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$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.