infosantÊsuisse : Dossier Comparaisons internationales
Sommaire L’Europe du Nord 1 Health Care in Sweden 5 Norway and Health: An introduction 45 Denmark: Health system review 232 Finland: Health system review
infosantésuisse : dossier Comparaisons internationales_ L'Europe du Nord 2/2011 1
Fact Sheet | health care
PHOTO: Miriam Preis/Image Bank Sweden
Swedes have one of the highest life expectancies in Europe.
Health care in Sweden Everyone in Sweden has equal access to health-care services. The Swedish health-care system is taxpayer-funded and largely decentralized. The system performs well in comparison with other countries at a similar level of development, with good medical results relative to investments and despite funding restrictions. Life expectancy in Sweden continues to rise. In 2008, it was 79 years for men and 83 years for women. This can be partly attributed to falling mortality risks for both heart attacks and strokes. A little more than 5 percent of the population is aged 80 or more. That means that Sweden – along with Italy – has Europe’s largest elderly population as a proportion of the national total. However, the number of children born in Sweden has been increasing steadily since the end of the 1990s, a shift that will reduce the relative proportion of elderly residents. Chronic diseases that require monitoring and treatment – and often life-long medication – place great demands on the system. One positive fact is that Sweden
has relatively few smokers – almost 85 percent of Swedes are non-smokers. Shared responsibility
In the Swedish health-care system, responsibility for health and medical care is shared by the central government, county councils and municipalities. The Health and Medical Service Act (Hälso- och sjukvårdslagen, HSL) regulates the responsibilities of the county councils and municipalities. The act is designed to give county councils and municipalities more freedom in this area. The role of the central government is to establish principles and guidelines for care and to set the political agenda for health and medical care. It does this
using laws and ordinances or by reaching agreements with the Swedish Association of Local Authorities and Regions (SALAR), which represents the county councils and municipalities. Health care decentralized
Responsibility for providing health care is decentralized to the county councils and, in some cases, municipal governments. County councils are political bodies whose representatives are elected by their residents every four years on the same day as national general elections. In line with Swedish policy, every county council must provide residents with good-quality health and medical care, and work toward promoting good health
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Fact Sheet | health care Players within the health-care field There are several authorities and organizations involved in health care at a national level. The National Board of Health and Welfare (Socialstyrelsen) plays a fundamental role as the central government’s expert and supervisory authority. www.socialstyrelsen.se The Swedish Association of Local Authorities and Regions (SALAR) represents the governmental, professional and employer-related interests of Sweden’s 290 municipalities, 18 county councils and the two regions, Västra Götaland and Skåne. www.skl.se The Medical Responsibility Board (Hälso- och sjukvårdens ansvarsnämnd) is a government agency that investigates possible breaches of standards by healthcare professionals. www.hsan.se The Swedish Council on Technology Assessment in Health Care (SBU Kunskapscentrum för sjuk- och hälsovården) carries out assessments of which healthcare measures produce the greatest benefit for patients and how the care system can use its resources most advantageously. www.sbu.se The Dental and Pharmaceutical Benefits Agency (Tandvårdsoch läkemedelsförmånsverket) is a central government agency whose remit is to determine whether a pharmaceutical product or dental procedure is to be subsidized by the state. www.tlv.se The Medical Products Agency (Läkemedelsverket) is the Swedish national authority responsible for regulation and monitoring of the development, manufacturing and marketing of drugs and other medical products. www.lakemedelsverket.se
for the entire population. County councils are also responsible for dental care for local residents up to the age of 20.
health and medical care. The number of patients seeking treatment in other EU countries has grown in recent years, as has the number of health-care profesShared medical care sionals working in other member states. Sweden is divided into 290 municipaliSweden is actively involved in cooperties, 18 county councils and two regions, ation across the EU to improve access to Västra Götaland and Skåne. (One munici- health and medical services. This pality Gotland, an island in the Baltic Sea, includes collaborating on specialized has the same responsibilities for health care care, improving patient safety and as the county councils.) enhancing patient influence. There is no hierarchical relation between municipalities, county councils Patient safety and regions, since all have their own selfThere is also more discussion of health governing local authorities with responsiand medical services outside the EU, parbility for different activities. Around 90 ticularly in organizations such as the percent of the Swedish county councils’ WHO, the OECD, the Council of Europe work involves health care, but they are and the Nordic Council of Ministers. also involved in other areas, such as culMany of the challenges confronting ture and infrastructure. Swedish health care can also be seen in Sweden’s municipalities are responsible other countries. These include issues of for care for elderly people in the home or accessibility, quality, efficiency and in special accommodation. Their remit funding. also includes care for people with physical One prioritized area is patient safety; disabilities or psychological disorders. the Swedish Association of Local Municipalities are also responsible for Authorities and Regions is driving a providing support and services for people national effort together with all the released from hospital care as well as for regions and county councils to ensure school health care. that patients are protected from accidents, incorrect treatments and other International work incidents. Greater mobility among EU citizens has Another goal is to halve the incidence increased the need for cooperation on of health-care-related infection by 2010.
Care within 90 days Waiting times for preplanned care, such as cataract or hipreplacement surgery, have long been a cause of dissatisfaction. As a result, Sweden has introduced a health-care guarantee. In 2005, the county councils and central government agreed to introduce a health-care guarantee. This means that no patient should have to wait more than 90 days once it has been determined what care is needed. If the time limit expires, patients are offered care elsewhere; the cost, including any travel costs, is then paid by their own county council. The situation has improved since the health-care guarantee was introduced. Collated waiting times as of December 31, 2008, showed that 75
percent of patients had received treatment within 90 days. To improve matters further, the central government, in consultation with the Swedish Association of Local Authorities and Regions, decided to allocate an extra SEK 1 billion (USD 140 million) each year starting in 2010 and through to 2012. For county councils to get a share of the billion kronor, they must meet the requirement that 80 percent of their patients receive care within the allotted time. They must also submit information about waiting times to a new national database. | 2
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Fact Sheet | health care PHOTO: Magnus Neideman/SvD/SCANPIX
Learn more High quality of care Comparisons show that Swedish health care performs well compared with care in other countries. This includes the areas of access, quality, outcomes and results. The Swedish system is also efficient compared with other countries. Patient fees The fee for staying in a hospital is SEK 80 per day. Patient fees for primary care vary between SEK 100 and 200 depending on the county council. For specialist visits there is an additional fee of a maximum SEK 300. High-cost ceiling A cost ceiling applies to limit an individual’s costs. After a patient has paid a total of SEK 900 during one year, medical consultations within 12 months of the first consultation are free of charge. There is a similar ceiling for prescription medication, so nobody pays more than SEK 1,800 in a 12-month period. End of monopoly In the spring of 2009, the state-owned company Apoteket AB lost its pharmacy monopoly. This means Apoteket no longer has the sole right to sell medicines. Some of the pharmacies are being sold, and about two-thirds of Sweden’s pharmacies are expected to get new owners. The aim is to increase access and improve service for patients and customers. PHOTO: Elisabet Omsén/Scanpix
SWEDISH MIDWIVES IN FOCUS Sweden has long had trained professional midwives. Research shows that this meant a sharp reduction in mortality among women giving birth. Between 1860 and 1900, mortality fell 75 percent as more parishes employed midwives. Today, maternal mortality in Sweden is among the lowest in the world. There are, on average, 3 deaths per 100,000 children born. The Swedish system of midwives is now attracting international attention. The UN organizations UNFPA and WHO are highlighting the system as a model for achieving the target of halving mortality among mothers by 2015.
Operation waitlists are shorter thanks to the health-care guarantee.
Costs for care Costs for health and medical care account for about 9 percent of Sweden’s gross domestic product (GDP), a figure that has remained fairly stable since the early 1980s. Costs are on par with those in most other European countries. In the US, by comparison, health-care costs are almost twice as high. The bulk of health and medical costs in Sweden are paid for by county council and municipal taxes. Contributions from the national government are another source of funding, while patient fees cover only a small percentage of costs. Primary care most expensive
County council costs for health and medical care, excluding dental care, were SEK 186 billion in 2008. That is an increase of
SEK 9.2 billion or 5.2 percent on 2007.
Primary care accounts for the largest increase in costs, with a greater need for general medical care and physiotherapy than in previous years. More private health-care providers
It is now more common for county councils to buy services from private healthcare providers; 10 percent of health care is financed by county councils but carried out by private care providers. An agreement guarantees that patients are covered by the same regulations and fees that apply to municipal care facilities.
Benchmarking leads to improvements Local taxes are the basis for funding health and medical care, which means opportunities for economic expansion are strictly limited. Cost restrictions mean it is essential to get the most out of existing resources. Benchmarking between county councils has led to improvements, but significant decentralization has meant that there is often a lack of national data. For this reason, the National Board of Health and Welfare and the Swedish Association of Local Authorities and Regions are developing a model to compare targets and evaluate results. The aims include: • Providing a better platform for public debate and political decisions • Making it easier for county councils and
municipalities to manage and streamline health care • Providing the general public and patients with more accessible information. Statistics based on national research have already been produced on issues such as the quality of health care, patient safety, waiting times, patient opinions and costs, and the effects of factors such as lifestyle, food and the environment on health, allowing comparisons between counties. Improvements can already be seen in several areas. One is mortality related to stroke or heart attack, where a decrease for both men and women of more than two percentage points can be seen in almost every county. The percentage of patients who survive breast cancer has been increasing since the project started. | 3
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Fact Sheet | health care
IN BRIEF Sweden’s eight regional hospitals: • Skåne University Hospital, Malmö and Lund • Sahlgrenska University Hospital, Göteborg • Linköping University Hospital • Örebro University Hospital • Karolinska University Hospital, Stockholm • Uppsala University Hospital • Norrland University Hospital, Umeå
How care is organized Most health care today is provided in health centers where a variety of health professionals – doctors, nurses, midwives, physiotherapists and other staff – work. This simplifies care for patients and fosters teamwork. Patients are able to choose their own doctor. There are special clinics for children and expecting mothers, as well as youth clinics that offer advice on a range of issues, including family planning. Free choice
1 Umeå
2 Uppsala Örebro
3
Stockholm
Linköping
4
Göteborg 5
People in Sweden have had free choice in health care since 2003. This means that patients can seek treatment anywhere in the country under the same conditions as in their home county. By January 2010, all county councils are to have introduced what is known as the primary choice system in primary care. This was adopted by the Riksdag (Swedish parliament) in February 2009. The system entails patients choosing whether they would prefer to go to a private or public health center. All care providers that meet county council requirements are entitled to start a health center that is reimbursed with public funds from the county council. For instance, they must provide social
workers or psychologists, ordinary home health services, and emergency services until 9 pm. All care centers are paid the same amount for each patient seen. Eight regional hospitals
Sweden has 60 hospitals that provide specialist care, with emergency services 24 hours a day. Eight of these are regional hospitals where highly specialized care is offered and where most teaching and research is based. Six health-care regions
Because many county councils have small service areas, six health-care regions have been set up for more advanced care. This is coordinated by the Committee for National Specialised Medical Care (Rikssjukvårdsnämnden) within the National Board of Health and Welfare. The counties own all emergency hospitals, but health-care services can be outsourced to contractors. For preplanned care, there are several private clinics from which counties can purchase certain services to complement those offered within their own units. This is an important component of the effort to increase access.
