Health Systems in Transition (HiT) Denmark: Health System Review 2012 Allan Krasnik Professor, MD, MPH, PhD University of Copenhagen Dept. of Public Health.

Health Systems in Transition (HiT)Denmark: Health System Review 2012

Allan KrasnikProfessor, MD, MPH, PhDUniversity 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.

InternationalAgencies

• 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

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:

TransferBridge between policymakers and

researchers: information users and producers

TrustHigh-quality evidence and a

neutral stance recognising the real context and pressures of

health systems

TailoredTo the specific needs of

policy makers

TimelinessOf 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

Developing practical lessons

and options

in health policy-making

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

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

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 Act2007 Waiting time guarantee 1 month2009 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

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!”