Transcript The Danish Health System

The Danish Health System
Karsten Vrangbæk
University of Copenhagen
Political Science
The Danish Health System
•A short overview of the Danish
health system
•Decentralization and coordination
•Performance and cross regional
variation
Who is covered?
Coverage is universal. All those
registered as resident in
Denmark are entitled to health
care that is largely free at the
point of use.
What is covered?
Services: The publicly-financed health system covers all
primary and specialist (hospital) services based on
medical assessment of need.
Cost sharing: There are very few cost-sharing
arrangements for publicly-covered services. Cost
sharing applies to dental care for those aged 18 and
over, to outpatient drugs and to personal aids such
as glasses (but not hearing aids, which are free).
Out of pocket payments (including cost sharing) account
for about 14% of total health expenditure (World
Health Organization 2007).
How are revenues generated?
Publicly-financed health care: Since 2007 the central
government through a centrally-collected tax set at
8% of taxable income and earmarked for health
The central government allocates this revenue to 5
regions (80%) and 98 municipalities (20%) using a
risk-adjusted capitation formula and some activitybased payment. Public expenditure accounts for
around 82% of total health expenditure.
Voluntary private health insurance growing fast!
How is the delivery system
organised?
Five regions are responsible for providing
hospital care and own and run hospitals
and prenatal care centres.
The regions also finance general practitioners,
specialists, physiotherapists, dentists and
pharmaceuticals.
The 98 municipalities are responsible for
public health, school dental care,
rehabilitation outside hospitals
How is the delivery system
organised?
Physicians: Self-employed general practitioners act
as gatekeepers to secondary care and are paid
via a combination of capitation (30%) and fee for
service. Hospital physicians are employed by the
regions and paid a salary. Non-hospital based
specialists are paid on a fee for service basis.
Hospitals: Almost all hospitals are publicly owned
(99% of hospital beds are public). They are paid
via fixed budgets (determined through soft
contracts with the regions) and some fee for
service.
How was decentralisation introduced
in the Danish health care system?
Decentralized democratic management of welfare
services has been a feature of the Danish system
for many years.
A major reform in 1970 reduced the number of
counties to 14 and established the counties as the
main public authority within health care. The
counties took ownership of almost all hospitals
and became responsible for financing and
providing health care.
How was decentralisation introduced
in the Danish health care system?
In 2007, a major structural reform introduced 5
regions to replace the 13 counties. The
271 municipalites were amalgamated into
98.
The regions retained the responsibility for
providing hospital and outpatient care for
citizens, but importantly lost the right to
issue taxes, as financing was centralized to
the state level.
Decentralization and its limits
The regions are responsible for
delivering health services, within
national framework legislation,
national guidelines and national
agreements e.g. between medical
professionals and the Association of
Regions.
Decentralization and its limits
National legislation: Establishes the duties for the
Regions in providing health care.

Free choice of public and some private hospitals
upon referral

Access to a range of private facilities in Denmark
and abroad when waiting times exceed 1 month.

Fees for choice patients travelling to other regions
and private providers are paid according to
nationally set DRG prices.
-> Both types of choice reduce the scope for regional
level deviation e.g. on waiting times and quality
Decentralization and its limits
Planning, guidelines and recommendations:

Developed by the National Board of Health but in
collaboration with medical societies and regions

The National Board of health is also in charge of
general supervision and supervision of medical
personnel

The NBoH houses units for Health Technology
Assessment and development of reference
programs

A comprehensive “Danish Program for Quality
Assessment” is currently being implemented.
Decentralization and its limits
Planning, guidelines and recommendations:

A comprehensive “Danish Program for Quality
Assessment” is currently being implemented.

The program combines organizational selfassessment with mandatory accreditation based
on nationally developed standards.

Hospital level results will be published on the
internet. And will replace the current publication of
waiting time and quality indicators
(sundhedskvalitet.dk)
Decentralization and its limits
National agreements:

Annual agreements between the
regions/municipalities and the government specify
expenditure levels and average tax levels (for
municipalites). - The agreements also serve as an
arena for negotiating new policy initiatives

National agreements between the Association of
Regions and medical professions determine
salaries and working conditions (for hospital
doctors) and fees for the publicly funded contacts to
GPs and practicing specialists.
Decentralization and its limits
Some regional and hospital level variation
can be observed in spite of these
coordination mechanisms, and the
focus on geographical equity in the
structural reform
Regional differences in
hospital productivity
Source: Ministry of Health and Prevention 2007
Regional differences in
contacts to general practice
Source: Region Zealand
Hospital Variation in Use of Secondary Preventive
Medicine After Discharge for First Acute Myocardial
Infarction During 1995-2004.
Rasmussen S, Abildstrom SZ, Rasmussen JN, Gislason GH, Schramm TK, Folke F, Køber L,
Torp-Pedersen C, Madsen M, Medical Care 2008 Jan;46(1):70-77
Strengths , weaknesses, opportunities
and threats





