Summary of Danish health system oriented to public health services.
Denmark has universal healthcare, which means that access to a wide range of health services is largely free of charge for all residents.
Governance in Denmark is divided into three different administrative levels: The state, the regions, and the municipalities. This general governance division is implemented within the health sector as well. From an international perspective, Denmark can be characterized as having a relatively good health status; however, regarding some health measures such as life expectancy, it lags behind the other Scandinavian countries. The proportion of people overweight or obese has increased over the last few years and alcohol consumption and tobacco use continue to be a problem, although the proportion of smokers has decreased in recent years. Socioeconomic inequalities in health have increased and are a further challenge.
The health system can be characterized as fairly decentralized, with responsibility for primary and secondary care located at local levels. However, a process of (re)centralization has been taking place. In 2007, a major structural reform was implemented. This lowered the number of regions from 14 to 5 and the municipalities from 275 to 98. Hence, the health system is organized according to three administrative levels: State, region, and municipalities (local level). Planning and regulation take place at both state and local levels. The state holds the overall regulatory and supervisory functions, as well as fiscal functions, but is also increasingly taking responsibility for more specific planning activities, such as quality monitoring and planning of the distribution of medical specialties at the hospital level. The five regions are, among other things, responsible for hospitals, as well as for self-employed healthcare professionals. The municipalities are responsible for disease prevention and health promotion, as well as rehabilitation and elderly care. Aside from the municipalities, the social sector, the occupational sector, and the educational sector have also obtained a greater role in rehabilitative care. Consequently, one area that is attracting attention within rehabilitation and intermediate care is the problem of securing a more coordinated patient pathway.
More than 80% of healthcare expenditure is financed by the state through a combination of block grants and activity-based financing. The importance of out-of-pocket payments differs markedly by service, playing a major role in financing drugs, dental services, and glasses, while playing only a minor role for other services. Voluntary health insurance (VHI) is available for the population. Since 2002, supplementary VHI subsidized by the state has played a small but rapidly growing role in financing elective surgery and physiotherapy–and has been the subject of intense political debate between politicians, who argue that VHI contributes to a more effective healthcare sector or that it introduces inequality in access to care. The municipalities are financed through income taxes (rates set locally, collected centrally) and block grants from the state, while the regions are financed by the state (income tax, value-added tax (VAT), taxes on specific goods, etc.) and the municipalities. The financing structure reflects attempts to control costs through global budgeting and upper limits to the private providers’ turnover. It also reflects efforts to strengthen health promotion, clinical production, and responsiveness to patients by use of the free choice of hospital. This is combined with activity-based hospital financing and by the introduction of reimbursement from the municipalities to the regions, thereby providing the municipalities with a financial incentive to keep their citizens healthy.
Public health services are partly integrated with curative services and partly organized as separate activities run by special institutions. Since 1999, the government has launched a number of national public health programs and strategies focusing on risk factors such as diet, smoking, alcohol intake, and physical activity. In the last few years, the importance of the primary sector has also been recognized in ensuring that people receive comprehensive health services—ranging from promotion and prevention to treatment. The primary sector consists of private (self-employed) practitioners (general practitioners (GPs), specialists, physiotherapists, dentists, chiropractors, and pharmacists) and municipal health services, such as nursing homes, home nurses, health visitors, and municipal dentists. The GPs act as gatekeepers, referring patients to hospital and specialist treatment. Most secondary and tertiary care takes place in general hospitals owned and operated by the regions. Doctors and other health professionals are employed in hospitals on a salaried basis. Hospitals have both inpatient and outpatient clinics, as well as 24 h emergency wards. Outpatient clinics are often used for pre- or post-hospitalization diagnosis and treatments. Most public hospitals are general hospitals with different specialization levels. Community pharmacies are privately organized but subject to comprehensive state regulation on price and location to ensure that everybody has reasonable access to a pharmacy, even in rural areas. A collective financial equalization system requires pharmacies with above-average turnovers to contribute to pharmacies with below-average.
In recent years, the development of a more coordinated or integrated health system has attracted considerable attention. As mentioned earlier, the structural reform in 2007 changed the administrative landscape of Denmark by creating larger municipalities and regions and redistributing tasks and responsibilities. Modernization and specialization of the hospital sector have included a restructuring of acute care, with centralization of units in so-called “joint acute wards.” Other initiatives include the introduction of national clinical pathways for cancer and heart disease and national planning of the distribution of specialties across hospitals. A stated objective of the structural reform was to create incentives for the municipalities to place more emphasis on prevention, health promotion, and rehabilitation outside of hospitals. Incentives have not yet shown significant effects in the municipalities, and the financial crisis has contributed to very tight municipal budgets and difficulties in finding means for new preventive initiatives. Transparency of the health system has increasingly been a political priority during recent decades. Initiatives for improving this transparency have included quality indicators on clinical performance becoming available on the Internet. Information for the public on actual waiting times for admission to public hospitals has been ensured in order to facilitate the use of the right to free choice by patients. There is generally a high level of awareness of general rights such as waiting time guarantees and free choice in the general population. Accountability of payers and providers, however, is largely ensured by hierarchical control within political–bureaucratic structures at national, regional, and municipal levels. In recent years, the hospital sector has shown a gradually higher productivity, with a 5.6% increase from 2009 to 2010, whereas the stated objective of the structural reform in 2007 has not yet shown significant effects on the general productivity and efficiency of municipalities within the health field.
This summary is based on the “Health System in Transition; Denmark” report available at https://www.euro.who.int/__data/assets/pdf_file/0004/160519/e96442.pdf?ua=1
developed in collaboration with the University of Copenhagen, Copenhagen, Denmark, the European observatory on health systems and policies, Brussels, The National Board of Health of Denmark, and the Danish Presidency of European Union.