$Unique_ID{bob00174} $Pretitle{} $Title{Denmark Health Care in Denmark} $Subtitle{} $Author{Henning Dehn Nielsen} $Affiliation{Ministry of Foreign Affairs} $Subject{health services care hospital danish local free children denmark authorities see tables } $Date{1990} $Log{See Table 2.*0017401.tab See Table 3.*0017402.tab See Table 4.*0017403.tab See Table 5.*0017404.tab See Table 6.*0017405.tab See Table 7.*0017406.tab See Table 8.*0017407.tab } Title: Denmark Book: Facts about Denmark Author: Henning Dehn Nielsen Affiliation: Ministry of Foreign Affairs Date: 1990 Health Care in Denmark A description of public health in Denmark could easily become a description of the welfare state itself. For the health sector as such constitutes only one element in a comprehensive health and welfare policy. It is a policy which has been based on good housing, wholesome food, good working conditions, pollution control and an adequate social network. Thus the health sector plays a key role in the welfare state. It is in the institutions belonging to the health sector that most Danes are born and die, and it is very largely the health sector which must deal with the crises that affect the individual and society. History The Danish health care system and the various health care measures are a result of the demographic and structural development of Danish society. Major reforms of the health care services took place during the first half of the 20th century. An organisational framework was created on the national level to supervise the health conditions of the population and to supervise and counsel the local health authorities and personnel. The establishment of a health insurance system gave the population free access to general practitioners and hospitals. Furthermore, a number of primary health care services were established on a national basis, which contributed to the fight against the great epidemic diseases. An important administrative reform was enacted in the 1970s when the local government entities (counties and local authorities) were enlarged and thus given greater financial responsibility at the local level. This administrative change was an important prerequisite for a further decentralisation of the responsibility for and financing of health care measures. Basic principles Today, the basic principles and main features of Danish health policies are: - equal and free (or almost free) access for all to the various health care measures, irrespective of employment, financial and social status etc., financed mainly through general taxation, - coordination of the various health services, - a high standard of treatment taking into consideration the needs and condition of the patients, - decentralisation of responsibility and financing of health care services, - state authorisation, supervision and training of health personnel. Future Increasing economic restraints and changing health patterns have affected Danish health policies, which now concentrate more and more on the prevention of diseases, on health education and on organising the primary health services. New challenges and a new approach to the problems which health policies are to cope with during the rest of this century require policies of adaptation and reorientation. These policies of change have not yet been fully implemented, but the intended and expected accomplishments within the Danish health sector will accord with WHO strategy aiming at Health for All by the Year 2000, a strategy which Denmark, together with the other member states of the European Region of WHO, in 1984 adopted as a target of Danish health policies. Some of the Danish pioneers in medical science: Thomas Bartholin the Elder (1616-1680), Danish anatomist, who discovered the lymphatic system. His father, Caspar Bartholin the Elder (1585-1629), was author of a famous textbook of anatomy, Institutiones Anatomicae (1611), which was translated into numerous languages. Thomas Bartholin's son, Caspar Bartholin the Younger (1655-1738) discovered an accessory duct of the sublingual salivary gland and the socalled glands of Bartholin near the vagina. Niels Stensen, Latin: Nicolaus Steno (1638-1686), Danish anatomist, geologist and theologian. He discovered the excretory duct of the parotid gland and described the origin and function of the lachrymal fluid. He founded the science of geology, was a convert to Roman Catholicism and eventually became bishop. Niels Finsen (1860-1904), Danish physician, especially concerned with the effect of light in treating disease. The significance of his method was first seen in the treatment of lupus. He founded the Finsen Institute, which employs X-rays in treating cancer. He received the 1903 Nobel Prize in Physiology and Medicine. Johannes Fibiger (1867-1928), Danish physician, from 1900 professor at the University of Copenhagen. He is especially known for being the first to produce cancer experimentally. He received the 1926 Nobel Prize in Physiology and Medicine. August Krogh (1874-1949), Danish physiologist and professor. He studied the physiology of respiration and circulation, invented scientific apparatus and in this way contributed significantly to the development of physiology (the study of the normal functioning of living organisms) in the 19th century. For his discovery of the regulation of the vasomotor mechanism of the capillaries he received the 1920 Nobel Prize in Physiology and Medicine. Niels Jerne (b. 1911), Danish professor, who for his lifelong achievements in the science of immunology (the study of immunity, vaccination etc.) received the 1984 Nobel Prize in Physiology and Medicine. Administrative organisation The Danish health care system comprises hospital services and primary health services, including preventive health programmes. State level On the state level the task is essentially to initiate, coordinate and supervise the health system. The Ministry of Health is the principal health authority and is responsible for legislation on health insurance, medical and non-medical personnel, hospitals and pharmacies, the marketing of pharmaceutical products, epidemics, vaccinations, maternal and child care and certain other fields. The Government supervises the health care system mainly by issuing general rules and economic guidelines