6 Lund Malmö
Sweden’s six health-care regions: 1. Northern region 2. Uppsala-Örebro region 3. Stockholm-Gotland region 4. Western region 5. South-eastern region 6. Southern region
Published by the Swedish Institute October 2009 FS 10 More facts can be found on www.sweden.se
Useful links www.sweden.gov.se – The Government Offices of Sweden www.socialstyrelsen.se – The National Board of Health and Welfare www.skl.se – The Swedish Association of Local Authorities and Regions www.sbu.se – The Swedish Council on Technology Assessment in Health Care www.fhi.se – The Swedish National Institute of Public Health www.smittskyddsinstitutet.se – The Swedish Institute for Infectious Disease Control www.lfn.se – The Pharmaceutical Benefits Board www.lakemedelsverket.se – The Medical Products Agency
Copyright: Published by the Swedish Institute on www.sweden.se. All content is protected by Swedish copyright law. The text may be reproduced, transmitted, displayed, published or broadcast in any media for non-commercial use with reference to www.sweden.se. But never photographs or illustrations. For more information on general copyright and permission click here. The Swedish Institute (SI) is a public agency that promotes interest in Sweden abroad. SI seeks to establish cooperation and lasting relations with other countries through strategic communication and cultural, educational and scientific exchanges.
Further information about Sweden: www.sweden.se, the Swedish embassy or consulate in your country, or the Swedish Institute, Box 7434, SE-103 91 Stockholm, Sweden Phone: +46 8 453 78 00 Mail: si@si.se www.si.se, www.swedenbookshop.com
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Norway and Health
IS-1730 E
an introduction
Title:
infosantésuisse : dossier Comparaisons internationales_ L'Europe du Nord 2/2011 6
.
Published:
Norway and Health. An introduction.
04/2009
Reference Number: IS-1730 E
Published by: Contact: Postal adress: Visiting adress:
Norwegian Directorate of Health Secretariat for International Cooperation Pb. 7000 St Olavs plass, 0130 Oslo Universitetsgata 2, Oslo
Tel: 810 20 050 Fax: 24 16 30 01 www.helsedirektoratet.no This booklet may beordered at: Norwegian Directorate of Health att. “Trykksaksekspedisjonen” e-mail: trykksak@helsedir.no We are planning to update this publication at regular intervals. Please send your comments to: f-arkivar@helsedir.no, att. ”Secretariat for International Cooperation”.
Editorial Team:
Sigurd Røed Dahl Lal Manavado Øydis Monsen Harald Siem
Subject contributors:
Bente Hatling, Hospital Services Bente Moe, Community Health Services Bente Nystad, Care and Dental Health Services Freja U. Kärki, Mental Health Gabrielle Katrine Welle-Strand, Substance Abuse Heidi Tomten, Physical Activity Kaja Lund-Iversen, Nutrition Katrine S. Edvardsen, Medical Devices and Medical Products Linda Haugen, Health and Social Services Personnel Michael Kaurin, Health Statistics Øyvind Christensen, Norwegian Patient Register Department Ragnar Salmén, Emergency Preparedness Rita Lill Lindbak, Tobacco Tone P. Torgersen, Environmental Health Toril Laberg, Delta Centre
Preface
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There has been a growing interest abroad in the Norwegian health and care services. This booklet outlines the structure and some key factors that shaped the system into what it is today. It is firmly anchored in the Norwegian traditional political tenet that society is collectively responsible for the welfare of its citizens. Thus, an overarching aim is to provide services of high quality, available within acceptable waiting times and distances, reaching out to everyone regardless of their financial situation, social status, age, gender and ethnic background. During the last four decades, Norway has undergone a substantial socio-economic transformation, and is now among the wealthiest nations in the world. This development has been of great significance to the health status of the nation, the services provided and the public expectations of the health services. A national health system is the result of a dynamic interplay between health needs, public expectations, professions, interest groups and available resources. As all these elements change over time, the system is in constant evolution. To be adequate, a health system in evolution has to contain mechanisms for priority and capacity revision, quality assurance, structural adjustment, and optimal resource utilisation. One major concern in Norway as an egalitarian society is the growing disparity in health between social groups, in spite of universal access to care and services. A comprehensive policy on social determinants of health is developed in order to reduce social inequalities in health. The principal elements of the structure and activities are outlined here, with a slight bias to the work under the responsibility of the Norwegian Directorate of Health. There have been many contributors, which is apparent in the variation in writing style of the chapters. A special note of gratitude goes to Lal Manavado, who initiated this project and contributed extensively throughout the process. We hope this booklet will give you a quick overview that you will find interesting, informative and useful as a first introduction to health in Norway.
Bjørn-Inge Larsen Director General Bjørn-Inge Larsen, (MD, BC, MBA, MPH), is a member (and chair 2009) of WHO Standing Committee of the Regional Committee for Europe for the period 2006-2009.
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Contents Preface
1
1
International cooperation on health
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2
Norway, the nation 2.1 Geography 2.2 Demography (2007) 2.3 Government 2.4 Economy 2.5 Health
5 5 7 8 9 9
3
Health: Financial and human resources 3.1 Manpower 3.2 Registration/licensing of personnel
11 12 12
4
Health management 4.1 Health at the national level 4.2 Health at the provincial level 4.3 Health at the local level
14 14 17 17
5 Primary health services 5.1 Scope 5.2 Roles 5.3 Financing 5.4 The general practitioners’ scheme 5.5 The health clinics 5.6 Health and care services for the elderly and disabled 5.6.1 Users 5.6.2 Personnel 5.7 Public dental health services 5.7.1 Frequency of use 5.7.2 Costs
2
18 18 18 18 19 19 20 20 20 20 21 21
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6 Specialist health care services 6.1 Health enterprises 6.2 Allocations 6.3 Patients rights 6.4 Priority-setting 6.5 Pharmaceuticals safe use 6.6 Mental health services 6.7 Alcohol and drug abuse 6.7.1 Main goals 6.7.2 Treatment
22 23 23 24 25 25 25 27 27 27
7 Public health and health promotion 7.1 Strategy to reduce social inequalities in health 7.2 Tobacco use and tobacco control 7.2.1 Strong legislation 7.2.2 Reducing use 7.3 Nutrition 7.4 Physical activity
29 29 29 30 30 31 33
8
Universal design - The Delta centre
34
9
Preparedness 9.1 Aims
34 34
Links
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1
International cooperation on health
Norway is an active participant in the international efforts to enhance global public health. Over the years, Norway has seen the World Health Organization (WHO) as the central arena for international health. Karl Evang, former Director of health, was one of the founders of the organization in 1948, while former Prime Minister Gro Harlem Brundtland served as Director General from 1998 to 2003. The Director of health, Bjørn-Inge Larsen, is a member (and chair 2009) of WHO Standing Committee of the Regional Committee for Europe for the period 2006-2009. Prime Minister Jens Stoltenberg (2005-) has been actively involved in UN-reform and the intensified campaign to meet the Millennium Development Goals four and five by 2015. Minister of Foreign Affairs, Jonas Gahr Støre, has in collaboration with six other Ministers of Foreign Affairs initiated a process of looking at health and diplomacy, to explore the areas where foreign affairs cover global health issues. This embraces threats like pandemics, trade issues like patent rights and the cost of essential treatment in poor countries, as well as responsible recruitment of health personnel. Last but not least, reconstruction of failed states and humanitarian assistance in emergencies shall also be added to these issues. Mention must also be made of regional health cooperation. Collaboration with the Nordic and Baltic States, as well as Russia, is given high priority. The latter in particular has seen a dramatic upturn since the early nineties. Many health projects and programs related to tuberculosis control, prevention of HIV-infections, child health care and prevention of lifestyle-related disease, have been carried out. The EU plays a significant role in European health cooperation, and although not an EU-member, Norway is involved in a variety of EU activities. A large number of EU directives are implemented in Norway. This is particularly true in the field of food safety. Other areas of cooperation include health preparedness, cross-border patient mobility and participation in EU-programmes. Norway also participates in four health-related EU-agencies: European Medicines Agency (EMEA), European Centre for Disease Prevention and Control (ECDC), European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and the European Food Safety Authority (EFSA).
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2
Norway, the nation
Norway is a founding member of the United Nations, NATO and the Council of Europe, but is not a member of the European Union (EU). Norwegian voters turned down EU membership by narrow margins in 1972 and 1994. However, Norway is part of the EU internal market, and has an extensive cooperation on most policy areas through the European Economic Area (EEA) agreement. 2.1 Geography Norway is located in Northern Europe, bordering the North Sea and the North Atlantic Ocean. Half the country lies north of the Polar Circle. It borders Sweden, Finland and the Russian Federation. The country is divided into 19 regional authority areas, counties (fylker), which in turn are divided into more than 430 local authority areas, municipalities (kommuner). The capital is Oslo.The Norwegian climate is temperate and wet along the coast, modified by the North Atlantic Current. The inland climate is dry, and cold in winter. The terrain is mostly high plateaus and mountains broken by fertile valleys. The coastline is deeply indented by fjords. About two-thirds of the country consists of mountains, and there are some 50,000 islands along the coastline. Norway has rich resources of petroleum, natural gas, hydropower, fish, timber, and minerals like iron, copper, lead, zinc, titanium, pyrites and nickel. As for land use, only 3 percent of the land is arable, while 27 percent of the land is forests and woodlands.
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Figure 1 Neighbours and communications
Map by Egil Sire
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2.2 Demography (2007) Norway has a population of 4,799,300 (01.01.2009). Life expectancy at birth Year Male Female 1970 71 77 2007 78,2 82,7 Age Structure 0-14 years 15-64 years 65 years and over
Percent 19 66 15
Population growth rate: 0,38 percent Birth rate: 11,5 births/1,000 population Death rate: 9,4 deaths/1,000 population Infant mortality rate: 3,7 deaths/1,000 live births Total fertility rate: 1,78
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Figure 2 Demographic map
Map by Egil Sire 2.3 Government Norway, officially the Kingdom of Norway, is a constitutional monarchy with a parliamentary system of government. Norway adopted its constitution in 1814, and the King was given executive powers. Today, these are effectively exercised by the government, headed by the Prime Minister. In 1898, all men were granted universal suffrage, followed by all women in 1913. In terms of government, the social democratic Labour party has played a predominant role after the Second World War. The counties, or the provincial councils and the local authorities, have a great deal of political autonomy. They also set their own tax range within limits prescribed by the Parliament. Representatives to the provincial and local councils are elected every four years by proportional representation. A representative usually from the largest political party or coalition is chosen as the chair of the council, and he or she is also the Mayor of the local authority area. 8
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2.4 Economy The Norwegian economy may be described as welfare capitalism, featuring a combination of free market economy and government interventions and regulations. The government controls key areas, such as the petroleum sector. International oil prices are important as oil and gas account for a third of the exports. Surpluses from the gas and oil exports are kept in a Government Pension Fund - Global, which is invested abroad. In 2007, the size of the fund was 373 USD billion. (Norwegian Ministry of Finance, 2007). The Norwegian progressive tax system is based on indirect taxes such as valueadded tax (VAT), personal income tax and corporate tax, including employers´ social security contributions. Food processing, shipbuilding, pulp and paper products, metals, chemicals, timber, mining, textiles, aquaculture and fishing are among the most important other industries. Barley, other grains, potatoes, beef, milk, and fish are among the principal agricultural products of the country. 2.5 Health Selected data on the population’s health: In 2006, cancer and cardiovascular diseases accounted for over 60 per cent of deaths. Cancer is the primary cause of death for people under 70 years of age, while cardiovascular diseases, such as heart attack, are the primary killers for people 70 years and over. This trend is unchanged over the past decade. Owing to the increasing life expectancy, the number of elderly has risen considerably. This has brought a high prevalence of dementia, cancer, heart and lung insufficiencies and musculoskeletal illness among the elderly. As for infectious diseases, 250 to 350 cases of tuberculosis are diagnosed every year. Active tuberculosis among native Norwegians is rare, while immigration in recent years has led to an increase in the incidence of the disease.
