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

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 International Agencies • WHO Europe (host) • European Commission • European Investment Bank • World Bank • WHO Europe (host) • European Commission • European Investment Bank • World Bank National and Regional Authorities • Belgium ● Norway • Finland ● Spain • Slovenia ● Sweden • Netherlands • French Union of Health Insurance Funds • Veneto Region of Italy • Belgium ● Norway • Finland ● Spain • Slovenia ● Sweden • 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) • 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 Bridge between policymakers and researchers: information users and producers Transfer Bridge between policymakers and researchers: information users and producers Trust High-quality evidence and a neutral stance recognising the real context and pressures of health systems Trust High-quality evidence and a neutral stance recognising the real context and pressures of health systems Tailored To the specific needs of policy makers Tailored To the specific needs of policy makers Timeliness Of response to policy maker’s needs and requests Timeliness Of response to policy maker’s needs and requests

What and How? Core Mission: The European Observatory supports and promotes evidence-based health policy-making Comparative analysis of existing evidence Comparative analysis of existing evidence Developing practical lessons and options in health policy-making Developing practical lessons and options in health policy-making Bridge Between policymakers and researchers Bridge Between policymakers and researchers

Comparative Analysis: Tools Vertical: Country Monitoring (HiTs) Describing national health systems Common template for direct comparison 53 European + selected OECD countries Horizontal: Health Systems and Policy Analysis Detailed focus on one topic across national health systems 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 Policy- makers 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

Who A partnership of international agencies, national and regional authorities and academic institutions, hosted by WHO/Europe 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 What Supporting and promoting evidence-based health policy-making Summary

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

Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Indsæt” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato og ”Enhedens navn” i Sidefod From 274 to 98 municipalities From 14 counties to 5 regions Structural reform 2007 Afdeling for Sundhedstjenesteforskning

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

Tekst starter uden punktopstilling For at få punkt- opstilling på teksten, brug forøg indrykning For at få venstre- stillet tekst uden punktopstilling, brug formindsk indrykning Overskrift her For at ændre ”Enhedens navn” og ”Sted og dato”: Klik i menulinjen, vælg ”Indsæt” > ”Sidehoved / Sidefod”. Indføj ”Sted og dato” i feltet for dato og ”Enhedens navn” i Sidefod 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 Free choice of hospitals 2002 Extended free choice (2 months) 2005 The new comprehensive Health Act 2007 Waiting time guarantee 1 month 2009 Waiting time guarantee and extended free choice for child and adolescent psychiatry (2 months) 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

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

Municipal expenses for health promotion and prevention Sted og datoEnhedens navn

Municipal rehabilitation plans per 1,000 inhabitants Sted og datoEnhedens navn

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!”