Introduction

Health care provision in Denmark is to a very great extent a public task, as 81 % of health care costs are financed through taxes. The responsibility for running the service is decentralized, and lies mostly with the regional authorities. In fulfilling this task they work in close cooperation with the Government and the Local Authorities.

This document, which is a summary of the publication “Health Care in Denmark” - gives an overview of the scope and organization of the Danish health care services. Readers interested in a more thorough pre­sentation of the Danish health care system are refer­red to the publication.

The document gives an overview of the scope and orga­nization of the Danish health care service and the health status of the Danish population and initiatives to improve it. Furthermore, preventive services are described together with training and research as well as regulations governing the patient’s rights. Finally, there is a short overview of the international coopera­tion in the health field.

1.      Organization of Health Care in Denmark

The Danish health care service can be divided into two sectors: Primary health care and the hospital sector.

The primary sector can be divided into two parts:

· One part which chiefly deals with treatment and care

· One part which is predominantly preventive and deals with preventive health schemes etc.

A patient’s first contact with the public health care service is the primary sector. The hospital sector deals with medical conditions that require more specialized treatment, equipment and intensive care.

1.1      The patient and the health care service

The general practitioner (GP) provides essential primary care and acts as “gatekeeper” referring patients where appropriate to hospital or specialist treatment.

In case of immediate need of hospital treatment of an accident or an acute illness a referral from a GP is not required.

1.2      Administrative levels

The Danish health care sector has three political and administrative levels: the State, the counties and the municipalities (national, regional and local levels).

The municipalities, of which there are 275 in Denmark including the municipalities of Copenhagen and Frederiksberg, are local administrative bodies and have a number of tasks of which health represents a small part. The municipalities are responsible for home nursing, dental care and preventive health schemes for children and young people. The municipalities are also responsi­ble for a majority of the social services, some of which (old people’s homes, old people’s housing) have to do with the health care service and are of great importance for the functioning of the health care service.

The Copenhagen Hospital Cooperation is responsible for the City of Copenhagen and the City of Frederiksberg whereas the two cities are responsible for activities under the Health Care Reimbursement Scheme.

The counties, of which there are 14 in Denmark, are responsible for the hospitals and for the practising sec­tor. The counties have wide-ranging powers to organize the health service for their citizens, according to regional wishes and possibilities and can adjust services and staff etc. according to needs at the different levels.

A special administrative body, The Copenhagen Hospital Cooperation, is responsible for running the hospitals in the municipalities of Copenhagen and Frederiksberg whereas the two municipalities are responsible for activi­ties under the Health Care Reimbursement Scheme.

The task of the State in health care provision is to initia­te, coordinate and advise. One of the main tasks is to establish the goals for a national health policy. The Parliament and the Ministry of Health, in its capacity of principal health authority, are responsible for legislation on health care. The legislation covers the task of the counties and the local authorities in the health area. The Ministry of Health also sets up guidelines for the run­ning of the health care service.

In order to improve the coordination and efficiency of the different administrative levels involved in health care, the counties and the local authorities every fourth year formulate a health care plan.

1.3       Structural adjustments of the health care service

As medical science and the specialization associated with it have developed, the work of the hospitals has changed more and more towards intensive examination, treat­ment and care of patients. At the same time, many pati­ents are only hospitalized for short periods or treated in ambulatories.

Similarly, in the psychiatric field there has been a deve­lopment towards less and shorter hospitalization and more out-patient activity. District psychiatric help has also been introduced.

As a result of this development, general practitioners play a more important role as coordinators of treatment offered to patients by the various professional groups practising within the Health Care Reimbursement Scheme.

2.    The Financing of Health Care Services

In Denmark the vast majority of health services are free of charge for the users.

Of the total expenditure on health care in Denmark in 1999, public expenditure constituted 82% and private expenditure almost 18 %. Private health care expenditure mainly covers user payments for pharmaceuticals, dentis­try and physiotherapy.

The total public expenditure on health care measured in fixed prices has increased by 27% from 1980 to 1999. The large increase in primary sector expenditure is main­ly due to the significant increase in expenditure on phar­maceuticals between 1980 and 1999. Nevertheless, the total public and private health care expenditure has in the same time decreased by 0,7% to 8,4% of the gross national product (GNP).

