3.1 Technology types & definitions: the “technologies discourse”
The technologies discourse is dominated by a focus on e-Health and ICT technologies,
electronic patient journals, welfare technologies, and biotechnologies. Although there
is often significant overlap between these groupings, the technologies within each
of these categories are often discussed in isolation, with distinct definitions and
objectives.
3.1.1 e-Health & ICT
E-health technologies dominate in the early years (1997-2005). During these years,
there is a heavy focus on the use of the internet (more generally as a platform for
sharing information using online portals, databases and websites) and internet-based
communication technologies (email, telemedicine, online booking). Tools to access
and use the internet (mobile phones, computers, tablets) are naturally a large part
of this discourse from early on but it is not until after 2010 that we begin to see
technologies like modern applications for smart phones and tablets enter the discourse
(m-Health), strengthening in more recent years. The years after 2010 also mark the
rise of monitoring and surveillance technologies (portable, wearable or home-based
sensors and measurement devices). The post-2013 years also see big data, cloud-computing,
robotics, and the internet of things enter the technologies discourse. Throughout
the study period, e-Health technologies are discussed in relation to health services
settings, however the technologies discourse becomes increasingly focused on consumer,
(digital) self-service, and home-based technologies, particularly in the years after
2013.
3.1.2 Electronic patient journals
Although electronic patient journals (EPJ’s) are themselves an e-Health technology,
they are often prioritized as a distinct technological innovation. EPJ’s begin permeating
the technologies discourse in the years following 2000. They quickly become a central
and persistent thread. Their dominant position is strengthened in the years following
2008, with a focus on implementing a streamlined national EPJ system (called “one inhabitant – one journal”, outlined in the white paper with the same name in 2012). EPJ development is, throughout
the study period, discussed in conjunction with, and dependent on, an internet-based
platform used to offer various individualized services.
3.1.3 Welfare technology
Welfare technologies, as a distinct group of technologies, enter the technologies
discourse in the years following 2010 (however some of the individual technologies
later classified as welfare technologies appear in the discourse before this). Not
coincidentally, this dominant position in the discourse coincides with the term “welfare
technology” being more concretely defined and its use becoming more universally recognized
(politically, technically, etc.) around the year 2010/11. Although we see a strong
overlap with e-Health, welfare technology after 2010 is often addressed as a distinct
technological innovation, divided into four categories: 1) Safety and security technologies
(such as alarm systems that monitor various conditions of the individual or the home);
2) “Compensation and wellness” technologies (technologies that compensate for reduced
physical or mental functioning such as robotics, smart home technologies, home-based
physical activity and rehabilitation technologies, and automatic scheduling technologies
such as electronic medication reminders); 3) Technologies for social contact (such
as video communication, social media, the internet, and robotics); 4) Treatment technologies
(such as patient journals, technologies for information and communication sharing
with health personnel, and sensor technologies that monitor, record and send health-related
information). The technologies discourse is inspired largely by technologies that
act as logistical aids, sensors for 24-hour surveillance and monitoring of both the
home and the patient/individual (with GPS capability for example), remote home-based
communication, and home-based treatment, analysis and care.
3.1.4 Biotechnologies
Although biotechnologies are mentioned in documents before 2010 (gene technologies,
systems biology, designer medications, and biological implants such as sensors and
micro/nanotechnologies), biotechnology does not become a dominant part of the technologies
discourse until the years following 2010. Focus is given to molecular and gene-based
technologies (gene sequencing and testing, diagnostics and therapies) and novel prescription
medications (including advanced therapy medicinal products), sometimes mentioning
stem cell, biological implant and nanotechnologies. The gene-based technologies also
inspire discussion of the value of personalized medicine as an innovation (witnessed
in part in a 2011 document detailing the national strategy for biotechnology).
3.1.5 Other technologies
Other technologies enter the technologies discourse from time to time but tend to
be much less influential when compared to those listed above. Technologies of note,
however, include innovations to more traditionally institutionalized diagnostic and
treatment technologies (such as mobile x-ray and ultrasound devices, MR, CT, PET,
image guided surgery).