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In 2007, 248 new cases of HIV infection were reported, against 276 cases the previous year. The decline can be explained by a reduction in the number of asylum seekers and family unifications from high endemic countries, and a decrease in the number of men having sex with men (MSM) diagnosed with HIV the same year. However, from 2003, there has been a marked and disturbing increase in contamination among MSM, similar to the situation in other parts of Europe. Each year, 400,000 to 450,000 accidents occur that require medical attention. About 53 000 of these require hospitalization. In 2006, accidents accounted for 1824 deaths. As for drug and alcohol abuse, it is estimated that there are about 9,000 to 12,000 heroin addicts out of whom 4,500 are enrolled in medical (methadone) assisted rehabilitation programs in 2006. The highest consumption of alcohol since 1870 was recorded in 2007 (6,6 litres of pure alcohol per inhabitant). However, statistics from 2008 shows a decrease in consumption among youth the last decade. In 2004, 35,000 cases of alcohol and diverse types of substance abuse required medical treatment. In 2006, 2,037 hospital admissions presented cirrhosis as their main or secondary complaint. Compared to the beginning of the 1990s, the birth rate among teenagers for 2007 is reduced by half. In 1990, the birth rate among teenagers (15-19 years) was 17,1 per 1000 women, compared to 9,1 in 2007. In the same age group, about 65 percent of the pregnancies terminate in abortion. The age group 20-24 years has the highest rate of abortion. In 2007, there were 29,3 terminations per 1000 women. Although the general level of health in Norway is high compared to other countries, there is still a marked social gradient in morbidity and mortality.
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3
Health: Financial and human resources
In 2006, the Norwegian per capita total health expenditure of USD 4,520 (adjusted for purchasing power parity) ranked second among the OECD countries (OECD Health Data 2008). The period between 1997 and 2006 saw a variation in the health expenditure as GDP ratio ranging from 8,4 percent to 10 percent, peaking in 2003, decreasing to 8,7 percent in 2006. In 2007, the total health expenditure, public and private, was 203 billion Norwegian kroner. Norway has one of the largest shares of public financing of health services per capita in the world. As the figure below shows, public expenditure on health as a percentage of GDP is currently 7,6 percent, whilst private expenditure amounts to 1,5 percent. The largest part of public health expenditure is incurred by the curative care provided in hospitals. At the local level, more than 80 percent of public health expenditure is related to care services. In 2006, only 2,7 percent of the total health expenditure was spent on prevention (including administration). Figure 3 Expenditure on health. As a percentage of GDP, OECD Factbook 2008: Economic, Environ
United States
Switzerland
France
Germany
Belgium
Portugal
Austria
Greece
Canada
Iceland
Australia
Netherlands
Sweden
Norway
Denmark
New Zealand
OECD average
Italy
Spain
United Kingdom
Hungary
Japan
Luxembourg
Turkey
Ireland
Finland
Czech Republic
Slovak Republic
Mexico
Poland
Korea
mental and Social Statistics, OECD 2008, www.sourceoecd.org/factbook.
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3.1 Manpower The health authorities have been active, both on the national and international arena, in order to seek a better balance between demand and supply of health care personnel. Important issues are capacity and skills mix on the domestic level, and fair treatment and understanding of the needs in poorer countries. The demand for health personnel at home will be met in the short run with minor adjustments. In 2008, there were four thousand more health and care personnel with university degrees on the job market than ten years earlier. However, there will be a shortage of auxiliary nurses and dentists. There has been an attempt to regulate the supply and distribution of physicians from the end of the 1980s. However, during the 1990s, this regulation was undermined by hospitals; many positions were occupied without official approval. At the same time problems with unoccupied positions in the municipalities increased, especially in rural areas. In 1999, the regulatory system for physicians was changed from a contract-based system to a statutory system. The National Council for Physicians Distribution and Specialist Structure was set up to advise the Ministry of Health and Care Services. The new regulatory regime came into effect in 1999. 3.2 Registration/licensing of personnel The Health Care Personnel Act sets out the regulations with regard to the authorisation and licensing of health personnel. The Norwegian Registration Authority for Health Personnel (SAFH) is responsible for granting professional authorisation, which an applicant need in order to practise within the regulated health personnel categories. Authorisation represents full and permanent approval, while a license imposes one or more limitations with respect to duration, independent or supervised practice, et cetera. www.safh.no Following the European Economic Agreement (EEA), Norway adheres to the EU directive on the recognition of professional qualifications, also in the case of health care personnel. Furthermore, according to the Health Personnel Act, an applicant from a country outside the EEA may also be authorised if she or he has passed a foreign examination that is recognised as equivalent to the Norwegian requirement, or has otherwise been proven to possess the necessary skills. 12
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At present, employment in 36 health professions requires prior authorisation. A peculiarity in Norway is the renewals upon application of doctor’s licence to practice, which expires routinely at 75 years of age.
Table 1 Health professionals in Norway, by profession, 2006. Profession
Auxiliary nurses Dieticians Dental nurses Dental technicians Dentists Dispensers Doctors Ergotherapists Medlab technicians Midwives Nurses Opticians Other professional or paraprofessional Pharmacists Pharmacy technicians Physiotherapists Psychiatric nurses Psychologists X-ray technicians
Number 108 200 258 1 300 700 6 200 1 500 30 300 3 400 6 200 4 100 122 700 1 600 3 000 3 400 4 500 11 700 10 800 5 400 2 900
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4
Health management
The health administration can be divided into three parts; the national, provincial and local levels. 4.1 Health at the national level The Ministry of Health and Care Services formulates and implements the national health policy with the help of several subordinate institutions. www.hod.dep.no The Norwegian Directorate of Health is a specialized agency under the Norwegian Ministry of Health and Care Services. As such, it is responsible for the compilation of various ordinances, national guidelines and campaigns. It also advises the ministries concerned on health policy and legislation. Its administrative activities involve management of grants for service projects and research, the Norwegian Patient Register and the implementation of certain statutes, while it executes diverse projects designed to promote public health and improve the living conditions in general. www.helsedirektoratet.no The Norwegian Board of Health is an independent authority responsible for the general supervision of the health services of the country. It has a tiered structure, and its central office directs its regional units set up at the province level. The medical officer of a county, who is reporting to the provincial governor, directs the unit. The supervisory authorities are concerned with quality, legal aspects, complaints and the task of ensuring adequate and equitable health services. www.helsetilsynet.no The Norwegian Institute of Public Health (NIPH) is the main source of medical information and advice. The institute is responsible for six out of seven national health registries. The Cancer Registry is a separate administrative unit. The registries are used for research and surveillance purposes. NIPH bears the responsibility for ensuring good utilisation, high quality and easy access to the data in the registers, as well as assuring that health information is treated in accordance with privacy 14
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protection rules. The seven central health registers have been established in accordance with the Personal Health Data Filing System Act. They are: 1. The Cause of Death Register 2. The Cancer Registry of Norway 3. The Medical Birth Registry of Norway 4. The Norwegian Surveillance System for Communicable Diseases (MSIS) 5. The Tuberculosis Registry 6. The Childhood Vaccination Register (SYSVAK) 7. The Norwegian Prescription Database www.fhi.no The Cancer Registry of Norway is a governmental institute for population based cancer research. The Registry has recorded cancer cases nationwide since 1953. A computerized population registry combined with the matching of information from several sources has resulted in accurate and complete cancer registration. This information is used in research projects to establish new knowledge about cancer causes, progression, diagnosis and effect of treatment. www.kreftregisteret.no The Norwegian Medicines Agency is the administrative organ for drugs approval. It authorises and monitors the use and sale of pharmaceuticals, as well as the proper and economical use of them. It licenses the importers of pharmaceuticals and their local distributors. The agency is also responsible for the classification of pharmaceuticals, the drug and doping list, standardisation, pharmaceutical post-marketing control, medical post-marketing control, monitoring adverse drug reactions, supervision of pricing, and the determination of the pharmaceuticals to be included in the national subsidy list. www.legemiddelverket.no The Norwegian Radiation Protection Authority (NRPA) is the technical authority on radiation and nuclear safety, on which it is consulted by various home authorities. It administers statutes concerned with radiation and nuclear safety, and supervises 15
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the medical, industrial and research activities that involve the emission of radiation. NRPA monitors the natural and man-made radiation in the work place and in the environment, and also manages the national nuclear emergency preparedness plan. www.nrpa.no Several Norwegian public institutions collect information for statistical purposes, but Statistics Norway (SSB) is the central body responsible for collecting, analysing and disseminating official statistics, including statistics on health. According to the Statistics Act of 1989, Statistics Norway has the authority to decide what should be official statistics and is responsible for organising all official statistics in Norway. www.ssb.no/english The Norwegian Patient Registry (NPR) is part of the Norwegian Directorate of Health, and is responsible for providing data for planning, evaluation and financing for publicly funded specialized health care. The NPR covers nearly all in-patient and out-patient hospital care. The registry covers mental health and somatic care, and includes activity and waiting lists. Data on specialized treatment for substance abuse and additional data on accidents is also provided. Data on the patient's age, sex and residence, hospital and department, diagnose(s), medical and surgical procedure(s), dates of admission and discharge as well as date of procedure are included in the registry. The unique personal identification number that each citizen possesses is to date not included. However, the Parliament has decided that an encrypted version of the unique personal identification number can be added from March 2007 and onwards. The NPR has data covering 629 specialists who work as private practitioners in the somatic sector, performing 1 772 610 consultations, which amounts to about 35 percent of all publicly financed out-patient consultations in 2007 for somatic illness. Data from the somatic sector for the first quarter of 2008 contain information about 300 000 hospital stays, 191 000 day care episodes and 1 376 000 out-patient episodes. As regards the mental health sector, there are similar data available for 16
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adult in- and out-patient clinics and adolescent in- and out-patient clinics, respectively. Health at the provincial level 4.2 The provincial authorities represented by the county council do not deal with health matters. Specialist services are organized in “health enterprises�, see below. The chief state representative of a province is the governor, who is appointed by the central government. He or she is assisted by an executive board of civil servants, including the County Medical Officer and the Dental Surgeon of the province. Health at the local level 4.3 Local authorities, the municipalities, through its council and administration represent the ground level of the administrative hierarchy. It is entrusted with the provision of a wide variety of primary health services.