The counties and the local authorities pay about 81% of the health services. The counties and the local authorities finance the health care services partly through taxes which they levy themselves, partly through block grants from the Government allocated according to objective criteria (including demography).

Most private expenditure on health care is paid directly to the service providers. However, about 30% of the

population are covered by private health insurance which reimburses part of patients* own expenditures. Hospitals* budgets are set by the counties, and hospitals are expected to organize and conduct their affairs within the limits of these budgets.

Under the Health Care Reimbursement Scheme services are provided by self-employed professionals such as general practitioners, specialists, dentists, etc. who are licensed by the State. These services are provided in accordance with collective agreements between the coun­ties and the relevant unions. Collective agreements inclu­de prices of individual services which are covered by the Health Care Reimbursement Scheme. The provider of a service is not permitted to demand extra payment from a Group 1 patient in addition to that stipulated by the col­lective agreement.

General practitioners are paid partly through capitation and partly through fees for their services. Other provi­ders under the Health Care Reimbursement Scheme are paid fees for their services.

Pharmacies operate on the basis of public authorizations which are allocated by the Minister for Health. The total number of these authorizations is limited to a balanced geographical coverage throughout the country.

3.      State of Health in Denmark

In an international perspective, health status in Denmark can generally be characterized as good. However, over the last 10 to 20 years it has progressed less than other European countries, so that it is no longer among the top few in Europe. Life expectancy, an important indica­tor, shows that there has been modest improvement in the health status until 1995, but from 1996 onwards the increase in life expectancy has gained momentum and the improvements were relatively high. During recent decades surveys show that people consider their own health as good.

3.1       Life expectancy

A comparison of the development of life expectancy in Denmark from 1960 to 1994 with the development in a number of other countries shows that life expectancy in 1960 was relatively high in Denmark for women as well as for men where Denmark had the highest life expec­tancy. Since then Denmark has lost this leading position. A survey concluded that first and foremost it is the health status of women which is lagging behind. Middle-aged women in Denmark have a 40 to 50% higher mor­tality rate in comparison with the other EU countries. Especially the development in the incidence of cancer amongst women (breast cancer and lung cancer) gives cause for concern. However, the average life expectancy increased notably during the period of 1995-1999:

From 77,8 to 78,8 years for women and from 72,6 to 74,0 years for men. This increase is relatively higher compared to the EU-average.

3.2       Mortality

The most important cause of death among men and women in 1997 was cancer; primarily lung cancer among men and breast cancer among women. Furthermore, ischemic heart disease is an important case of death amongst both men and woman.

For Danish men, the increase in cancer is no greater than in the other western European countries, but for Danish women there is a relatively greater increase in death due to especially breast cancer than in the other European countries.

During the period 1960 to 1994, there was a fall in the mortality rate due to cardio vascular diseases in all the EU countries. But for Danes mortality was higher than in the other countries. Unlike the other EU countries no appreciable improvement has been registered amongst Danish women since 1975. A moderate improvement in the mortality rate has nevertheless taken place since 1995. The number of deaths pr. 1000 Danes declined from 12,1 in 1995 to 11,1 in 1999.

Regarding bronchitis, enlarged lungs and asthma it can be mentioned that mortality increased for Danish men and women over the whole period whereas from 1970 and onwards it decreased in all the other EU countries.

The same picture is shown regarding cirrhosis (contrac­ted liver disease) where there was an increase between 1960 and 1994 in mortality.

In spite of a substantial decrease in the suicide rate in recent years, the frequency of suicide amongst Danish men and women is still relatively high compared with some EU countries.

As regard morbidity recent research amongst Danes shows a rise within the population in the last few years. The percentage of the population suffering from one or more prolonged illnesses is also increasing, especially asthma, hay fever and other allergic head colds, muscu­lar and skeletal diseases. As regards preventive work, both groups of illnesses have had high priority in recent years.

4.      The Primary Health Care Service

4.1      The public Health Care Reimbursement Scheme

All residents in Denmark are covered by the public Health Care Reimbursement Scheme. The citizens do not pay any special contributions to the Health Care Reimbursement Scheme as this is financed through coun­ty taxes.

In Denmark there are about 3,400 general practitioners, 900 practising specialists; 3,800 dentists; 1,400 physio­therapists; 250 chiropractors; and 300 pharmacies.