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Expenditure control is good
Significant activity and productivity increases
in recent years
Short hospital stays and high degree of
conversion to ambulatory care
Waiting times reduced (one month guarantee
in place)
Administrative costs considered to be low
Patient satisfaction ratings are among the
highest in Europe.
Choice and flexibility
Implementation of “cancer packages”
OECD Economic Survey for Danmark 2007, Ministry of Health Benchmarking reports
Health Care Expenditure per Capita
2005, USD PPP
Satisfaction: population reporting the
quality of the following are fairly or
very good
Ge ne ra lis ts
Hos pita ls
S pe c ia lis ts
93%
Fr an ce
Ge r m an y
88%
Ge r m an y
77%
Ge r m an y
De n m ar k
91%
De n m ar k
75%
De n m ar k
Sw e d e n
UK
68%
87%
Fr an ce
Fr an ce
Sw e d e n
71%
Sw e d e n
UK
71%
UK
87%
Source: Euro-barometer, 2007.
83%
79%
85%
90%
77%
Affordability of health-care: percentage
of persons reporting the following are
not very or not at all affordable
Ge ne ra lis ts
Fr an ce
8%
Ge r m an y
De n m ar k
S pe c ia lis ts
10%
1%
Fr an ce
Hos pita ls
48%
Ge r m an y
28%
Fr an ce
17%
Ge r m an y
24%
De n m ar k
7%
De n m ar k
7%
Sw e d e n
7%
UK
8%
Sw e d e n
4%
Sw e d e n
UK
4%
UK
Source: Euro-barometer, 2007.
13%
1%
Strengths , weaknesses, opportunities
and threats

Life expectancy relatively poor (but
improving)
 Scope for quality improvement in some
treatment areas
-> Life style issues rather than health
system performance per se?
Strengths , weaknesses, opportunities
and threats
Table 8.1 Life expectancy, females at birth
1960
1970
1980
1990
2000
2005
Denmark
74.4
75.9
77.3
77.7
79.3
80.2
Finland
72.5
75.0
77.6
78.9
81.0
82.3
Iceland
75.0
77.3
79.7
80.5
81.8
83.1
Norway
75.8
77.3
79.2
79.8
81.4
82.5
Sweden
74.9
77.1
78.8
80.4
82.0
82.8
Austria
71.9
73.4
76.1
78.8
81.1
82.2
Belgium
73.5
74.2
76.8
79.4
81.4
81.6
Nordic countries
Other European Countries
Strengths , weaknesses, opportunities
and threats
Table 8.2 Life expectancy, males at birth
1960
1970
1980
1990
2000
2005
Denmark
70.4
70.7
71.2
72.0
74.5
75.6
Finland
65.5
66.5
69.2
70.9
74.2
75.5
Iceland
70.7
71.2
73.7
75.4
78.4
79.2
Norway
71.3
71.0
72.3
73.4
76.0
77.7
Sweden
71.2
72.2
72.8
74.8
77.4
78.4
Austria
65.4
66.5
69.0
72.2
75.1
76.7
Belgium
67.7
67.8
70.0
72.7
75.1
75.8
Nordic countries
Other European Countries
Strengths , weaknesses, opportunities
and threats
Ne o n a ta l m o r ta lity
Life e x pe nta nc y a t 6 5
D e a th s /1 0 0 0 liv e b irth s
y e a rs
Fr a n c e
2 ,5
Fr a n c e
Ge r m an y
2 ,6
Ge r m an y
1 8 ,9
Sw e d e n
1 9 ,2
Sw e d e n
De n m a r k
UK
1 ,8
3 ,2
3 ,5
De n m a r k
UK
2 0 ,4
1 7 ,7
1 8 ,4
Strengths , weaknesses, opportunities
and threats
Br e a s t c a nc e r s ur viva l
P r o s ta te c a n c e r s u r v.
5 -y e a r s u rv iv a l ra te (% )
5 -y e a r s u rv iv a l ra te (% )
Fr a n c e
7 9 ,8
Fr a n c e
Ge r m an y
7 5 ,5
Ge r m an y
Sw e d e n
82
Sw e d e n
De n m a r k
En g la n d
7 3 ,6
6 9 ,8
De n m a r k
En g la n d
7 3 ,7
7 6 ,4
66
3 8 ,4
5 0 ,9
Opportunities and threats
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Life style (prevention and health promotion)
Coordinated care (patient pathways),
Ageing population (implications for both funding and
demands for health care),
More demand for chronic care
Changing family structure
Rapid growth in voluntary health insurance and private
care delivery (threat to solidarity in the long run?)
Reaping the benefits of the new regional structure:
Infrastructure investments and cost control
Internationalization, EU and cross border health care
Implementation of “Quality Assessment Program”