also within areas which are formally assigned to the local authorities. With a view to coordinating the activities of the various bodies concerned with health matters, the Government runs two central agencies: The National Food Institute administers the legislation on food, controls and analyses foods and foodstuffs, etc. The National Board of Health: Besides certain executive functions in the administration of health services, the agency has an advisory and supervisory role with respect to the various health functions of the central government and local authorities. On the local level the functions of the National Board of Health are to some extent carried out by state medical officers. Almost the entire responsibility for running the institutions, programmes etc. is assigned to the local authorities. There are a few major exceptions, for instance the Copenhagen University Hospital and the State Serum Institute, which are state institutions. Local level The counties (16, incl. the City of Copenhagen and of Frederiksberg) are responsible for running and planning the major health care services such as the hospital services and the primary health services. The local authorities (275) are responsible for running and planning most of the social welfare system and also for certain parts of the local health services such as home nurses, infant health visitors and school health and dental services. Finance In 1985 total expenditures on public health services amounted to 5.5 per cent of the gross national product (GNP). About 93 per cent of public health expenditure is met by the counties and local authorities, which finance costs mainly through taxes and to some extent through block grants from the state. The allocation of costs in 1985 can be seen below. [See Table 2.: Public Expenditure on Health Care] The table below shows the total number of persons employed within the Danish health sector, divided into primary health services and hospital services. About 75-80 per cent of health expenditure goes to health personnel. About 77 per cent of the health personnel is employed by the hospital services. [See Table 3.: Personnel Resources] Primary health care The table below shows various categories of primary health personnel. [See Table 4.: Health resources at primary level] General practitioners and practising specialists The patient's first point of contact with the primary health care services is normally the general practitioners, of whom there are about 3,000 in Denmark. Anyone aged 16 or over may choose his own general practitioner. Families often keep the same family doctor for a number of years, which gives the doctor a thorough knowledge of the family's social and medical condition. As a matter of principle the general practitioner normally sees the patient before referring him for further examination or treatment either to a practising specialist at primary care level or to hospitals. They can also call on the services of health visitors, home nurses and the local social services. All these facilities are available to the patient free of charge. In principle, the general practitioner runs a private practice either on his own or in collaboration with other general practitioners and carries on his practice independently of the hospital services. In actuality, however, his income derives from the services he carries out for the National Health Insurance Scheme, calculated according to the scale of fees agreed to by his own professional organisation and the National Health Insurance Board. The practising specialists are also connected to the National Health Insurance Scheme and treat patients referred to them by general practitioners. The largest group of specialists working within primary health services are the ear-nose-throat specialists and the eye specialists. Most specialists have other positions, usually within the hospital services, and carry on their private practice on a part-time basis. Physiotherapists General practitioners can refer patients for treatment by physiotherapists, who are permitted to establish private clinics. They work under an agreement with the National Health Insurance Scheme, which partly reimburses the fees paid by their patients. Many local communities also employ physiotherapists, for instance in nursing homes. On a per capita basis Denmark is the world's second largest exporter of pharmaceuticals. Since the inter-war period a number of medium-sized pharmaceutical firms have sprung up. The leading Danish company, Novo Industri, is the world's largest producer of enzymes. Novo Industri and Nordisk Gentofte are among the world's leading producers of insulin, an indispensable medicine in the treatment of diabetes. It was a Dane, H.C. Hagedorn, who invented the method now used in the production of 90 per cent of all the world's insulin. Novo Industri and Nordisk Gentofte (photo) are both employing the latest gene-splicing techniques in their production. The export of pharmaceuticals is supplemented by a very large export of equipment to the health sector generally. Denmark is unrivalled, for example, as the world's leading producer of hearing-aids. Other exports include turnkey hospitals and know-how to the health sector. Dispensing chemists In Denmark all medicine is sold by dispensing chemists authorised by the State. The Minister of Health determines the number and location of pharmacies. The National Health Insurance Scheme refunds some of the patients' expenses for medicine. Many elderly patients and some with severe chronic diseases and disabilities are supplied with medicine free of charge. Practising dentists The majority of the practising dentists work on their own premises, but an agreement with the National Health Insurance Scheme gives the patients the possibility of reimbursement of some of the expenses for dental treatment. The population has a free choice of dentist. Home nurses A home nursing service is obligatory for all local communities. The general practitioner or the hospital can refer patients to home nursing care, which is free of charge and is often integrated locally with the home helper services. From quacks to healers An official report from 1983 showed that Denmark in 1980 had at least 1000 so-called healers, and the figure is unlikely to have