Persons over the age of 16 can choose between Group 1 or Group 2 insurance. Persons insured in Group 1 must choose a general practitioner and must be referred by this GP to specialists etc. who have joined collective agreements with the Health Care Reimbursement Scheme. Persons insured in Group 2 can use any GP or specialist without referral.

For persons insured in Group 1, medical help from their general practitioner is free of charge.

Persons insured in Group 2 are only entitled to a reim­bursement equivalent to the amount fixed by the public Health Care Reimbursement Scheme for a person in Group 1.

Dental care is free for children under the age of 18. Persons with serious physical or mental disabilities who find it difficult to visit dentists, are normally offered dentistry free of charge.

For persons who are 18 years old or more the public Health Care Reimbursement Scheme pays between 40 and 65% of costs for certain preventive and other den­tistry treatment.

The Health Care Reimbursement Scheme subsidises other forms of treatment for certain patients on referral from a GP, such as: Treatments by physiotherapists, chiropodists, psychologist, etc.

Treatment by chiropractors is partly paid. A referral from a GP is not required.

Home nursing is provided free of charge by the local authorities when prescribed by the general practitioner.

All reimbursable medicinal products have an equal sta­tus from the point of view of reimbursement. The reim­bursement system is based on individual need, and the reimbursement rate for reimbursable medicinal products depends on a given patient’s prior consumption of phar­maceuticals within an individual reimbursement period of one year.

All pharmaceuticals are sold by pharmacies who are aut­horized by the State. The Ministry of Health decides the number of pharmacies and where they may be situated.

5.     The Hospital Service

The counties and Copenhagen Hospital Cooperation are responsible for the hospital service in Denmark. The counties and Copenhagen Hospital Cooperation must provide free hospital treatment for the residents of the county and emergency treatment for persons in need who are temporarily resident.

In the vast majority of cases the counties* obligation to provide its citizens with hospital treatment will be fulfil­led by the county’s own hospitals and to a certain extent in hospitals in other counties. Furthermore, private hos­pitals are used to a certain degree, especially specialist hospitals which have an agreement with one or several counties.

From 1993 the citizens who are in need of hospital treat­ment have had the possibility, within certain limits, to choose freely which hospital they wish to be treated in. The patient may choose among all public hospitals which offer basic treatment including a number of small specialist hospitals owned by associations which have agreements with the public authority.

If the citizen, after a medical evaluation, is judged to need treatment on a specialist level, he has the further choice between the hospitals which offer treatment on a highly specialized level.

5.1      The tasks of the hospital service

The hospitals are responsible for specialized examina­tions, prevention, treatment and care of somatic and mental illnesses which it would not be more expedient to treat in the primary or social sector.

The principal framework for how the counties provide hospital services is established in a plan setting out the counties’ activities in the health area.

Prior to the conception of the health care plan, the Minister for Health makes a statement in preparation for health care planning within the counties and the Ministry of Health contributes to health care planning in the form of guidance regarding the national and regional functions within the hospital services.

The counties and the Copenhagen Hospital Cooperation are obliged to make agreements regarding the use of highly specialized departments with a view to ensuring the inhabitants’ equal access to necessary specialized treatment.

Furthermore, the counties may, after authorization of the National Board of Health, refer patients to highly speci­alized treatment abroad.

6.      Health Professions

In Denmark a number of treatments and health services are reserved for those who have obtained the authoriza­tion to practice a particular profession via their training. A person who is not an authorized doctor can be punis­hed if he treats people who are ill and thereby exposes them to discernible danger.

Furthermore, within the authorization system the titles of doctor, nurse, physiotherapist etc. are reserved for those who are authorized by the National Board of Health.

Medical training is controlled centrally by the Ministry of Education together with a number of councils in cooperation with the Ministry of Health, the National Board of Health and others.

Further training in the health sector, for instance specia­lists and nurses with diplomas, is the responsibility of the Ministry of Health, and is adjusted continually.

7.      Patient's Rights

In order to ensure patient's legal rights a number of laws have been passed in Denmark regulating patient's rights and the possibility of making complaints and receiving damages. The aim of these laws is to create a set of rules to ensure patients the best possible treatment and care in all situations.

