Denmark Health Profile 2012

Denmark is a small country and relatively prosperous country in northern Europe. Like the other Scandinavian countries, Denmark is characterized by a strong welfare state tradition, with universal coverage of health services mainly financed via taxation. Access to the health system, including diagnostic and treatment services, is free for all citizens except for certain services such as dental care, physiotherapy and medicine requiring patient co-payment. Equity and solidarity are important underlying values in the system, and surveys show a persistently high level of patient satisfaction. The system has a relatively good track record in terms of controlling expenditure
and introducing organizational and management changes, such as transition to ambulatory care, and introduction of activity-based payment. The Danish health system is governed by a combination of national state institutions, regions and municipalities. All three levels have democratically elected assemblies and there is a tradition of decentralization of management and  planning to the regions and municipalities. National-level institutions include
the Parliament, the Government and various state bureaucratic institutions. The state level is responsible for the overall legal framework for health care, and for coordinating and supervising the regional and municipal delivery of services. Five regions are responsible for delivering both primary and secondary health services. Most hospitals are owned and operated by the regions, and hospital doctors are salaried employees of the regions. Practising doctors are private, rather than state practitioners, but receive almost all of their income from services paid by the regions.

Several current and future challenges can be identified. Danes have shorter life expectancy than many other Europeans. This has mostly been attributed to lifestyle issues, but health system performance has also been questioned, particularly in areas such as cancer care and cardiovascular disease. Coordination of care has also emerged as a general issue with potential for improvement, and waiting times have been a persistent political concern. More generally, the Danish system, like many other European health systems, faces challenges of guaranteeing access and quality while at the same time keeping costs under control. An ageing population and rising expectations regarding service are contributing factors in challenging the sustainability of the public
health system. Activity-based payments, performance management and benchmarking, elements of managed competition and administrative reforms are some of the general policy responses that have been introduced to meet the challenges. Free choice of hospital was introduced in 1993, partially in response to waiting time issues. More recent initiatives have been an administrative reform in 2007, the introduction of a 1-month general waiting time guarantee and guaranteed access to hospital specialists within 48 hours of cancer diagnosis.
The administrative reform of 2007 created larger regions and municipalities and changed the distribution of tasks and responsibilities. The underlying rationale was to facilitate centralization of service delivery at the hospital level
and to give municipalities a stronger role in prevention and rehabilitation. Financing of regional health services was changed from predominantly regional taxation combined with some state grants, to a combination of state grants and municipal co-payments. The rationale behind this was to create more direct state control and to provide incentives for municipalities to step up their efforts in prevention, health promotion and rehabilitation.
Financing Until 2007, the Danish health system was financed through progressive general income taxes at the national level and through proportional income and property taxes at the regional and local levels. The national-level tax revenue was redistributed to the counties and municipalities via block grants, based on objective criteria and some activity-based financing for hospitals. The system was designed to support solidarity in financing and equity in coverage. Since 2007, financing has been obtained through earmarked proportional taxation at the national level. Most of this revenue (80%) is redistributed to the regions via block grants, based on objective criteria (social and demographic indicators), and 20% is redistributed to the new municipalities which will use these funds to co-finance regional hospital services for their respective populations. The system remains based on the general principles of solidarity, combined with some redistribution across the population. The earmarking of health care taxes is a new feature in Denmark and is intended to create greater transparency within this sector. However, it reduces the potential for redistribution of funds across sector areas. There is an increasing level of user payments for Danish health care, mostly involving payments for pharmaceuticals, dental care and physiotherapy, and it is related to a fast-growing private health insurance market, which has been partly established through labour market agreements for groups of employees. There is even some support for introducing more co-payments, such as patient fees for GP consultations, in order to reduce unnecessary utilization of services. These trends could lead to major changes in the health care financing patterns in Denmark over time, threatening the system’s general principles of solidarity, equity and tax-based financing of health care services.

Principles of equity
The current system is based on the principle of universal, free and equal access to health services. Although utilization patterns vary somewhat across regions, these objectives seem to be met to a fairly large extent. In practice, some groups, such as the homeless and mentally disabled, immigrants, and drug and alcohol abusers, appear to have a more unstable utilization pattern than other groups. The high individual costs for adult dental care seem to result in social inequity in the utilization of this kind of service, leading to social differences in dental
health status. The use of private practising specialists shows a geographic and social bias as services are mostly offered in affluent urban areas. Patient choice appears to favour patients with a higher level of education and stable employment. There is some speculation that the increasing use of activitybased financing will divert investments and activity away from fields such as internal medicine and geriatrics to areas where increases in activity are easier to demonstrate. However, the evidence base for this is limited. Current resource allocations for health care, by and large, seem to meet the needs of the population. The reduction in waiting times and the general waiting time guarantee, related to the “extended free choice”, together ensure access to health care with in relatively short periods. The waiting time guarantee ensures access to treatment within the public system or at private facilities in Denmark or abroad, in the event of expected waiting times exceeding 1–2 months. Patient satisfaction surveys continue to demonstrate remarkably high satisfaction figuresfor both GPs and hospital services. Equal access and utilization according to need are likely to remain a strong focus in the Danish health sector in the future. However, ever increasing demands for new technology and expected changes in population age distribution and disease patterns might foster political initiatives to reduce access to publicly funded services through new financial and structural reforms.