diminished since then. Healers are persons both with and without medical training, whose methods of treatment are usually not fully approved by the medical profession and the public health authorities. The term "healing" covers a great variety of treatments from the telepathic focusing on diseased organs and the laying on of hands to acupuncture (the last being recognised as curative in the report). Opinion polls reveal that a fairly high proportion of Danes believe in the efficacy of healing. Perhaps it is a symptom of the times that the old word "quack" with its somewhat disagreeable ring has now been widely replaced by "healer". The report, therefore, attaches great importance to the public being given to understand that the medical profession, far from adopting a hostile attitude to all alternative medicines, is actively prepared to examine their usefulness. However, some healers insist that their methods cannot be judged by the usual scientific standards. That is one reason why any thought of issuing some sort of licence to healers was abandoned. Still, "quackery" is not illegal. Since, however, the fee for consulting a healer is normally not covered by the Medical Health Insurance Scheme, the expense is likely to be much higher than treatment under the public health care system, which is mostly free of charge. Nursing homes Nursing homes receive patients who are not in need of hospital treatment, but who require intensive care. The local authorities pay for the main expenses of the nursing homes, while the patients contribute according to their means. Preventive health services Importance is attached to the prevention of illness as a means of raising health standards and of easing the pressure on the health services. The Ministry of Health has set up a National Prevention Council to promote preventive health efforts and to stimulate health educational measures. In Denmark the following preventive health services are available free of charge: Pre-natal care and guidance A pregnant woman can have her pre-natal care with her family doctor and a midwife at the local midwives' centre. She is offered several examinations by a midwife and her doctor before and immediately after delivery. A woman may choose to give birth at home or in a hospital. The vast majority of deliveries take place in hospital maternity wards and only about 1 per cent at home. All Danish midwives have received special training and are attached to public midwives' centres, which are affiliated to the hospital departments of obstetrics. The service of infant health visitors The local health authorities are notified of all births and are responsible for the health care facilities which are offered the mother and child in the form of visits by a health nurse. Each child is visited several times during its first year depending on the need of the individual child or family. The main concern of the infant health visiting service is to supervise the child's health, to give advice and support to the parents and to provide information about supplementary health services. Preventive health examinations All children are entitled to 8 preventive health examinations by a doctor from the age of 5 weeks to the age of 5. Vaccination of children All children are offered free vaccination by the family doctor against diphtheria, polio, tetanus and whooping cough. Some children are vaccinated against tuberculosis while smallpox inoculations have been abolished. Inoculation against measles, mumps and German measles is offered free of charge to all children below 13. To certain groups of adult women who have not had German measles inoculation against the disease is offered free of charge. School health service The local authorities are responsible for the medical examination and treatment of all children of school and nursery school age. Medical examinations are carried out on the school premises by doctors. The school nurse and the doctor also participate in the health education together with the teaching staff. Child dental care All children up to 18 years have access to free dental care for both routine examinations and treatment. A preventive programme is carried out in daycare institutions and schools. Occupational health services Occupational health services seek to prevent diseases and accidents at places of work. Legislation sets certain standards covering health, safety and facilities in factories and offices. Other preventive health measures Each county has a child guidance clinic where psychologists and child psychiatrists examine children and advise families with children having emotional or other psychological disturbances. Some counties screen all women in certain age groups for uterine cancer, and some counties screen for breast cancer as well. All schools have sex education in their curriculum at various levels. Everyone is entitled to free examinations and advice concerning contraceptive methods, either with their own doctor or at a special clinic. Fewer and fewer Danish children develop cavities. The percentage of five-year-olds who have not had any cavities rose from 27 to 54 between 1978 and 1985, and the Danish health authorities expect the figure to reach 90 per cent by the year 2000. The percentage of twelve-year-olds who have no history of cavities rose from 4 to 16 between 1978 and 1985, and here the target for the year 2000 is 60 per cent. The healthier teeth are due to the free dental care for children which has progressively been introduced since 1971. Today all children aged 0 to 18 are entitled to free dental care. Close to 100 per cent of the children have joined the dental care scheme, and free dental care has helped to ensure that children from low-income families now have almost as healthy teeth as children from families with larger incomes. Every adult above 25 years is entitled to sterilisation on request. All sterilisations must take place in hospitals and must be reported to the National Board of Health. Since 1973 every woman can have an abortion within the first twelve weeks of pregnancy. The law stipulates that prior to the termination of pregnancy, the woman must be counselled as to the nature of the operation and be informed of the social benefits to which she is entitled, should she wish to have the