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5
Primary health services
The primary health services in the present form were established through The Norwegian Primary Health Services Act of 1982. The responsibility for the primary health services was given to the 430 local authorities. According to the act, the municipalities are to provide for care and treatment of all persons within its boundaries, including health promotion and prevention, emergency care and immigrant health care. 5.1 Scope The services include general practice, pregnancy and antenatal care, health clinics for mother and child, school clinics, mental health care, nursing homes, rehabilitation, physiotherapy, communicable disease control, preventive medicine, environmental health and health promotion. They are assigned components of the national emergency preparedness plan, and provide for prisoners, refugees and asylum seekers located in the area. 5.2 Roles The municipal council plans and implements these services through a director of primary health services. A municipal medical officer is appointed to advise the local council on health issues. In scarcely populated areas, some municipalities jointly establish and run all or a part of their primary health services. The municipal medical officer is concerned with public health in the municipality. He provides information on available services, prevention of diseases, health promotion and organization of services. He also works to ensure that the building and operation of industrial installations, commercial and other activities pose no threat to public health. In serious cases, activities may be stopped. Health personnel are either contracted to provide services, or employed by the municipality. The former is true for most of the general practitioners (GPs), while nurses and midwives usually are employees. 5.3 Financing Primary health services are financed through grants from the national government, local tax revenues, reimbursements from the National Social Security 18
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System and through out-of-pocket payments. Services of the pre- and antenatal clinics, youth clinics, school clinics, and all consultations for children under 12 years of age are free. The general practitioners’ scheme 5.4 In 2002, the national authorities introduced a regular general practitioners’ scheme, giving individuals the right to choose one general practitioner as family doctor. In 2008, about 3,800 physicians are enlisted in this scheme. They are private practitioners who enter into a contractual agreement with the municipality, and are required to have a regular clientele not exceeding 2,500 persons. In addition to consultation fees, they receive a regular monthly capitation allowance for each person on the list from the municipality. It is part of the agreement that they also serve in health clinics, school clinics, local authority nursing homes, prison health service and emergency units on a part-time salaried basis. Patients may choose a practitioner anywhere, also in another municipality. If dissatisfied, they may change their physician up to two times within a calendar year. 5.5 The health clinics The health clinics comprise four units. Pregnancy clinics and clinics for mother and child provide antenatal services and child health services that extend up to pre-school age. A public health nurse runs the clinics with a physician at hand for consultation when indicated. Midwifes, physiotherapists, psychologists and other professionals may also be engaged at these clinics. The services provided include assessments, follow-ups, referrals, vaccinations, counselling, home visits and provision of information and cooperation with other social services for more comprehensive service packages. Youth clinics provide integrated individual prevention services, covering physical and mental health assessment and advice, nutrition, physical fitness, sexual hygiene, problems of adolescence, contraception, family problems, and rehabilitation of the disabled and the chronically ill. School health services serve school children and youth under 20 years of age. The school clinics provide vaccinations, health promotion and social and psychological support in the school environment. 19
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The clinics for school children are usually located at schools, while the youth clinics are strategically located elsewhere in the municipality. They have flexible hours of consultation. Health and care services for the elderly and disabled 5.6 The most important services include health and medical services, nursing homes, home based care and services, assistance at home and community nursing, relief services for family members and day care and activity centres. There has been a shift away from institutional care in favour of community-based care. Most importantly, this concerns community-based care for the mentally ill and disabled, and functional homes for the physically disabled to facilitate living at home. 5.6.1 Users The services have more than 200,000 users, of which 40,000 live in nursing homes, and more than 160,000 people receive home care services in community care housing or their own home. The number of users aged under 67 has doubled over ten years and totals 50,000. In 2005, around 110,000 man-labour years were employed; half in nursing homes and half in home care services and community care. 5.6.2 Personnel The growing population of the elderly demands new ways of thinking and training of new skills. Towards year 2020 efforts will be intensified to train personnel and invest in appropriate buildings and technology. Special attention is given to patients with dementia. At present, about 66,000 people suffer from this condition, a number that will probably double during the next 35 years. 5.7 Public dental health services The Public Dental Health Services (PDHS) were established in 1950. Local government is responsible for planning and funding of the service. All children aged 0-18 years receive free treatment, except for orthodontic care, for which parents have to pay a partial fee according to the degree of malocclusion .
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5.7.1 Frequency of use About 75 percent of adults use the services every year, and 85 percent visit at least every second year. Since 1996, there have been no set fees in the private sector. A private dental insurance scheme was introduced in 1996 without success. A few companies offer subsidised dental treatment to their employees. In 2006, for a population of 4,6 million there were 1000 full time dentists in the public sector compared to 2700 private sector dentists. There were 339 full time dental hygienists in PDHS and 261 in the private sector. 5.7.2 Costs In 2007, the total cost of dental treatment in PDHS and the private sector combined was EUR 1,285 million. The total cost included EUR 175 million spent in the PDHS, and a further EUR 122 million refund from the State Insurance System to adults for dental treatment as well as orthodontic treatment for children. Out-of-pocket spending on dental care for adults was thus about EUR 1 billion. The oral health of the adult population is considered to be good. In 2006, the national mean DMFT score, number of fillings, in 12 year-olds was 1,6 and 44 percent had no visible caries.
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6 Specialist health care services Specialist health care services include hospitals for patients with somatic or psychiatric/psychological disorders, out-patients departments, centers for training and rehabilitation, institutions for drug addicts, centres for re-education for chronically ill patients and disabled, pre-hospital services and private specialists, laboratories and x-ray facilities. The Norwegian specialist system scores high in international comparison. In a WHO-study from 2004, Norway was ranked third. If asked, four out of five state that they are satisfied with services received.
Figure 4 The four health regions
Map by Egil Sire
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6.1 Health enterprises Major reforms in the specialised health care services were instituted by The Regional Health Authorities Act of 2002. Five regional health enterprises (later reduced to four through a merger) were set up to administer services within each region, with appointed boards responsible for governance and results. Following the reform, responsibility for all the public hospitals, policlinics and the district psychiatric centres in the country was transferred to the state, and a system of enterprise ownership and management was established. The services include all hospital services, ambulance services, emergency call system, laboratories, in-house pharmacies and some medical rehabilitation facilities. Each regional health enterprise directs a set of subordinate units, mostly hospitals, known as health enterprises. In 2007, about 84 public hospitals were part of this system. Private specialist health service facilities may be invited as partners to the system on a contractual basis. Each enterprise is directed by a board of management serving a two-year term. The boards are supposed to run the enterprises like businesses, in particular guaranteeing solvency. Towards the end of the decade, however, there has been great concern regarding the uptake of massive loans by the enterprises. 6.2 Allocations The Norwegian health system is, as mentioned, a tax-based system covering all inhabitants. In consultation with the health authorities, the government makes annual budget allocations for each regional health enterprise. The Ministry of Health and Care Services issues operational directives on general goals to be achieved with those allocations. In consultation with the boards of management of its health enterprises, each regional health enterprise then determines how funds are to be distributed among them. The allocations to health enterprises are accompanied by operational directives from regional health authorities on goals to be reached. 23
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The in-house pharmacies of the state-owned hospitals are administered by four separate Regional Pharmacy Enterprises. In June 1997, Norway introduced the activity-based funding system for the somatic hospital-based health services based on the DRG (Diagnose Regulated Groups) system. The share of activity-based funding is decided by the Parliament. In 2008, the share of activity-based funding was 40 percent, and 60 percent for block grants. 6.3 Patients rights The Patients Rights Act stipulates the right to become a patient and receive necessary treatment, as well as several procedural rights. • • • • • •
All members of the Norwegian population have a right to health care when certain criteria are met The health system as such (municipalities, enterprises) and the individual care provider are responsible for providing adequate health care Health services must meet minimum standards of adequate quality and safety The definition of “adequate standard” will vary with time due to develop ments in medicine, change in ethical values and prevailing best practice within a certain field The patients’ entitlement to necessary healthcare in the specialist health care services extends to the right to have care delivered within a specific, individually determined time limit Budgetary concerns and providers’ priorities cannot be reason to withhold health care treatment
People have several explicit rights as patients, which are based on the principle of patient autonomy and the right to necessary health care: • • •
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Patients have the right to participate in the treatment process, be in formed, make their own decisions, and have access to information recorded about them Patients also have the right to confidential treatment of personal informa tion The Patients Rights Act also stipulates free choice of hospital. The patients can not, however, choose the type of treatment or how specialized the treatment should be.
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6.4 Priority-setting Priority in the health sector is regulated by law. It defines “necessary care” by taking into account the seriousness of the condition in case and the expected benefit from treatment. Finally, there must be an acceptable equation as to cost and benefit. The National Council for Quality and Priority-setting advises the Government and the health establishment on issues such as distribution of and access to services, new technology and national guidelines. Cancer, rehabilitation, diabetes and KOLS are to be given special attention in the period 2007-2011, and a special strategy for the improvement of quality in services has been elaborated for the period 2005-2015. A more recent initiative stems from 2008, aiming at better collaboration in the services, in particular between the specialist services and the municipal health services. 6.5 Pharmaceuticals safe use Clinical studies have shown that up to 20 percent of patients do not receive correct medication. Errors may occur in all situations in which pharmaceuticals are being handled: during prescription (at physician level), dispensing (in the pharmacy) and at the patients’ point of actual use. Many patients, especially in the older age-groups, suffer from a multitude of diseases requiring complex drug treatment (“poly-pharmacy”). This increases the risk of drug related problems, like interactions, as well as incorrect use of the medication. In addition, studies have shown that inadequate training of health care personnel, lack of routines, proper instructions or unclear responsibilities increase the risk of incorrect use of pharmaceutical drugs. Correct use of pharmaceutical drugs is promoted through a wide range of recommendations, covering efforts such as paediatric networks, improved dispensing systems and electronic prescriptions. 6.6 Mental health services Estimates of prevalence of mental disorders in Norway vary considerably, according to methods and diagnostic criteria used. Approximately 15-20 percent of the adult population is estimated to have some kind of mental health problems, while 25
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about three percent is estimated to have a serious mental disorder. The rate of suicide is fairly low in comparison with other Northern European countries. Nevertheless, suicide is one of the most important causes of death for people under 45 years of age, responsible for 13 percent of all deaths in this age group. Of the population aged 6-67 years, three percent receive disability pensions based on a psychiatric diagnosis, constituting one third of all people on disability pension. An additional 0,6 percent of the population is on long term sick leave due to a mental health condition. The municipalities play a key role in the provision and co-ordination of services for people with mental health problems. Specialised mental health care is provided by the health enterprises. This includes care for patients with serious mental health problems and concurrent drug or alcohol problems (dual diagnoses). Young persons aged 15-30 years with mental health problems and drug abuse are also referred to specialised mental health units. In 1998, The Norwegian Parliament adopted a reform entitled “National Programme for Mental Health” (1999-2008), including major investments, expansion and reorganizing of services. Central components in the programme are: • • • •
Strengthening the user’s position through involvement at all levels in decision- making processes information programmes for public awareness on mental health issues strengthening community based services with special emphasis on prevention and early intervention expanding and restructuring specialized services for children, adolescents and adults.
In primary health care settings the emphasis has been placed on availability of competent services through • • • •
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general practitioners for the whole population recruitment of psychologists establishment of a competency centre for primary mental health services educational programmes in mental health for professionals employed in communities.
