Health Systems in Transition (HiT)
Denmark: Health System Review 2012
Allan Krasnik
Professor, MD, MPH, PhD
University of Copenhagen
Dept. of Public Health
NLI
European Observatory of Health Systems and Policies
Analysing
Health
Systems and Policies
www.healthobservatory.eu
The Observatory
WHO?
An Effective Partnership
The European Observatory is a three-way partnership building bridges
both across borders and between policy makers and researchers.
International
Agencies
National and Regional
Authorities
• WHO Europe (host)
• Belgium
●
• European
Commission
• Finland
●
Spain
• Slovenia
●
Sweden
• European
Investment Bank
• World Bank
Norway
• Netherlands
• French Union of
Health Insurance Funds
• Veneto Region of Italy
Academia
• London School
of Economics and
Political Science (LSE)
• London School of
Hygiene & Tropical
Medicine (LSHTM)
A Knowledge Broker
The European Observatory is a high-quality knowledge broker
based on following principles:
Transfer
Trust
Bridge between policymakers and
researchers: information
users and producers
High-quality evidence and a
neutral stance recognising the
real context and pressures of
health systems
Tailored
Timeliness
To the specific needs of
policy makers
Of response to policy maker’s
needs and requests
What and How?
Comparative
analysis
Bridge
of existing evidence
Between
policymakers
and researchers
Developing
practical lessons
and options
in health policy-making
Core Mission: The European Observatory supports and promotes
evidence-based health policy-making
Comparative Analysis: Tools
Vertical:
Country
Monitoring
(HiTs)
Horizontal:
Health
Systems and
Policy Analysis
Describing
national health
systems
Detailed focus on
one topic across
national health
systems
Common
template for
direct comparison
53 European +
selected OECD
countries
Secondary research
Practical Lessons and Options: Tools
Assessing and
Comparing
Performance
Provides better
understanding of
uses and abuses of
comparative
performance data
Creates a toolbox for
better measurement
and analysis
Engaging Policymakers
Two channels: policy
briefs and face-to-face
policy dialogues
Tailor-made, focussed
on one specific issue
Bring together evidence,
assess options and
formulate
implementation
roadmaps
Summary
Who
A partnership of international agencies, national and
regional authorities and academic institutions, hosted
by WHO/Europe
What
Supporting and promoting evidence-based health
policy-making
How
Carrying out comprehensive and rigorous analysis
of the dynamics of health systems in Europe
• Country Monitoring
• Health systems and policy analysis
• Assessing and comparing performance
• Disseminating evidence / engaging with policy-makers
University of
Copenhagen
Dept. of Public Health
Unit for Health
Services Research
The Nordic model?
• General entitlement
• Mainly tax financed
• Mainly public hospital
providers
• Mainly decentralized
governance
• GPs in a key role
But also many differences!
Life expectancy in selected countries
Health expenditure as a share of GDP
Financing Danish health care
• More than 80% of the total health care expenditure is financed by taxes
• The role of out-of-pocket payments differs markedly by service
• VHI financed by employers has increased dramatically since 2001
• VHI still only finances about 1.7% of total hospital services in Denmark[
• The five regions are financed through block grants as well as activity-based
financing from the municipalities and the state
• The 98 municipalities are financed through income taxes and block grants
from the state + intermunicipal transfers
Stepwise reforms ???????
of Danish health care
Afdeling for Sundhedstjenesteforskning
Structural reform 2007
From 274 to 98 municipalities
From 14 counties to 5 regions
Health service delivery
– a fragmented organization
• Municipalities are responsible for disease prevention, health
promotion, care and rehabilitation performed outside hospitals
• Primary care consists of private (self-employed) practitioners (GPs,
specialists, physiotherapists, dentists, chiropractors and
pharmacists) and municipal health services
• GPs act as gatekeepers, referring patients to hospital and specialist
treatment.
• Most secondary and highly specialized care takes place in general
hospitals owned and operated by the regions
The patient perspective:
Access to health services
Pathways for gynecological patients
Municipal
rehabilitation
Can GPs cope with the future challenges?
Major policy themes
• Free choice
• Waiting time
• Quality of care
– Survival
– Continuity
– Prevention
Free choice and waiting time
1993
2002
2005
2007
2009
Free choice of hospitals
Extended free choice (2 months)
The new comprehensive Health Act
Waiting time guarantee 1 month
Waiting time guarantee and extended
free choice for child and adolescent
psychiatry (2 months)
2010 + Adult psychiatry
Health care services: The pride of
Danish welfare society?
Quality issues: 30 days mortality after
acute myocardial infarction (%)
Quality issues: Cancer survival
Survival from lung cancer (%)
Denmark
Denmark
Solving problems of continuity of care?
• Health agreements
– Regions and municipalities
– National Board of Health
– GPs?
• GP coordinator fee
• Other incentives required
• Clinical pathways
– Cancer
– Heart disease
• IT innovations
– The EMR
– The Medcom project: Danish online health portal
– The Shared Medication Record
– The sentinel data capture system
Quality issues:
Prevention and rehabilitation
The new municipal responsibilities – a difficult task!
Local governance – local autonomy – soft national measures
Issues of
• Organization
• Evidence
• Competences
• Resources
• Political priority
på forskellig vis. Samtidig vil
sundhedsfremme og forebyggelse ofte være en integreretSted og dato
Enhedens navn
del af de kommunale kerneopgaver på fx børne- og ældreområdet. Således kan de
opgjorte udgifter ikke tages som udtryk for, hvor mange ressourcer kommunerne anvender på sundhedsfremme og forebyggelse.
Municipal expenses for health
promotion and prevention
Figur 2.1. Nettodriftsudgifter til sundhedsfremme og forebyggelse
Kilde: Danmarks Statistik
Anm: Tal fra 2008. Både konteringen, organiseringen og afgrænsningen af forebyggelse og sundhedsfremme kan
variere fra kommune til kommune. Det giver en vis usikkerhed i tallene.
Enhedens navn
Sted og dato
Municipal rehabilitation plans per
1,000 inhabitants
Conclusions
• The health status of the Danish population is
improving, but still relatively unfavorable
• The public health service provision and tax based
financing is still strongly supported
• The decentralized organization is under pressure
• Quality and continuity of care are major issues
• IT support and communication is a main focus
area – it is necessary, but not sufficient
• More major reforms can be expected in order to
meet future challenges
Evolution or revolution?
“It is raining
too much in
Denmark for
revolutions!”