baby. A request for abortion after the first twelve weeks will be considered by a special board. An anonymous test for AIDS anti-bodies is available free of charge, either from a general practitioner of one's own choice, at a clinic for venereal diseases, or at special health clinics. AIDS must be fought with a life style In Denmark the fight against the AIDS disease and the HIV contagion is based on information, counselling and voluntary cooperation. Coercive measures are avoided because, in the view of Danish health authorities, a hard-line approach entails the danger that highrisk AIDS groups, ie primarily homosexuals and drug addicts, might refrain from seeking advice or allowing themselves to be examined. Any physician with a patient who tests positive for AIDS must notify the health authorities. It is not required to report persons who only test positive for HIV. All donor blood is tested for antibodies. Since 1986 the fight against AIDS in Denmark has centred on an intensive information programme. The public is told that AIDS is a potential threat to all. Each person must think about his own conduct. The aim is not to prescribe a certain life style for the whole population but to described the consequences of different life styles and encourage everyone to accept responsibility for their own existence. The two main campaign goals are to demonstrate how AIDS spreads and to point out that the disease is only mildly contagious. The panic must not spread. All the media are mobilised, especially in an effort to reach the young. To quote: "Ads and other means of information should contain a considerable element of surprise and humour". This soft line has been criticised for underplaying the danger of the disease. The Danish writer, Klaus Rifbjerg, has praised the campaign for not moralising. An overly grim and moralising approach, he says, could cause many in the target audience to suppress the consequences of the disease and become indifferent. Hospital services The hospital services cover the whole spectrum of physical and mental illness, providing diagnoses, treatment and care. Although these are still mainly concerned with patients occupying hospital beds, they are also increasingly directed at out-patient treatment so as to relieve the pressure on the in-patient facilities. They also provide diagnostic assistance to general practitioners on a considerable scale through a well-established laboratory service including X-ray examinations. In the preventive field they provide a variety of prophylactic measures. Finally, they play an essential role as clinical training centres both for their own staff and for personnel engaged in primary health care. Hospital resources The table below summarises the resources in the hospital services. [See Table 5.: Hospital resources] Hospital structure The hospital service within a county consists of a number of hospitals of different size and type. Generally the hospital service in a county must provide departments for all major medical specialities. [See Table 6.: Hospitals divided by type and size] The large specialised hospitals with national or regional functions are hospitals which centralise the specialised treatment necessary. The other specialised hospitals provide the necessary specialities and expert service within a county. Local hospitals provide basic hospital service while specialised somatic and psychiatric hospitals provide treatment of specific diseases. Danish hospital physicians are full-time, salaried staff members. Hospital treatment is free of charge to people resident in Denmark. Patients are only admitted to hospital after referral from a general practitioner or via the hospital emergency units, which are available to everyone. Demography The Danish population is characterised by a fairly even distribution by age and sex. Since the 1950s the number of children has decreased and the number of elderly people increased. This development will greatly influence the allocation of resources within the health sector as the disease pattern changes in accordance with the age structure. Life expectancy The majority of elderly people live in their own homes, supported by social services, i.e. home nursing services and home helper services provided by the local authorities. About 7 per cent of elderly people lives in nursing homes. [See Table 7.: Life expectancy] Birth rates and infant mortality Danish families have fewer children than before. The average is now 1 or 2 children. At the same time women's age at first pregnancy has increased and the majority of women have their first child between the ages of 25 and 29. Most women use some kind of contraceptive and the number of legal abortions has dropped in recent years so that the figure was 16.6 per 100 (fertile) women in 1983. [See Table 8.: Birth and Death Rates] The disease pattern After the great epidemic diseases had been eradicated, the disease pattern changed. Other diseases partly brought on by life-style are now prevalent. International health cooperation Denmark takes an active part in international health cooperation. The Danish health authorities attach great importance to the work carried out within the World Health Organisation and supports its global activities to a large extent by means of general development aid. Together with the other member states of the European Region, Denmark has contributed to the preparation of the European strategy for Health for All by the Year 2000. Furthermore, Denmark cooperates with the other Nordic countries (Finland, Iceland, Norway and Sweden) also within the health field. This cooperation takes place on a ministerial level, in official committees and within Nordic institutions. Within the EC, health cooperation is concentrated on securing the free movement of goods, services and labour. Great importance is attached to the exchange of information on health matters between EC member states. Finally, Denmark is a member of the Council of Europe and participates in a number of expert committees concerned with the health area. Besides the above cooperation Denmark has a considerable number of informal bilateral contacts within the health field and has supplied know-how and expertise in connection with the establishment of health systems in other countries.