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During the National Programme for Mental Health there has been a marked increase in mental health professionals, which has contributed to better accessibility for out-patient clinic consultations for both children, adolescents and adults. The original goal of 50 percent increase (for adults) has been reached with good margins. An additional contribution has been the systematic establishment of outreach teams. Finally, large scale information campaigns for better understanding of mental health problems have been launched to reduce stigma. 6.7 Alcohol and drug abuse The medical and social challenges posed by substance abuse are substantial. In addition to structural policies that regulate price and availability of alcohol, much is invested in prevention through the municipal health services. A National Action Plan on Alcohol and Drugs (2007-2010) has been adopted in order to meet the increasing challenges. 6.7.1 Main goals The aim of the National Action Plan is a policy marked by a clear public health perspective. Main goals include better quality and increased competence, more accessible services and increased social inclusion, binding cooperation, increased user influence and greater attention to the interest of children and family members. 6.7.2 Treatment The treatment system for drug users is part of the general Health Care System. The Regional Health Authorities are responsible for Interdisciplinary Specialised Treatment (IST). IST indicates the necessity of different health and social welfare system professionals being involved in the treatment. There is a lack of IST treatment slots for both in- and out-patient treatment. The treatment system consists of both public and private institutions, financed by the state through contracts. Referral to drug treatment is performed either by the general practitioners or by the social welfare system. The referrals have to be dealt with by the IST services within 30 days (stated by The Patients Rights Act), 10 days for drug using patients below the age of 23 years. 27
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Most of the treatment services covers both alcohol and drug using patients, including patients dependent on prescribed drugs. Medication assisted treatment (MAT) was started on a national scale in 1998. The expansion has been quite rapid, approximately 500 new patients net each year. By the end of April 2008, there were approximately 4,700 patients in MAT with methadone or buprenorphine. Patients rights have been introduced in order to improve the treatment for substance abusing patients. Emphasis has increasingly been on user’s involvement in the treatment process.
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7
Public health and health promotion
The general level of health in Norway is high by international standards. However, the socioeconomic distribution of health still poses serious challenges for Norwegian public health policies. Thus, for instance, although life expectancy for Norwegian men in general is among the best in the world, a male university teacher can statistically expect to live some ten years longer than a male chef. Inequalities among female employees are smaller, but still substantial. 7.1 Strategy to reduce social inequalities in health A 2006 public health white paper, National strategy to reduce social inequalities in health, made the reduction of such health inequalities the central concern of Norwegian public health policy for ten years to come. The strategy was built on the principle that the way to change the social distribution of health is to change the social distribution of health determinants, which are ultimately to be found “upstream”, in the social distribution of resources. More specifically, the strategy operates with four priority areas: 1. 2. 3. 4.
Reduce social inequalities that contribute to inequalities in health – including factors such as income, childhood conditions, education, employment and working environment; Reduce social inequalities in health-related behaviour – such as nutrition, physical activity, smoking and substance abuse – and in the utilisation of health services; Targeted initiatives to promote social inclusion; and Develop knowledge and cross-sectoral tools.
Some of these areas are described further below or elsewhere in this document. No less important, however, are the factors outside the traditional limits of the health sector, such as income, education and employment. Thus, a main task in the years to come is cross-sectoral cooperation on issues of socioeconomic distribution. 7.2 Tobacco use and tobacco control Approximately 6,700 people die from smoking related diseases every year (in particular cardiovascular diseases, cancer and lung diseases), representing 16 percent of all deaths in Norway.
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Historically, smoking peaked in Norway around 1970. Since then, there has been comprehensive plan for tobacco control with a designated government agency. Smoking prevalence has declined significantly, while the use of smokeless tobacco has risen since 2000. 7.2.1 Strong legislation The Norwegian Tobacco Act entered into force in 1975, requiring health warnings on tobacco packaging, 16 year age limit and a ban on advertising of tobacco products. Today Norway is still considered a country with strong tobacco legislation. The EU Directive 2001/37/EC concerning the manufacture, sale and presentation of tobacco products is implemented in national legislation. Like Sweden, Norway has an exception from the EC ban on the sale of tobacco for oral use (moist snuff). The age limit for buying tobacco is 18 years. Since 1988, there has been legal protection from exposure to tobacco smoke in workplaces, only allowing separate smoking rooms. Since 2004, Norway has a complete ban on smoking in bars and restaurants. Norway was the first country to ratify the WHO Framework Convention on Tobacco Control (FCTC), which entered into force in 2005. 7.2.2 Reducing use The main goal of the National strategy for Tobacco Control 2006-2010 is to promote health in all segments of the population and to ensure more years of healthy life by reducing the use of tobacco. Reducing tobacco use is mainly done in two ways:
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•
Preventing the uptake of tobacco use: Most important are restrictive measures like legislation and high prices, as well as educational programmes in school and communication measures.
•
Smoking cessation: The quit line answers 11 000 calls a year, also offering follow-up calls. Help can also be found through health personnel and cessation courses around the country. Nicotine replacement therapy is available over the counter in general stores.
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In the years 1998-2008 daily smoking prevalence among adults decreased from 33 to 21 percent. There has been a remarkable development among young people, where smoking prevalence is cut in half in just five years.
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Men, smoking daily Women, smoking daily Men, using smokeless tobacco daily Women, using smokeless tobacco daily
50 40 % 30 20 10 0 1973
1978
1983
1988
1993
1998
2003
2008
Figure 5 Daily prevalence of smoking and use of smokeless tobacco. Men and women 16-74 years. Statistics Norway.
7.3 Nutrition In Norway, the population in general has abundant access to food and, at the outset, good opportunities to be able to eat a healthy and varied diet. Developments in the food market are increasing the diversity of products, but can also make it more difficult for people to put together a healthy diet. The incidence of obesity is increasing due to unhealthy diet and lack of physical activity. Diseases such as type 2 diabetes, cardiovascular diseases, and certain forms of cancer are closely linked to the diet in the population. Social inequalities in diet contribute to the social inequalities in health and disease. Much remains to be done before the diet in all segments of the population meets nutritional recommendations. The diet of many young people and adults still contains too much fat, especially saturated fat, and too much salt and sugar. The consumption of dietary fibre by most people is lower than recommended, and some groups get too little vitamin D, iron and folic acid. The work to improve the population’s diet is outlined in the national nutrition action plan “Recipe for a healthier diet”, for the period 2007-2011. The plan contains 73 specific measures that will promote health and prevent illness by changing eating habits. Five main strategies are implemented:
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1. Improve the availability of healthy food products Universal measures that make it easier for everyone to choose healthy foods is the most effective measure to improve healthy eating habits in a population 2. Consumer knowledge Widely distributed information and communication will help increase the public's knowledge of food, diet and health, which in turn will serve to make it easier for consumers to make informed dietary choices. 3. Qualifications of key personnel Policy makers and professions who directly or indirectly contribute to nutritionrelated activities need to have a sound and relevant level of knowledge about nutrition, diet and food 4. Local basis of nutrition-related activities In recent years, local partnerships for public health have grown to become one of the most important strategies for a healthier lifestyle. Continuous, binding and systematic interdisciplinary and cross-sectional collaboration is necessary for achieving good health 5. Strengthened focus on nutrition in the health care services Nutrition is a necessary part of prevention, treatment and rehabilitation of disease, and a basis and support for other medical treatments. The main topics under consideration in 2008 were development of a sign posting system on foods, marketing of food towards children, healthy meals in kindergarten and schools, provision of vitamin D supplementation to immigrant infants, nutrition among elderly, development of lifestyle intervention and capacity building of key personnel in work places and in the health system. Twelve ministries have collaborated to develop the current national nutrition action plan, and they all have a co-responsibility in implementing the actions. The action plan serves as a tool for decision-makers, professionals, experts and others in the public and private sectors and in the NGO sector.
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7.4 Physical activity During a relatively short course of time, society has gone through immense changes regarding daily demands of physical activity. Today, we have to actively seek out and give priority to a number of those experiences, challenges and skills that constituted an integral part of everyday life in the past. The level of physical activity in the Norwegian population is considered to be too low, and there are marked social differences. The World Health Organization points out that physical inactivity will be the great health challenge in the future. Due to lack of physical activity and unhealthy diet the incidence of obesity is increasing, and diseases such as type 2 diabetes, cardiovascular diseases and certain forms of cancer are closely linked to physical inactivity in the population. To meet the challenge, an Action Plan on Physical Activity (2005-2009) – “Working together for Physical Activity”, was published in 2004. The plan was developed through a co-operation between eight different Ministries, and contains 108 measures. The plan has two main targets: An increase in the number of children and youth who are physically active for at least 60 minutes pr day An increase in the number of adults and elderly people who are moderately physically active for at least 30 minutes pr day An evaluation of the action plan in 2009 will help to decide further actions on promoting physical activity.
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8
Universal design - The Delta centre
“Delta” is Norwegian for “participate”. The Delta centre is the national resource centre for participation and accessibility for persons with disabilities. The centre’s activities are based on the Government’s policy on persons with disabilities and on the Standard Rules of the United Nations. The main goal of the Delta centre is to ensure that persons with disabilities can actively participate in society on an equal footing with others. Its vision is participation and accessibility for all. The work of the Delta centre is based on the combination of universal design, environmental adaptation and assistive technology as methods to facilitate participation and accessibility for persons with disabilities. The main areas of work are to identify disabling barriers and to show how these can be reduced or removed, to develop knowledge on accessibility and to provide counselling on best practise. User participation is an overarching principle and a strategic method to be employed in all activities at the Delta centre.