Doctors are obliged to inform the patient about the pati­ent’s illness, the possibility of treatment, the side effects, etc. with a view to gaining the patient’s consent to the treatment, the so-called “informed consent”.

“Life will”, informing doctors about one’s wishes regar­ding pain, treatment and prolongation of life treatment if one is no longer able to communicate can be set up on beforehand.

Patients have a right to see their own medical records free of charge, and doctors or other medically trained persons have the obligation to interpret case records if the patient so wishes. Medical staff must not divulge any information regarding an individual patient.

An independent public authority complaints system has also been established regarding professional treatment in the health service - The Patient's Board of Complaints.

Patients may also claim damages in connection with tre­atment in public hospitals through the Patient Insurance Scheme which was set up in 1992.

Patients may receive compensation for harm caused by pharmaceuticals.

8.     Prevention and Health Promotion

Over the last 10-15 years preventive health and health promotion have been given higher priority in Denmark due to the fact that the pathological picture today is dominated by non-communicable diseases like cancer and cardio vascular diseases.

Only a part of total prevention and health promotion lies within the health sector and thus with the central health authorities. Developments in the environment, the working environment, the housing sector, traffic safety and product safety (and more indirectly in the educatio­nal and social sector) are of great importance for the general health status of the population. Health promo­tion and health education involve a large number of ini­tiatives in all parts of society, in the fields of work and leisure. It is primarily on a local level, in counties and local authorities, in institutions and at work places that preventive work takes place. Preventive measures on a local level are to a certain extent financed centrally, for instance through support of local projects and experi­ments.

The central health authorities’ preventive health measu­res are not limited to information campaigns which are realized in different subject areas; other important tools are legislation, organizational changes and overall for­mulation of policies.

In May 1999, the Danish Government published a natio­nal health promotion programme - The Danish Government Programme on Public Health and Health Promotion 1999-2008. It is a 10-year cross sectional programme with co-operation between 10 ministries. The programme is focusing on the health determinants instead of focusing on the diseases. In comparison to the neighbouring countries the Danish average life expectan­cy had developed very modestly since 1970. The main reason for this is lifestyle problems - tobacco, alcohol, accidents, eating habits and too little physical activity.

Lifestyle can not be changed separately from the living conditions and the social context in which people are living. Thus, the overall goals are to reduce premature death among middle-aged people and to reduce inequali­ty in health.

The Programme sets up 17 targets under three so called “perspectives”: Risk factors, age groups and settings. The Programme furthermore includes three structural targets and two overall targets for life expectancy and quality of life (target 1) and equity in health (target 2).

The following Ministers participate in the intersectoral Programme:

The Minister for Health, the Minister for Social Affairs, the Minister for Labour, the Minister for Education, the Minister for Housing and Cities, the Minister for Environment and Energy, the Minister for Traffic, the Minister for Trade and Industry, the Minister for Culture and the Minister for Food and Agriculture.

In January 2000, the Minister for Health made a state­ment in the Danish Parliament concerning the Programme.

The National Board of Health administrates actual pre­ventive and health promoting initiatives. A Centre for Public Health within the body of the National Board of Health carries out most of the tasks of the national health authorities in relation to the Danish Government Programme on Public Health and Health Promotion 1999-2008. The centre facilitates a close co-operation between state level and county and municipality level authorities and is the focal point of development and implementation of new methods in decease prevention and health promotion, especially targeting social inequa­lity in health and vulnerable target groups.

8.1       Prevention of the most important non-communicable diseases

As pointed out in the Danish Government Programme on Public Health and Health Promotion 1999-2008, the point of departure for the prevention of the important social diseases such as cancer, cardio vascular diseases, allergies and musculo-skeletal disease must be lifestyle factors. A large consumption of tobacco and alcohol, very little or no exercise and a deficient diet are the most important lifestyle factors behind the development of these illnesses.

In order to increase the general health status of the population, the Parliament in 1995 passed a law on no-smoking areas with the aim to ensure that no one is for­ced against their will to be a passive smoker. The law covers public transport, institutions, hospitals, work pla­ces and rooms to which the public has access, in state, county and local authority buildings. In 2000, the Parliament passed another law according to which smo­king is prohibited at primary and secondary schools, and a law of banning tobacco commercials are proposed for 2001. These legal changes have been accompanied by a number of public campaigns to prevent smoking.