Quality and efficiency of Danish health care International comparisons of survival rates among some patient groups (i.e. patients with lung cancer and ovarian tumours) seem to indicate that the quality of some diagnostic and curative services is not optimal. This may be due to a lack of staff, equipment or skills or to structural problems in the Danish health system related to scale, specialization and coordination. There is an ongoing process leading to fewer and larger hospitals and to centralization of highly specialized care. A recent reform has given more power to the National Board of Health regarding the planning of such highly specialized services. There are also some issues of personnel coverage in peripheral areas, but the regional authorities are seeking to remedy such issues through the use of non-native doctors and nurses. Recent years have seen special emphasis on psychiatric care and common life-threatening diseases such as cancer and cardiovascular problems. Psychiatric conditions are, however, fairly low priority, as is the treatment of musculoskeletal ailments, despite general statements to the contrary in national health policy. There is no evidence of significant shifts in the balance between primary, secondary and tertiary care. However, a stated objective of the current structural reform is to create incentives for the municipalities to place more emphasis on prevention, health promotion and rehabilitation outside of hospitals.
The health system is generally considered to provide good “value for money”. Consecutive government reports have indicated that the relationship between overall expenditure levels and service levels, including most available
indicators on waiting times and quality, is acceptable in comparison to other European countries. This is a result of the many different initiatives aimed at controlling expenditure, raising productivity and improving quality. The use of global budgeting and hard budget constraints is a pervasive feature of the system. In recent years, this has been combined with internal contracts and some activitybased payments to encourage higher activity levels and stronger productivity. A recent government report points to gradually improving productivity within the sector and a 2.4% increase from 2003 to 2004. Hospitals are compared to average productivity at national and regional levels, showing only limited variation across the regions. There is limited information on the efficiency of the primary sector, but it is assumed that combined per capita and fee-for-service
payment provides incentives towards both the optimization of activity levels
and composition. Doctors’ fees are negotiated with the public authorities on a regular basis and activity profiles are monitored regularly. GP gatekeeping has been a significant feature of the Danish system for many years, along with the general principle of treating patients at the lowest effective care level as opposed to providing free access to more specialized units. General policies are in place to promote the generic substitution of pharmaceuticals, and all regional authorities have implemented policies to monitor and influence the use of medicines in their health facilities. Efforts to reduce the general cost of pharmaceuticals have not been very successful, despite some positive results regarding drug pricing. Potential savings have been more than counterbalanced by the wider use of new and expensive pharmaceuticals and changes in indications for treatment of hypertension, high cholesterol, and so on. Some experiments with substituting doctors with nurses in selected
areas have been carried out but the most important efficiency drive has been a massive and largely successful effort to convert inpatient treatment to outpatient or ambulatory treatment. Accountability of payers and providers is mainly achieved through hierarchical control within the political-bureaucratic structures at national,
regional and municipal levels. The budgeting and economic management processes include accountability assessments at all levels. Annual negotiations between the State and the regional and municipal authorities involve evaluation of needs, outputs and new activity areas. Regional and municipal public management is based on contracting, incentives and monitoring measures to control the performance of hospitals and other public organizations. The activities of practising primary and secondary care doctors are monitored by the regional authorities, which also fund the activities in accordance with nationally negotiated fee schedules. Quality is monitored via internal management procedures, national measures of patient satisfaction and various national and regional initiatives to develop standards, clinical guidelines, clinical databases, and so on. Since 2007 all hospitals have been included in the Danish model for quality assurance and external accreditation takes place at regular intervals. A national system for reporting unintended events has been established. Health technology assessments (HTAs) are performed at national, regional and local levels. The HTA practice has become institutionalized via a national institute and several regional resource centres. HTA is recommended for major decisions, but has not yet been implemented across the board. Patient rights have been extended and formalized during recent years, and there are mechanisms for sanctioning professional misconduct and abuse.

Public health
As in other western European countries, mortality caused by heart diseases has declined remarkably during recent decades, partly due to better survival levels among patients with heart conditions. Survival of some types of cancer has increased due to better interventions. Denmark is, however, still lagging behind other Nordic countries as far as general mortality is concerned, as well as in relation to some cause-specific mortality rates. This is probably due to a combination of health care factors, environmental factors and lifestyle changes.
It has been argued  that the Danish population’s functional ability and quality of life have improved as a consequence of more advanced treatments both through surgery and pharmaceuticals, but there is little evidence to support this assumption. A recent study analysing mortality amenable to health care in 19 industrialized countries indicates that the Danish system is performing at an average level. Its performance is not as good as that of other Scandinavian countries (namely Norway and Sweden) but better than some other countries, such as the United Kingdom, Portugal, Ireland, the United States, Austria, New Zealand and Greece. In spite of rather weak Danish public health intervention regarding tobacco consumption, there has been a gradual, but recently stagnating, decline in tobacco consumption. Alcohol consumption is also high, despite efforts to improve this aspect of public health through general campaigns. These efforts, however, have been counteracted by a reduction in alcohol taxes. The present increase in obesity and related diseases, such as diabetes, has become a public health issue, but there have not been any major policy interventions to this effect.
Health inequalities are increasing between educational and occupational groups in Denmark. However, there is no evidence indicating that these inequalities are due to unequal access to, or utilization of, health care services, except in specific services such as dental care, where high co-payments apply. Rather, they are caused by unfavourable social and environmental conditions and health behaviours among some population groups, which cannot be addressed by the current, ongoing public health interventions.