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Preparedness
Health and social preparedness is directed towards the protection of the citizens’ health and social welfare during crises and other unexpected, extraordinary situations. All preparedness work within the health sector is based on the “principles of responsibility, similarity and proximity”. The organisational unit responsible for a particular task under normal circumstances is obliged by law to prepare for the continuation of its operations during an emergency. The crisis management should be as close to the normal organisation as possible and crises should be handled as close to the scene as the situation permits. 9.1 Aims It follows from the above mentioned principles that the responsibility for the local and regional preparedness lies with the regional municipal authorities. Guidance is given from the Emergency Preparedness Department based in the 34
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Directorate of Health. The aim is to build a robust, well functioning health and social preparedness system in the municipalities, the counties and the health regions. The following elements shall be mentioned: • • • •
Preparation of national plans and guidance material, including the National Influenza Pandemic Preparedness Plan and the National Smallpox Preparedness Plan Supporting regional exercises in the field of health and social preparedness Maintenance of a national stockpile of selected medicines, including antivirals against pandemic influenza and potassium iodide against radioactive iodine, a possible contaminant from a nuclear accident International, particularly inter-Nordic cooperation, in the field of health preparedness
Links Action plan on Physical Activity 2005-2009 – “Working together for Physical Activity”, www.1-2-30.no/bedrehelse/handlingsplanen Norway's National Strategy for Tobacco Control 2006-2010: www.helsedirektoratet. no/tobakk/english Norwegian Directorate of Health: www.helsedirektoratet.no Norwegian Institute for Alcohol and Drug Research, SIRUS: www.sirus.no Statistics Norway: www.ssb.no/english The Cancer Registry of Norway: www.kreftregisteret.no The Delta Centre: www.helsedirektoratet.no/deltasenteret/english The Ministry of Health and Care Services: www.hod.dep.no The Norwegian Board of Health: www.helsetilsynet.no The Norwegian Government: www.government.no The Norwegian Institute of Public Health: www.fhi.no The Norwegian Medicines Agency: www.legemiddelverket.no The Norwegian Radiation Protection Authority: www.nrpa.no The Norwegian Registration Authority for Health Personnel: www.safh.no 35
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Heftet er utgitt av Helsedirektoratet Postboks 7000 St.Olavs plass, 0130 Oslo. Flere eksemplarer kan bestilles fra mailadressen trykksak@shdir.no
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Health Systems in Transition Vol. 9 No. 6 2007
Denmark Health system review
Martin Strandberg-Larsen Mikkel Bernt Nielsen Signild Vallgårda • Allan Krasnik Karsten Vrangbæk
Editor: Elias Mossialos
Denmark HiT covers:IFC
26/2/08
15:41
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Editorial Board Editor in chief Elias Mossialos, London School of Economics and Political Science, United Kingdom and European Observatory on Health Systems and Policies Editors Reinhard Busse, Berlin Technical University, Germany Josep Figueras, European Observatory on Health Systems and Policies Martin McKee, London School of Hygiene and Tropical Medicine, United Kingdom and European Observatory on Health Systems and Policies Richard Saltman, Emory University, United States Editorial team Sara Allin, European Observatory on Health Systems and Policies Cristina Hernandez Quevedo, European Observatory on Health Systems and Policies Anna Maresso, European Observatory on Health Systems and Policies David McDaid, European Observatory on Health Systems and Policies Sherry Merkur, European Observatory on Health Systems and Policies Philipa Mladovsky, European Observatory on Health Systems and Policies Bernd Rechel, European Observatory on Health Systems and Policies Erica Richardson, European Observatory on Health Systems and Policies Sarah Thomson, European Observatory on Health Systems and Policies International advisory board Tit Albreht, Institute of Public Health, Slovenia Carlos Alvarez-Dardet Díaz, University of Alicante, Spain Rifat Atun, Imperial College London, United Kingdom Johan Calltorp, Swedish Association of Local Authorities and Regions, Sweden Armin Fidler, The World Bank Colleen Flood, University of Toronto, Canada Péter Gaál, Semmelweis University, Hungary Unto Häkkinen, Centre for Health Economics at Stakes, Finland William Hsiao, Harvard University, United States Alan Krasnik, University of Copenhagen, Denmark Joseph Kutzin, World Health Organization Regional Office for Europe Soonman Kwon, Seoul National University, Korea John Lavis, McMaster University, Canada Vivien Lin, La Trobe University, Australia Greg Marchildon, University of Regina, Canada Alan Maynard, University of York, United Kingdom Nata Menabde, World Health Organization Regional Office for Europe Ellen Nolte, London School of Hygiene and Tropical Medicine, United Kingdom Charles Normand, University of Dublin, Ireland Robin Osborn, The Commonwealth Fund, United States Dominique Polton, National Health Insurance Fund for Salaried Staff (CNAMTS), France Sophia Schlette, Health Policy Monitor, Germany Igor Sheiman, Higher School of Economics, Russia Peter C. Smith, University of York, United Kingdom Wynand P.M.M. van de Ven, Erasmus University, The Netherlands Witold Zatonski, Marie Sklodowska-Curie Memorial Cancer Centre, Poland
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Health Systems in Transition Written by Martin Strandberg-Larsen, Department of Public Health, University of Copenhagen Mikkel Bernt Nielsen, Department of Public Health, University of Copenhagen Signild Vallgårda, Department of Public Health, University of Copenhagen Allan Krasnik, Department of Public Health, University of Copenhagen Karsten Vrangbæk, Department of Political Science, University of Copenhagen Edited by Elias Mossialos, European Observatory on Health Systems and Policies
Denmark:
Health System Review
2007
The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.
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Keywords: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS – organization and administration DENMARK © World Health Organization 2007, on behalf of the European Observatory on Health Systems and Policies All rights reserved. The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full. Please address requests about this to:
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The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners.
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or any of its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
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Suggested citation: Strandberg-Larsen M, Nielsen MB, Vallgårda S, Krasnik A, Vrangbæk K and Mossialos E. Denmark: Health system review. Health Systems in Transition, 2007; 9(6): 1–164.
ISSN 1817-6127 Vol. 9 No. 6
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Contents
Preface.............................................................................................................v Acknowledgements...................................................................................... vii List of abbreviations......................................................................................ix List of tables and figures................................................................................xi Abstract....................................................................................................... xiii Executive summary.......................................................................................xv 1. Introduction...........................................................................................1 1.1 Overview of the health system.......................................................1 1.2 Geography and sociodemography..................................................1 1.3 Economic context...........................................................................4 1.4 Political context..............................................................................5 1.5 Health status....................................................................................6 2. Organizational structure......................................................................19 2.1 Historical background...................................................................19 2.2 Organizational overview...............................................................25 2.3 Decentralization and centralization..............................................26 2.4 Population coverage......................................................................29 2.5 Entitlements, benefits and patient rights.......................................30 3. Planning, regulation and management................................................39 3.1 Regulation.....................................................................................39 3.2 Planning and health information management.............................42 4. Financial resources.............................................................................51 4.1 Revenue mobilization...................................................................53 4.2 Allocation to purchasers...............................................................59 4.3 Purchasing and purchaser–provider relations...............................60 4.4 Payment mechanisms....................................................................62 4.5 Health care expenditure................................................................64 iii
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5. 6. 7. 8. 9. 10.
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Physical and human resources............................................................69 5.1 Physical resources.........................................................................69 5.2 Human resources..........................................................................80 Provision of services...........................................................................93 6.1 Public health.................................................................................93 6.2 Patient pathways...........................................................................98 6.3 Primary/ambulatory care............................................................100 6.4 Secondary/inpatient care.............................................................104 6.5 Pharmaceutical care....................................................................105 6.6 Rehabilitation/intermediate care.................................................108 6.7 Long-term care............................................................................109 6.8 Services for informal carers........................................................ 111 6.9 Palliative care..............................................................................112 6.10 Mental health care.....................................................................115 6.11 Dental health care.....................................................................120 6.12 Alternative/complementary medicine.......................................122 6.13 Maternal and child health.........................................................124 6.14 Health care for specific populations.........................................125 Principal health care reforms............................................................127 7.1 Analysis of recent reforms..........................................................127 7.2 Recent developments..................................................................130 Assessment of the health system......................................................133 8.1 Objectives of the health system..................................................133 8.2 Distribution of the health system’s costs and benefits across the population................................................................133 8.3 Efficiency of resource allocation in health care..........................135 8.4 Technical efficiency in the production of health care.................136 8.5 Accountability of payers and providers......................................137 8.6 The contribution of the health system to health improvement...137 Conclusions.......................................................................................139 Appendices.......................................................................................143 10.1 References.................................................................................143 10.2 Principal legislation..................................................................158 10.3 Useful web sites........................................................................159 10.4 HiT methodology and production process................................160
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Preface
T
he Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of reform and policy initiatives in progress or under development in a specific country. Each profile is produced by country experts in collaboration with the Observatory’s research directors and staff. In order to facilitate comparisons between countries, the profiles are based on a template, which is revised periodically. The template provides detailed guidelines and specific questions, definitions and examples needed to compile a profile. HiT profiles seek to provide relevant information to support policy-makers and analysts in the development of health systems in Europe. They are building blocks that can be used: • to learn in detail about different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; • to describe the institutional framework, the process, content and implementation of health care reform programmes; • to highlight challenges and areas that require more in-depth analysis; • to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in different countries. Compiling the profiles poses a number of methodological problems. In many countries, there is relatively little information available on the health system and the impact of reforms. Due to the lack of a uniform data source, quantitative data on health services are based on a number of different sources, including the v
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World Health Organization (WHO) Regional Office for Europe Health for All database, national statistical offices, Eurostat, the Organisation for Economic Co-operation and Development (OECD) Health Data, the International Monetary Fund (IMF), the World Bank, and any other relevant sources considered useful by the authors. Data collection methods and definitions sometimes vary, but typically are consistent within each separate series. A standardized profile has certain disadvantages because the financing and delivery of health care differ across countries. However, it also offers advantages, because it raises similar issues and questions. The HiT profiles can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situation. They can also be used to inform comparative analysis of health systems. This series is an ongoing initiative and material is updated at regular intervals. Comments and suggestions for the further development and improvement of the HiT series are most welcome and can be sent to: info@obs.euro.who.int. HiT profiles and HiT summaries are available on the Observatory’s web site at www.euro.who.int/observatory. A glossary of terms used in the profiles can be found at the following web page: www.euro.who.int/observatory/glossary/ toppage.
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Acknowledgements
T
he Health Systems in Transition profile on Denmark was written by Martin Strandberg-Larsen (PhD Fellow, Department of Public Health, University of Copenhagen), Mikkel Bernt Nielsen (Research Assistant, Department of Public Health, University of Copenhagen), Signild Vallgårda (Associate Professor, Department of Public Health, University of Copenhagen), Allan Krasnik (Professor, Department of Public Health, University of Copenhagen) and Karsten Vrangbæk (Associate Professor, Department of Political Science, University of Copenhagen). Hans Okkels Birk (Part-time Lecturer, Department of Public Health, University of Copenhagen) wrote the section on capital investments and provided critical input into Chapter 4 on financial resources. Ellen Westh Sørensen (Professor, Department of Pharmacology and Pharmacotherapy, University of Copenhagen) wrote the sections on pharmaceuticals and pharmaceutical care, which have been subsequently reviewed and commented on by Merete W Nielsen (Assistant Professor, Department of Pharmacology and Pharmacotherapy, University of Copenhagen) and Jørgen Clausen (Chief Economist, Department of Economics and Political Affairs, Danish Association of the Pharmaceutical Industry). The section on palliative care was commented on by Mogens Grønvold (Associate Professor, Department of Public Health, University of Copenhagen), and Christina Novinskey (London School of Economics and Political Science) helped with the editing and copy-editing of the first draft. The current series of HiT profiles has been prepared by the staff of the European Observatory on Health Systems and Policies. The European Observatory on Health Systems and Policies is a partnership between the vii
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WHO Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. The Observatory team is led by Josep Figueras, Director, and Elias Mossialos, Co-director, and by Martin McKee, Richard Saltman and Reinhard Busse, heads of the research hubs. Jonathan North managed the production of the profile, with the support of Nicole Satterley (copy-editing), Shirley and Johannes Frederiksen (layout) and Aki Hedigan (proofreading). Administrative support for preparing the HiT profile on Denmark was undertaken by Caroline White. Special thanks are extended to the WHO European Health for All database, from which data on health services were extracted; to the OECD for the data on health services in western Europe; and to the World Bank for the data on health expenditure in central and eastern European countries. Thanks are also due to national statistical offices which have provided national data. The data used in this report are based on information publicly available in August 2007.