Furthermore, on the basis of EU directives, regulations have been introduced in Denmark regarding the labelling of tobacco products with a warning as well as the esta­blishment of a maximum level for the amount of tar in cigarettes of 15 mg per cigarette.

The outcome is a declining share of smokers in the Danish population; from 44% in 1990 to 33% in 2000. Especially encouraging is the limited share of young smokers, but there is still a large number of Danish women who smoke (32%) compared to other countries.

To combat alcohol abuse a main effort takes place via the counties and the local authorities. Many private organizations work on a voluntary basis to combat alco­hol abuse often in close cooperation with public authori­ties.

The average consumption of alcohol per inhabitant over a 14-year period doubled in the years from 1960 to

1973. Since then annual consumption has remained con­stant at almost 12 litres of pure alcohol per person above the age of 14.

In 1998, the Parliament passed a law which banned the sale of alcohol to people below 15 years of age. Within two years the consumption of alcohol among 12-14 years old children declined by as much as 30%.

Regular exercise guards against musculo-skeletal disease. In addition, sports and exercise have a positive effect on a number of other illnesses: cardio vascular diseases, dia­betes, obesity and mental illnesses.

Over 10% of the population (or about half a million people) are not physically active which is a crucial risk factor in the occurrence of musculo-skeletal disease.

The most important condition for central preventive ini­tiatives is an appreciably local involvement in the local authority and not least in the local sports clubs, as most of the practical preventive work is initiated and carried on in the local environment and society where people live their everyday lives.

Central government also contributes by attempting to generate and preserve awareness and knowledge of the advantages of exercise.

The objective of Danish nutrition policy is to encourage the population to opt for a diet which promotes and pre­serves health and prevents sickness. The highest priority within this objective is to reduce the amount of fat con­sumed by the population. The share of fat in the diet was reduced from 43% in 1985 to 37% in 1995. It is the goal to reach the objective of 30% fat in 2008. Another objective is to promote intake of foodstuffs rich in complex carbohydrates and fibre, both having a signi­ficant impact on preventing cardio vascular disease and certain types of cancer. Information campaigns have addressed these issues with a particular focus on chil­dren, young people and the elderly.

8.2       Other preventive measures

Part of the prevention effort is aimed at particular areas where the State has an obligation to inform and prevent, for instance:

As regard HI V/AIDS the Danish AIDS policy is based on the principles that there should be no compulsion and that anonymity can be preserved. Open, direct, and honest information is available which is intended to ena­ble the individual freely to refer to the health authorities. It is an essential part of the policy that all sexually active people are responsible for and have the possibility of avoiding HIV.

Financial support is extended to the private organiza­tions which seek to limit the spread of HIV and offer psycho-social help to HIV-positive persons.

On the background of the Government’s drugs policy report from 1994 the Parliament subsequently passed legislation which places full responsibility for treating drug addicts on the counties as from 1996.

It is estimated that in Denmark there are about 14,000 drug addicts with a long record of abuse. Of these, around 5,000 are under methadone treatment.

The National Board of Health is centrally responsible for the prevention of drug abuse, development of information and education material, and prevention cam­paigns. The most important effort, however, takes place at local level and is aimed at vulnerable young people who experiment with hashish, ecstasy, heroin and other drugs.

As regard preventive health schemes a number are avai­lable to people resident in Denmark free of charge, for instance: Guidance on methods of contraception; Pregnancy and maternity (preventive examinations and treatment, free health check-ups by doctors and midwi­ves before and immediately after pregnancy); Preventive health schemes for children and young people (children under school age are entitled to seven free preventive health examinations); Dental care for children and ado­lescents under the age of 18; Vaccinations for  young peop­le below the age of 18 can be vaccinated against whoo­ping cough, diphtheria, tetanus, polio, measles, German measles and mumps and Haemophilus influenza type b. Furthermore, all females over the age of 17 may be vac­cinated free of charge against German measles. 