3.2 Technology, health and the “responsibility discourse”
Disentangling discourse strands relevant to the assigning of responsibility for public
health (broadly defined) and responsibility for health technologies (from development
to adoption) resulted in the emergence of the following trends in what we are calling
the “responsibility discourse:” 1) consistent general State oversight and promotion;
2) a transferring of increased responsibility to the local level; and 3) a continued
focus on strengthening public/private partnerships.
3.2.1 The State
While the State assumes central responsibility for ensuring equal services and population-wide
public health throughout the study period, the responsibility discourse is increasingly
framed within the confines of empowering the individual. Here, focus is on the State’s
responsibility to ensure equal opportunity while challenging the individual to assume
greater responsibility for personal health.
“It is about finding the right balance between the individual’s responsibility for
one’s own life and the authorities’ responsibility for creating the most equal conditions
possible.” (26)
For health technologies, the State assumes responsibility for setting national standards
as well as coordinating and constructing a national infrastructure for implementation,
particularly for e-health/ICT. The State accomplishes this through its departments,
directorates and organizations for research and innovation. After 2012, focus increased
on the State’s role as a major purchaser of health technologies and an agent for pro-innovation
regulation.
“The Government has an objective of increasing the degree of innovation in the health,
care and welfare services, and for the public sector to be a driving force for, and
active user of innovation.” (27)
This is to be accomplished primarily through a national center for health-IT and welfare
technologies – for which the national Health Directorate is assigned increased responsibility.
In 2016 the e-Health Directorate is established and given responsibility for strengthening
the State’s role in e-Health management, financing, delivery and organization at the
national level. Similarly, a national center for e-Health research is created to “collect,
produce and disseminate knowledge needed by authorities to develop a knowledge-based
e-Health policy” (28). This primarily to increase the pace of development and implementation
of technology in this sector.
“National governance…management, financing, delivery, organization and implementation
of e-Health shall contribute to realizing e-Health in a faster and more cost-effective
manner.” (29)
3.2.2 Local level actors
From the mid-2000’s a general focus on transferring responsibility to the municipality
level intensifies. This transfer of responsibility to local state actors is further
strengthened with a legal precedence anchored in a documented national coordination
reform for public health (30) released in 2009 and which went into effect in 2012
(the same year as the new national public health law).
“…the projected growth in needs within a collective health service must as far as
possible find solutions in the municipalities.” (30)
“The municipalities themselves have responsibility to exploit opportunities that lie
in new technology…” (25)
Although the State continued to assume responsibility for national coordination, municipalities
are increasingly expected to assume responsibility for making local-level decisions
concerning the implementation of public health services and the availability of health
technologies. It is argued that through decentralized decision-making at the municipality
level, health promotion and prevention efforts can be more effective, and available
technologies can more effectively meet local needs. This includes municipalities strengthening
their role as the State’s purchaser of health technologies and promoter of public
sector innovation, but also increasing private sector business development at the
local level.
“The municipalities have a central role in public health work across different sectors,
in primary services and in business development.” (31)
Focus on private individuals also increases, particularly as interest in transferring
responsibility to the local level intensifies. From the beginning of the study period,
the discourse in general stresses the importance of individual choice and responsibility,
but continues to mention the importance of structural and systemic environmental characteristics.
“Individuals and communities have responsibility for public health work, but the population’s
health is not least a result of developments and political choices beyond the reach
of the individual.” (32)
A responsibility discourse focused on individuals strengthens throughout the study
period, with the emergence of an “empowerment discourse” gaining strength in the mid
2000’s, complimenting the “responsibility discourse” and focusing attention on increased
user involvement. Discussions of user involvement center on a transfer of greater
freedom and control to the individual, improving service delivery and more effectively
meeting the needs of the user. A further, detailed explanation of who these users
are is however missing from the discourse.
In the wake of the 2009 national coordination reform, this empowerment discourse again
strengthens into an expectation of user involvement in both the delivery of health services and the formation of
public health efforts, but also in the adoption of health technologies. Although user
involvement is presented as a means of empowering the individual, the empowerment
discourse also provides legitimacy for the transfer of an increased amount of responsibility
to private individuals.