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List of abbreviations
AIDS BMI CAM CIS COPD CPR CT CVU DACEHTA DALE DDB DIHTA DKK DMFT DRG DSI EHR EU EU12 EU15 FBR FTDB GDP GNP GP HALE HIV HTA ICD IMF
Acquired immunodeficiency syndrome Body mass index Complementary and alternative medicine Commonwealth of Independent States Chronic obstructive pulmonary disease Personal identification (register and number) Computed tomography Centre(s) for Advanced Education Danish Centre for Evaluation and Health Technology Assessment Disability-adjusted life expectancy Demographic Database Danish Institute for Health Technology Assessment Danish krone (unit of currency) Decayed, missing and filled teeth Diagnosis-related group(s) Danish Institute of Health Services Research Electronic health record(s) European Union Countries that joined the EU in May 2004 and January 2007 European Union Member States before May 2004 Prevention Register Fertility Database Gross domestic product Gross national product General practitioner Healthy life expectancy Human immunodeficiency virus Health technology assessment (WHO) International Classification of Diseases International Monetary Fund ix
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IT IVF LPR MMR MRI OECD OTC PLO PPP SBR SIF SSI SUSY TB VAT VHI WHO WTO XML
x
Information technology In vitro fertilization National Patient Register Immunization against measles, mumps and rubella Magnetic resonance imaging Organisation for Economic Co-operation and Development Over-the-counter (pharmaceuticals) Organisation of General Practitioners in Denmark Purchasing power parity Hospital Use Statistics Register National Institute of Public Health National Serum Institute Danish Health and Morbidity Survey Tuberculosis Value-added tax Voluntary health insurance World Health Organization World Trade Organization eXtensible Markup Language
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List of tables and figures Tables
Table 1.1 Table 1.2 Table 1.3 Table 1.4 Table 1.5 Table 1.6 Table 1.7 Table 1.8 Table 2.1 Table 2.2 Table 4.1 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 5.5 Table 6.1 Table 6.2 Table 7.1
Population/demographic indicators, 1970–2004 (selected years) Macroeconomic indicators, 1996–2006 (selected years) Average life expectancy at birth in Denmark, Norway, Sweden and the United Kingdom in 1970–1994 and 1995–2000 Mortality and health indicators, 1960–2002 (selected years) Main causes of death, 1995, 1997 and 1999 (ICD 10 Classification) The 10 most common diagnoses on discharge from hospital, 2000 Healthy life expectancy and disability-adjusted life expectancy (DALE), 2000–2002 Decayed, missing and filled teeth (DMFT) at age 12 years, 1975–2003 (selected years) Trends in the evolution of the health care sector, 1936–2003 (selected years) Political bodies, administrative bodies and health care responsibilities Trends in health care expenditure, 1980–2003 (selected years) Activity in somatic hospitals, 1996–2005 (selected years) Activity in psychiatric hospitals, 1997–2003 Pharmaceutical consumption in Europe, 2002 Health care personnel per 1000 population, 1980–2003 (selected years) Intake of other health care personnel for 2001 and 2002 Number of full-time specialist professionals involved in the delivery of mental health care, 2001–2003 Reproductive health, 1991–2004 (selected years) Overview of major reforms and policy initiatives with a substantial impact on health care, 1970–2007
4 5 7 8 10 11 12 17 25 28 64 70 70 75 86 88 119 124 128
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Figures
Fig. 1.1 Fig. 1.2 Fig. 1.3 Fig. 1.4 Fig. 1.5 Fig. 1.6 Fig. 1.7 Fig. 2.1 Fig. 4.1 Fig. 4.2 Fig. 4.3 Fig. 4.4 Fig. 5.1 Fig. 5.2 Fig. 5.3 Fig. 5.4 Fig. 5.5 Fig. 5.6 Fig. 5.7 Fig. 5.8 Fig. 5.9 Fig. 6.1 Fig. 6.2 Fig. 6.3
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Overview chart of the health system Map of Denmark Average life expectancy (in years) for men and women, 1901–2003 Mortality for different age groups, 1985–2005 Number of men and women who are overweight or severely overweight, 1987, 1994, 2000 Share of daily smokers as a percentage of the total population, 1953–2004 (selected years) Levels of immunization for measles in the WHO European Region, 2005 Organizational chart of the statutory health system Financing flow chart Health care expenditure as a share (%) of GDP in the WHO European Region, 2004, WHO estimates Trends in health care expenditure as a percentage of GDP in Denmark and selected other countries, 1998–2004, WHO estimates Health care expenditure in US$ PPP per capita in the WHO European Region, 2004, WHO estimates Beds in acute hospitals per 1000 population in Denmark, selected countries and EU averages, 1990–2005 Internet access by the Danish population, 2004 (%) Number of people treated with prescribed medicinal products in the primary health care sector, by sex and age Price index for medicines, 2003 Number of physicians per 1000 population in Denmark, selected countries and EU averages, 1990–2005 Number of nurses per 1000 population in Denmark, selected countries and EU averages, 1990–2005 Number of physicians and nurses per 1000 inhabitants in the WHO European Region, 2005 or latest available year (in parentheses) Number of dentists per 1000 inhabitants in Denmark, selected countries and EU averages, 1990–2005 Number of pharmacists per 1000 population in Denmark, selected countries and EU averages, 1990–2005 Group 1 patient pathway in the statutory health care system Organization of the distribution system for pharmaceuticals, 2006 Percentage of the population having received different forms of alternative treatment in 2003
2 3 7 10 13 14 18 27 52 65 66 67 71 73 76 77 81 82 83 84 86 98 106 123
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Abstract
T
he Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. Denmark is a small country with 5.4 million inhabitants; however, it is one of the wealthiest countries in the world. It is a monarchy with fairly autonomous local governments, consisting of 5 regions and 98 municipalities. Population health, as measured by life expectancy, is relatively low in comparison to other European countries, but it has recently increased. The Danish health care sector is dominated by the public sector and is financed by local and state taxes. Somatic and psychiatric health care, carried out at public hospitals, and primary health services, which are delivered by general practitioners (GPs) and other practising health professionals, are administered by the regions. The regions are financed by the State and to a certain extent by the municipalities. The regions own and run most hospitals, and practising health professionals are self-employed and reimbursed by the regions, mainly using a fee-forservice mechanism. The municipalities are responsible for elderly care, social psychiatry, prevention and health promotion, rehabilitation and other types of care that are not directly related to hospital inpatient care. Access to health care is fairly equal when health status is taken into account. For all citizens with residence permits, access to health care is free of charge at hospitals and from GPs, whereas access to pharmaceuticals, dentists and some other services require co-payment. During recent years, the focus of health care reforms has been on xiii
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patient choice, waiting times, quality assurance and coordination of care. A major structural reform in 2007 has changed the political and administrative landscape of health care, dramatically reducing the number of regional and local units and transferring health care responsibilities for prevention and rehabilitation from the regional to the local level.
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Executive summary
D
enmark is a small country and relatively prosperous country in northern Europe. Like the other Scandinavian countries, Denmark is characterized by a strong welfare state tradition, with universal coverage of health services mainly financed via taxation. Access to the health system, including diagnostic and treatment services, is free for all citizens except for certain services such as dental care, physiotherapy and medicine requiring patient co-payment. Equity and solidarity are important underlying values in the system, and surveys show a persistently high level of patient satisfaction. The system has a relatively good track record in terms of controlling expenditure and introducing organizational and management changes, such as transition to ambulatory care, and introduction of activity-based payment. The Danish health system is governed by a combination of national state institutions, regions and municipalities. All three levels have democratically elected assemblies and there is a tradition of decentralization of management and planning to the regions and municipalities. National-level institutions include the Parliament, the Government and various state bureaucratic institutions. The state level is responsible for the overall legal framework for health care, and for coordinating and supervising the regional and municipal delivery of services. Five regions are responsible for delivering both primary and secondary health services. Most hospitals are owned and operated by the regions, and hospital doctors are salaried employees of the regions. Practising doctors are private, rather than state practitioners, but receive almost all of their income from services paid by the regions.
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Several current and future challenges can be identified. Danes have shorter life expectancy than many other Europeans. This has mostly been attributed to lifestyle issues, but health system performance has also been questioned, particularly in areas such as cancer care and cardiovascular disease. Coordination of care has also emerged as a general issue with potential for improvement, and waiting times have been a persistent political concern. More generally, the Danish system, like many other European health systems, faces challenges of guaranteeing access and quality while at the same time keeping costs under control. An ageing population and rising expectations regarding service are contributing factors in challenging the sustainability of the public health system. Activity-based payments, performance management and benchmarking, elements of managed competition and administrative reforms are some of the general policy responses that have been introduced to meet the challenges. Free choice of hospital was introduced in 1993, partially in response to waiting time issues. More recent initiatives have been an administrative reform in 2007, the introduction of a 1-month general waiting time guarantee and guaranteed access to hospital specialists within 48 hours of cancer diagnosis. The administrative reform of 2007 created larger regions and municipalities and changed the distribution of tasks and responsibilities. The underlying rationale was to facilitate centralization of service delivery at the hospital level and to give municipalities a stronger role in prevention and rehabilitation. Financing of regional health services was changed from predominantly regional taxation combined with some state grants, to a combination of state grants and municipal co-payments. The rationale behind this was to create more direct state control and to provide incentives for municipalities to step up their efforts in prevention, health promotion and rehabilitation. Financing Until 2007, the Danish health system was financed through progressive general income taxes at the national level and through proportional income and property taxes at the regional and local levels. The national-level tax revenue was redistributed to the counties and municipalities via block grants, based on objective criteria and some activity-based financing for hospitals. The system was designed to support solidarity in financing and equity in coverage. Since 2007, financing has been obtained through earmarked proportional taxation at the national level. Most of this revenue (80%) is redistributed to the regions via block grants, based on objective criteria (social and demographic indicators), and 20% is redistributed to the new municipalities which will use these funds xvi
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to co-finance regional hospital services for their respective populations. The system remains based on the general principles of solidarity, combined with some redistribution across the population. The earmarking of health care taxes is a new feature in Denmark and is intended to create greater transparency within this sector. However, it reduces the potential for redistribution of funds across sector areas. There is an increasing level of user payments for Danish health care, mostly involving payments for pharmaceuticals, dental care and physiotherapy, and it is related to a fast-growing private health insurance market, which has been partly established through labour market agreements for groups of employees. There is even some support for introducing more co-payments, such as patient fees for GP consultations, in order to reduce unnecessary utilization of services. These trends could lead to major changes in the health care financing patterns in Denmark over time, threatening the system’s general principles of solidarity, equity and tax-based financing of health care services. Principles of equity The current system is based on the principle of universal, free and equal access to health services. Although utilization patterns vary somewhat across regions, these objectives seem to be met to a fairly large extent. In practice, some groups, such as the homeless and mentally disabled, immigrants, and drug and alcohol abusers, appear to have a more unstable utilization pattern than other groups. The high individual costs for adult dental care seem to result in social inequity in the utilization of this kind of service, leading to social differences in dental health status. The use of private practising specialists shows a geographic and social bias as services are mostly offered in affluent urban areas. Patient choice appears to favour patients with a higher level of education and stable employment. There is some speculation that the increasing use of activitybased financing will divert investments and activity away from fields such as internal medicine and geriatrics to areas where increases in activity are easier to demonstrate. However, the evidence base for this is limited. Current resource allocations for health care, by and large, seem to meet the needs of the population. The reduction in waiting times and the general waiting time guarantee, related to the “extended free choice”, together ensure access to health care within relatively short periods. The waiting time guarantee ensures access to treatment within the public system or at private facilities in Denmark or abroad, in the event of expected waiting times exceeding 1–2 months. Patient satisfaction surveys continue to demonstrate remarkably high satisfaction figures for both GPs and hospital services. Equal access and utilization according xvii