9.      Research and Ethics

9.1       Health science research

Health science pursues three important and closely con­nected and interdependent epistemological questions:

1.   What is the function of the human organism, and how is it affected?

2.   What is illness, the cause of illness, and how should it be treated?

3.   What are the environmental and social conditions needed to enable people to remain healthy and avoid illness?

The responsibility for and financing of health science research is divided among a number of official authoriti­es and private firms. The research is carried out under the auspices of many different bodies (universities, hos­pitals, private firms, etc.).

The overall responsibility for health science research lies with the Danish Ministry of Research; however, being responsible for the health service as such, the Ministry of Health plays an important role in the research. Two ministerial research institutions under the Ministry of Health carry out health science research: The State Serum Institute and the National Institute of Public Health.

9.2       The Scientific Ethical Committee system

At the end of the 1970s a Scientific Ethical Committee system was set up in Denmark. In 1992, a legally bin­ding framework for the work of the committee system was established with a system made up of seven regional committees and one Central Scientific Ethical Com­mittee. The committee system is administered by the counties. Each year the regional committees assess about 3,000 research projects.

The task of the committee system is to judge and appro­ve biomedical research projects on the subject of experi­ments on humans, deceased human beings, human fertil­ized eggs etc. according to scientific ethical criteria. The main aim of the committee system is to ensure pro­tection of the subjects who take part in biomedical rese­arch projects while at the same time creating the possibi­lity of developing new, worthwhile knowledge.

9.3       The Danish Council of Ethics

The Council of Ethics was established by the Danish Council of Ethics Act of 1988. The Council comprises 17 members who are appointed by the Minister for Health.

Part of the Council’s function is to inform and encoura­ge debate in the public sector. The Council also has an advisory function for the health authorities on general ethical issues (for instance new methods of treatment, medical technology and setting priorities) and may address issues within its field on its own initiative.

According to the legislation, the Council must give recommendations to the Ministry of Health on the esta­blishment of rules and provisions in statutes on fertilized eggs, embryos, genetic experiments on sex cells, new techniques for pre-diagnosis and other issues.

The task of the Central Scientific Ethical Committee is to coordinate the work of the regional committees and to assess appeals against the regional committees* decisions.

10.  International Health Cooperation

10.1       The European Union

Within the European Union the Ministry of Health con­centrates its efforts on Single Market issues (pharmaceu­ticals, medical devices and the medical professions) as well as public health (Article 152 of the Treaty).

Within the field of pharmaceuticals as regard the Single Market the aim of harmonization is to harmonize the regulations of member states in order to ensure free trade across borders and a high level of health protec­tion.

The overall principles of the Treaty on the European Union as regard the Public Health stipulate that a com­mon effort must be made towards ensuring a high level of health protection.

Community action programmes regarding AIDS, cancer, drug prevention, health promotion, health education, etc. have been adopted.

The effective implementation of these programmes, espe­cially the choice of eligible projects, is determined in close cooperation by the European Commission and the competent authorities of the member states.

Furthermore, an action programme on health surveillan­ce has been adopted as one of the measures in the public health area.

At the same time a special network for the surveillance of infectious diseases is being established.

The vertical programmes are expected to be replaced by an overall action programme in the field of public health from the year 2002.

10.2        The Nordic Council of Ministers

Together with the other Nordic countries (Finland, Iceland, Norway, and Sweden), Denmark contributes to the work of a large number of Nordic institutions and to specific projects within the health sector.

10.3         WHO

The WHO strategy “Health for all” is part of Danish health policy adapted to the national situation and it plays a role with regard to Danish aid to the European Region’s Eastern European members.

10.4        The Council of Europe

Denmark is represented on a number of expert commit­tees including committees on blood issues (safety etc.), bioethical questions and narcotics. Cooperation within the Council of Europe has gained a new dimension since the admission of several Eastern European countries.

10.5         Other international work

In connection with Danish aid to countries in Eastern Europe, the Ministry of Health has set up sector pro­grammes with Lithuania, Estonia and Latvia.

The sector programmes are of three years* duration and are arranged in close cooperation with the central autho­rities in the recipient countries. The overall goal of the sector programmes is to assist in the establishment of a self-supporting health sector.

Furthermore, the Ministry of Health is involved in a Nordic project concerning tuberculosis in the 3 Baltic countries and a Task Force on Communicable Disease Control in the Baltic Sea Region as a whole.
 
              Health Care in Denmark - Summary

 Publisher: The Ministry of Health

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