“Measures for improving patients’ and users’ ability to care for their own health
contributes to a better quality of life for the individual, and to the development
of a more sustainable health and care service…It is also crucial that patients and
users are encouraged to set their own goals for health and health behavior, and are
not just passive recipients of others' advice and recommendations.” (33)
“Although the public sector accounts for much of the health and care sector procurement,
we expect users and their relatives to become an increasingly important customer group
that will demand technology, such as tablets and digital measuring devices.” (34)
As these “responsibility” and “empowerment” discourses evolve, health technologies
are themselves increasingly seen as an active resource for supporting and promoting
the effective transfer of responsibility.
“Technology will challenge people to take responsibility, both for welfare programs,
their own life and in relationships to other people in daily life.” (35)
“New technology gives patients more responsibility and control.” (36)
Home-based health technologies are seen as central to this objective. These technologies
provide an opportunity for physically relocating the point of services, and therefore
responsibility, to settings controlled by individuals and, to a lesser extent, municipalities.
The empowerment discourse contributes to emphasizing the importance of innovative
health technology and further legitimizing its development, adoption and use.
“The monitoring of one’s own health, home-based solutions and technology that can
help people remain at home for as long as possible, will be important with respect
to sustainable development, disease prevention, improved quality of life and active
ageing.” (27)
3.2.3 Public-private partnerships
Focus on strengthening public-private partnerships, by investing in innovative health
technologies, for delivering health services and general public health is central
to the responsibility discourse throughout the entire study period.
“The Norwegian health and care sector needs an improved interaction with the business
sector to achieve its goals.” (31)
Public-private partnerships are justified as a means of improving health services
throughout the sector, but are also presented as a means of commercializing these
technologies, by strengthening and supporting a health technologies industry, and
therefore promoting national value creation. The research community is presented as
a central State agent for strengthening this partnership, by using public funds and
research grants to support private sector technology development and transfer.
"Today the industry is small, but it can become a growth industry with global potential...
A business community with strong and innovative companies that embraces innovations
from the research community is a prerequisite for good health and welfare services
in the future.” (31)
Municipalities are again challenged to take increased responsibility for health technologies
by partnering with industry to develop and implement effective technologies to innovate
and streamline service delivery (i.e. an “innovative public purchaser”). Local and
regional healthcare institutions are expected to be actively involved in these efforts,
to test and implement technologies. Municipalities are also expected to involve individual
users in development and implementation processes. Focus on involving these partners,
particularly individual users, once again connects the responsibility discourse to
the empowerment discourse, with a stated goal of better integrating user needs. However,
a discussion around whether strengthening public private partnerships is an effective
political strategy for achieving this goal seems mostly assumed and expected.
“Municipalities have also had close cooperation with suppliers to improve products
so that they better meet user and service needs.” (37)
“The public sector constitutes an important domestic market for Norwegian industry.
Purchasing through innovative acquisitions…is an important tool.” (31)
Focus on building and strengthening public-private partnerships intensifies in the
post-2013 years.
3.3 Technology, health and the “legitimization discourse”
Throughout the study period, the discourse is highly partial to positively representing
health technologies. Although some of the challenges associated with these technologies
are at times discussed in detail, focuses tends to be on technical and security issues,
which are seen as barriers to the development and implementation of these technologies.
The technologies themselves are rarely questioned and broader social concerns are
largely ignored. Although questions of social inequality are sometimes referenced,
attention is mostly on regional inequalities, based on variations in municipal priority-setting
and financial resources. Issues of social inequalities are rarely addressed, and technologies
are often seen as likely of reducing social inequalities as they are a mechanism for
increasing them. This positive representation of health technologies leads to a discourse
increasingly focused on legitimizing the role of health technologies (i.e. the legitimization
discourse).
3.3.1 Pro-Innovation (technology) bias
A pro-innovation bias dominates throughout. Technologies are presented as a necessary
resource for the proper functioning and effectiveness of health and welfare services.
Promoting the adoption and diffusion of these technologies is therefore explicit in
the discourse.
“eHealth is the single-most important revolution in healthcare since the advent of
modern medicines, vaccines, or even public health measures like sanitation and clean
water.” (25)
“Medical technology, welfare technology and new innovative solutions must be developed
and implemented.” (38)
This legitimization discourse tends to emphasize the pressing nature of rapidly promoting
adoption and diffusion of these innovations and stress the inevitability of a technology-based
public health service. Furthermore, rather than discussing broader potential social
consequences of these innovations, the consequences of not adopting are often insinuated to strengthen the power of a pro-innovation and pro-technology
ideology.
