19%
Finland 20%
Finland 24%
Sweden 38%
Norway 47%
Norway 36%
If’s Annual Report 2008
33
Industrial
Baltic & Russia
Business Area Industrial is the biggest industrial insurer in the Nordic
region and the fifth biggest purveyor of industrial insurance in Europe.
Its customers are Nordic companies with sales of more than MSEK 500
and more than 500 employees. Business Area Industrial has around
1,300 customers. The technical result was MSEK 657. Total combined
ratio was 93,4 per cent.
Business Area Baltic & Russia comprises Estonia, Latvia, Lithuania and
Russia. Customers number around 425,000, both private individuals
and companies. The technical result was MSEK 183. Total combined
ratio was 92,6 per cent.
How was 2008 in your business area?
“Profits were satisfactory, especially considering that If and the
entire insurance industry was hit by a great number of large claims
events last year. The first half of 2008 was the worst year for claims
costs ever seen globally.”
How was 2008 in your business area?
“It was a dramatic year. The crisis hit the Baltic states hard. For
example, we can see sales growth dropping off even though the
volume increase is still above ten per cent. Profitability is excellent, but this is also partially due to the crisis. People are short of
money and they drive less because petrol is expensive, so fewer
losses result. In 2008 we acquired Region, a Russian insurance
company, so now we are established in the private market there.
It is an investment in the future with great
potential. Even though Russia is now living
through a difficult economic period, they will
recover and we will be there. We got off to a
good start; Region grew by more than 25 per
cent in 2008.”
How will you be affected by the financial crisis?
“The financial crisis confirms If ’s position as the leading player
in the major customer segment in our part of
Europe. We have worked single-mindedly at
being a professional partner to our customers,
with transparent terms and conditions whose
interpretation is agreed. This pays in tough
times. Another effect of course is that those
insurance companies that have, in contrast to
If, been directly hurt by the crisis have had sigMorten Thorsrud,
nificant problems in competing assertively.
Business Area
“I hope that the financial crisis will lead to
Industrial.
simpler insurance models. Today, many large
customers make proposals that are so complex they cannot be easily
looked over. We must achieve much more transparency. The risks
with today’s arrangements are just too great.”
How will you be affected by the financial
Timo Vuorinen,
crisis?
Business Area Baltic “We clearly are affected. Especially in the Baltic
& Russia.
states which are in deep crisis and in my judgement it will be several years before the difficult period is over. In
Russia the turnaround will probably be quicker.”
What will you invest in during 2009?
“In my judgement prices will rise. I say this with great humility
because many large companies have been forced to the wall by the
financial crisis. But many factors speak for price rises. Reinsurance
has become more expensive since the many major claims last year.
Risky competitors who fought on price for years are now threatened with ruin; their business model collapses as the cost of capital
rises. The market will sober up and we will see a longer-term, more
businesslike price structure.”
What will you invest in during 2009?
“We will make special efforts to strengthen our offers to existing
customers in the Baltic states. We are especially important for them
in these tough times. We will also launch new solutions for customers that are exposed economically, a group that unfortunately is
growing fast in the Baltic states these days. And of course we are
constantly reviewing our cost structure.
“Our focus in Russia will chiefly be to integrate Region into
If and exploit our mutual strengths in the market, for example by
creating alliances with banks and car dealers.”
Premiums written,
gross, by country
Premiums written,
gross, by country
Denmark 12%
Finland 22%
Norway 23%
Sweden 42%
Russia 12%
Lithuania 20%
Estonia 45%
Latvia 23%
If’s Annual Report 2008
34
Five-year Summary
1)
Condensed Income Statement
MSEK
Premiums earned, net of reinsurance
Claims incurred, net of reinsurance
Operating expenses in insurance operations, net of reinsurance
Allocated investment income transferred from the non-technical account Other technical income
Other operating expenses
Technical result
2008
2007
2006
2005
2004
36,635
35,128
34,837
34,426
32,764
-27,269
–25,795
–25,252
–25,028
–24,105
-6,372
–6,045
–6,063
–6,135
–6,233
2,242
1,894
1,602
1,537
1,816
249
272
210
164
406
-212
–228
–210
–179
–178
5,273
5,226
5,124
4,785
4,470
Investment income and other items
Results before income tax
64
–217
1,702
2,708
849
5,337
5,009
6,826
7,493
5,319
Income taxes
-1,451
–1,321
–1,955
–2,015
–1,290
Net profit/loss for the year
3,886
3,688
4,871
5,478
4,029
If’s Annual Report 2008
35
Balance sheet, December 31, current value
MSEK
2008
2007
2006
2005
2004
Assets
Intangible assets
1,335
1,138
1,228
1,324
1,359
Investment assets
98,036
94,307
89,796
92,283
80,815
Reinsurer’s share of technical provisions
4,686
4,573
4,711
5,192
6,129
Deferred tax assets
1,497
721
947
1,113
1,643
Debtors
9,750
9,069
8,087
7,901
7,230
Other assets, prepayments and accrued income
4,935
4,297
6,982
5,066
4,296
120,239
114,105
111,751
112,879
101,472
Total assets
Shareholders’ equity, provisions and liabilities
17,140
18,504
19,304
24,363
20,822
Subordinated debt
Shareholders’ equity
4,489
3,893
3,721
3,859
2,362
Deferred tax liability
4,011
3,640
3,603
3,087
1,921
Technical provisions
85,749
80,506
74,554
74,027
68,554
Creditors
6,109
4,655
7,705
4,645
5,013
Provisions, accruals and deferred income
2,471
2,907
2,864
2,898
2,800
120,239
114,105
111,751
112,879
101,472 Total shareholders’ equity, provisions and liabilities
Solvency capital
24,143
25,316
25,681
30,196
23,462 Key data, property and casualty operations
Claims ratio
74,4%
73,4%
72,5%
72,7%
73,6%
Expense ratio
17,4%
17,2%
17,4%
17,8%
19,0%
Combined ratio
91,8%
90,6%
89,9%
90,5%
92,6%
Cost ratio
23,7%
23,7%
24,0%
24,3%
25,6%
Key data, asset management
Total return ratio2)
-3,1%
2,6%
4,3%
5,8%
4,3%
Other key data
Regulatory capital
Solvency margin
Solvency ratio
1)
2)
21,890
23,426
25,400
25,985
6,199
6,094
5,868
5,938
21,482
6,368
65,7%
71,3%
73,6%
87,5%
69,8%
S ince January 1, 2005 If applies International Financial Reporting Standards (IFRS), whereby all figures for 2004 have been recalculated in accordance with these principles and
taking into account the stipulations contained in IFRS 1 First Timed Adoption of IFRS.
Calculations have been made according to If’s internal principles for evaluation of asset management.
Publisher: Försäkringsbolaget If. Production: Tidningskompaniet AB, Stockholm.
Print: Trydells tryckeri, Laholm. Printed on eco-friendly paper. Cover picture: Getty Images.
If’s Annual Report 2008
contact:
Sweden: tel. +46 771 430 000, www.if.se
Norway: tel. +47 980 024 00, www.if.no
Denmark: tel. +45 77 01 21212, www.if.dk
Finland: tel. +358 105 1510, www.if.fi