“We are facing a rapid development in medical technology and welfare technology.”
(38)
“It is necessary to focus on innovation, knowledge and technology in order to meet
the challenges in the sector, as well as to facilitate safe, high-quality services,
renewal and industrial development.” (27)
This pro-innovation ideology continuously emphasizes the benefits of these technologies.
These benefits tend to be grounded in prevailing social values, such as government
efficiency, individual freedom, quality and safety, and economic growth, adding strength
to this pro-innovation ideology. Whether these benefits are based on reliable and
representative data for specific technologies or a general faith in innovative technologies
is sometimes unclear.
"Demands for action, belief in progress and expectations of increased prosperity and
welfare are among the main driving forces behind the demand for new technology." (39)
3.3.2 Legitimizing health technology
Discourse strands focused on public empowerment and market potential are used to further
legitimize the development, adoption and implementation of health technologies, defending
a general pro-innovation ideology.
As a focus on increased user involvement and responsibility evolves, so too does the
empowering capabilities of innovative health technologies – connecting the legitimization
and empowerment discourses. Health technologies are presented as effective tools for
promoting empowering social processes such as democratic decision-making, the personalization
of services, and an increase in individual freedom, control and autonomy. The legitimization
discourse however is ambiguous in discussing whether these technologies have in fact
demonstrated these effects or whether these effects are simply expected and desired.
Additionally, whether unanticipated and undesirable consequences could potentially
undermine or outweigh the positive capabilities of these technologies is left completely
unaddressed. In general, it is assumed that the empowering effect of these technologies
will consequently improve quality of life for adopters and users.
“Increased use of welfare technology will give new generations of older people and
other user groups more choice, increased security and independence and greater opportunities
for participation in social life.” (35)
“The use of technological facilities for localization, such as the use of GPS, can
help to provide greater freedom for patients/users in that they can go out without
a follower, which will be important and increase the quality of life for many.” (40)
The legitimization discourse leans on a general assumption that the public desires
and demands technological innovation and is generally familiar with and satisfied
with the general development and direction of health technologies in society. These
statements however rarely contain reference to information that may in fact support
these claims.
“At the same time, users, patients and society have expectations that ICT in the healthcare
system will develop in line with the development they know from other areas of society.”
(41)
Furthermore, a general presupposition that technological innovation will invariably
create value in society is persistently used to legitimize the development, adoption
and diffusion of technological innovations. The research community is expected to
be an active stakeholder in these efforts, explicitly contributing to the development
of products, resources and research results that can be patented and commercialized.
By the late 2000’s the market potential of technological innovations in the health
sector is strongly embedded throughout the general discourse. The ability to innovate
is explicitly linked to an ability to create value. There is a general representation
that innovation is, and always has been, the foundation of the welfare state.
“Innovation has always been a central source of value creation and for the development
of the welfare society.” (42)
“The Government will support the development of health-friendly business as a political
priority area for innovation and industry.” (43)
The State’s role is therefore to support private sector innovation with the justification
that innovative health technologies are a mechanism for driving both large national
economic returns as well as improving public health services more generally. Innovation,
particularly technological innovation, is presented as nothing other than a win-win
for all sectors of society.
“The health industry can be described as an industry with double gains. The advances
that are made contribute to welfare and health while simultaneously creating value
and jobs.” (36)
Whether this is truly the case is rarely investigated, or in any case presented, in
a comprehensive way. Moreover, the legitimization discourse suggests a dominant ideological
positioning of innovation, particularly technological innovation, as a means of promoting
a particularly economic international competitive advantage.
“Stronger industrial development in the health and care sector…will also ensure improved
conditions for the Norwegian private sector in terms of technology development and
service innovation in a broad and growing global market.” (27)
The technological innovation paradigm therefore becomes a political “necessity” that
must be exploited to a much larger degree. Attention is given to the significance
of negative economic (as well as social) consequences of slow or no technological
innovation, while simultaneously highlighting the endless benefits of increased innovation.
After 2013, particular attention is given to internationalization and the development
of an export market for these innovations.