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to need are likely to remain a strong focus in the Danish health sector in the future. However, ever increasing demands for new technology and expected changes in population age distribution and disease patterns might foster political initiatives to reduce access to publicly funded services through new financial and structural reforms. Quality and efficiency of Danish health care International comparisons of survival rates among some patient groups (i.e. patients with lung cancer and ovarian tumours) seem to indicate that the quality of some diagnostic and curative services is not optimal. This may be due to a lack of staff, equipment or skills or to structural problems in the Danish health system related to scale, specialization and coordination. There is an ongoing process leading to fewer and larger hospitals and to centralization of highly specialized care. A recent reform has given more power to the National Board of Health regarding the planning of such highly specialized services. There are also some issues of personnel coverage in peripheral areas, but the regional authorities are seeking to remedy such issues through the use of non-native doctors and nurses. Recent years have seen special emphasis on psychiatric care and common life-threatening diseases such as cancer and cardiovascular problems. Psychiatric conditions are, however, fairly low priority, as is the treatment of musculoskeletal ailments, despite general statements to the contrary in national health policy. There is no evidence of significant shifts in the balance between primary, secondary and tertiary care. However, a stated objective of the current structural reform is to create incentives for the municipalities to place more emphasis on prevention, health promotion and rehabilitation outside of hospitals. The health system is generally considered to provide good “value for money�. Consecutive government reports have indicated that the relationship between overall expenditure levels and service levels, including most available indicators on waiting times and quality, is acceptable in comparison to other European countries. This is a result of the many different initiatives aimed at controlling expenditure, raising productivity and improving quality. The use of global budgeting and hard budget constraints is a pervasive feature of the system. In recent years, this has been combined with internal contracts and some activitybased payments to encourage higher activity levels and stronger productivity. A recent government report points to gradually improving productivity within the sector and a 2.4% increase from 2003 to 2004. Hospitals are compared to average productivity at national and regional levels, showing only limited variation across the regions. There is limited information on the efficiency of the xviii
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primary sector, but it is assumed that combined per capita and fee-for-service payment provides incentives towards both the optimization of activity levels and composition. Doctors’ fees are negotiated with the public authorities on a regular basis and activity profiles are monitored regularly. GP gatekeeping has been a significant feature of the Danish system for many years, along with the general principle of treating patients at the lowest effective care level as opposed to providing free access to more specialized units. General policies are in place to promote the generic substitution of pharmaceuticals, and all regional authorities have implemented policies to monitor and influence the use of medicines in their health facilities. Efforts to reduce the general cost of pharmaceuticals have not been very successful, despite some positive results regarding drug pricing. Potential savings have been more than counterbalanced by the wider use of new and expensive pharmaceuticals and changes in indications for treatment of hypertension, high cholesterol, and so on. Some experiments with substituting doctors with nurses in selected areas have been carried out but the most important efficiency drive has been a massive and largely successful effort to convert inpatient treatment to outpatient or ambulatory treatment. Accountability of payers and providers is mainly achieved through hierarchical control within the political-bureaucratic structures at national, regional and municipal levels. The budgeting and economic management processes include accountability assessments at all levels. Annual negotiations between the State and the regional and municipal authorities involve evaluation of needs, outputs and new activity areas. Regional and municipal public management is based on contracting, incentives and monitoring measures to control the performance of hospitals and other public organizations. The activities of practising primary and secondary care doctors are monitored by the regional authorities, which also fund the activities in accordance with nationally negotiated fee schedules. Quality is monitored via internal management procedures, national measures of patient satisfaction and various national and regional initiatives to develop standards, clinical guidelines, clinical databases, and so on. Since 2007 all hospitals have been included in the Danish model for quality assurance and external accreditation takes place at regular intervals. A national system for reporting unintended events has been established. Health technology assessments (HTAs) are performed at national, regional and local levels. The HTA practice has become institutionalized via a national institute and several regional resource centres. HTA is recommended for major decisions, but has not yet been implemented across the board. Patient rights have been extended and formalized during recent years, and there are mechanisms for sanctioning professional misconduct and abuse. xix
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Public health As in other western European countries, mortality caused by heart diseases has declined remarkably during recent decades, partly due to better survival levels among patients with heart conditions. Survival of some types of cancer has increased due to better interventions. Denmark is, however, still lagging behind other Nordic countries as far as general mortality is concerned, as well as in relation to some cause-specific mortality rates. This is probably due to a combination of health care factors, environmental factors and lifestyle changes. It has been argued that the Danish population’s functional ability and quality of life have improved as a consequence of more advanced treatments both through surgery and pharmaceuticals, but there is little evidence to support this assumption. A recent study analysing mortality amenable to health care in 19 industrialized countries indicates that the Danish system is performing at an average level. Its performance is not as good as that of other Scandinavian countries (namely Norway and Sweden) but better than some other countries, such as the United Kingdom, Portugal, Ireland, the United States, Austria, New Zealand and Greece. In spite of rather weak Danish public health intervention regarding tobacco consumption, there has been a gradual, but recently stagnating, decline in tobacco consumption. Alcohol consumption is also high, despite efforts to improve this aspect of public health through general campaigns. These efforts, however, have been counteracted by a reduction in alcohol taxes. The present increase in obesity and related diseases, such as diabetes, has become a public health issue, but there have not been any major policy interventions to this effect. Health inequalities are increasing between educational and occupational groups in Denmark. However, there is no evidence indicating that these inequalities are due to unequal access to, or utilization of, health care services, except in specific services such as dental care, where high co-payments apply. Rather, they are caused by unfavourable social and environmental conditions and health behaviours among some population groups, which cannot be addressed by the current, ongoing public health interventions.
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1
1.1
Denmark
Introduction
T
Overview of the health system
1.2
Geography and sociodemography
he defining feature of the Danish health system is decentralized responsibility for primary and secondary health care, as illustrated in Fig. 1.1. At the state level the Ministry of Health has a governing role over municipal organization and management, as well as the supervision and partial financing of the municipalities and regions. In the field of health care, the Ministry is in charge of the administrative functions that are related to the organization and financing of the health system, psychiatry and health insurance as well as the market authorization of pharmaceuticals and supervision of the pharmacy sector. Prevention and health promotion are also part of the Ministry’s remit. Figure 1.1 provides further details of the Ministry’s responsibilities. The regions own and run hospitals, and partly or fully finance private practitioners such as general practitioners (GPs), specialists, chiropractors and physiotherapists. They also provide reimbursement for pharmaceutical care. At the local level, the municipalities are responsible for disease prevention, health promotion and rehabilitation outside hospitals, as well as other areas of health care, as illustrated in Fig. 1.1. For an expanded description of the structure of the health system, see Section 2.2 “Organizational overview”.
Denmark is one of the Scandinavian countries. The mainland is located north of its only land neighbour, Germany, south-west of Sweden, and south of Norway. Denmark also encompasses two off-shore territories, Greenland and 1
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Fig. 1.1
Denmark
Overview chart of the health system
Central Government
National Board of Health
Medical public health officers
Danish Medicines Agency The National Serum Institute a
Patients’ Complaints Board Ministry of Health
Complaints Board for Patients´ Injury
a
Knowledge and Resource Center for Alternative Medicine The Danish National Committee for Biomedical Research Ethics The Danish Council of Ethics
Public General and Psychiatric Hospitals Regions
Maternity Care Payment to private practitioners and pharmaceuticals District Psychiatry Disease prevention and health promotion Child preventive care
Municipalities
Nursing home and home care Treatment of drug and alcohol abusers Dental care for children and disabled Social psychiatry
Private owners
Primary care providers and clinics with an agreement with the regions Primary care providers and clinics without an agreement with the regions Pharmacies Private hospitals
Source: Authors’ composition. Note: a The Patients’ Complaints Board and the Complaints Board for Patients’ Injury are two separate institutions. The Patients’ Complaints Board is responsible for processing complaints regarding health professional activities in the health care system. The Complaints Board for Patients’ Injury handles patients’ applications for compensation regarding injuries caused by malpractice in the health care system. 2
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the Faroe Islands, granted home rule in 1979 and 1948, respectively. It is a country consisting of a mainland peninsula and a number of islands (Fig. 1.2). The climate is temperate. Denmark is a small country with few inhabitants, but with a high population density (Table 1.1). The demographic development is similar to other western European countries, with an increasing proportion of elderly people and a low birth rate. Fig. 1.2
Map of Denmark
Norway Skagerrak
Skagen
Sweden
Ålborg Kattegat
Jutland Århus
Helsingør Horsens Vejle Esbjerg Fredericia Roskilde Odense
Funen Åbenrå
North Sea
Copenhagen
Zealand
Bornholm
Lolland Falster
Baltic Sea
Germany 0 0
50 km 50 mi
Poland
Source: CIA, 2005.
3
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Table 1.1 Population/demographic indicators, 1970–2004 (selected years)
Total population Population, female (% of total) Population, ages 0–14 (% of total) Population, ages 65 and above (% of total) Population growth (%) Population density (people per km2) Fertility rate, total (births per woman) Birth rate, crude (per 1000 people) Standardized death rate (per 1000 people) Age dependency ratio (population aged 0–14 and 65+ divided by population aged 15–64 years x100) Distribution of population (% urban)
1970 4 920 966
1980 5 122 065
1990 5 135 409
2000 5 330 020
2004 5 397 640
50.28
50.62
50.72
50.58
50.53
23.36
21.11
17.15
18.41
18.85
12.15
14.34
15.59
14.83
14.91
–
4.09
0.26
3.79
1.27
114.6
118.9
119.2
123.7
125.2
1.95
1.55
1.67a
1.77
1.72a
14.39
11.19
12.35
12.59
12.46b
9.58
9.22
8.74
7.52
7.49c
0.55
0.55
0.49
0.50
0.51
–
84
85
85c
–
Sources: European Union, 2005; Statistics Denmark, 2005; WHO, 2005. Notes: a 2002; b 2003; c 2001.
1.3
Economic context
Denmark is one of the richest countries in the world. It is characterized by a fairly equal distribution of income across the population (Table 1.2). Until the 1950s, agriculture provided the biggest share of export and national income; since then, industry and services have dominated, with the latter growing the most rapidly. Except for oil, natural gas and fertile soil, the country is poor in natural resources. The general level of education of the population is fairly high, with 32% and 18% of the population between 20 and 69 years having attended secondary and tertiary education, respectively. Unemployment has decreased since the mid-1990s; however, it is still high among some ethnic minority groups.
4
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Table 1.2 Macroeconomic indicators, 1996–2006 (selected years) GDP, million US$ at exchange rate GDP per capita, US$ at exchange rate Value added in industry (% of GDP) Value added in agriculture (% of GDP) Value added in services (% of GDP) Labour force (thousands of persons) Unemployment, total (% of labour force) Gini coefficient
1996
1998
2000
2002
2004
2006
184.394
173.674
160.144
173.984
243.639
275.227
35.036
32.743
29.992
32.375
45.110
47.759*
–
–
27.2
26
25.5
–
–
–
2.9
2.6
2.2
–
–
–
69.9
71
72.3
–
2.822
2.848
2.853
2.849
2.883
2.875*
6.9 –
5.4 –
4.6 –
4.7 0.25
5.7 –
5* –
Sources: OECD, 2007; CIA, 2007. Notes: GDP: Gross domestic product; *2005, latest available.
1.4
Political context
Denmark is a constitutional monarchy and a parliamentary democracy. The Government is the executive body and the Parliament is the legislative body. Over the decades, the high court has dealt with what could be referred to as political issues, but plays a minor role in this sense. The minimum percentage of the votes necessary for a party to be represented in the Parliament is 2% and at the time of writing there are seven political parties, plus four representatives for Greenland and the Faeroe Islands. The three largest parties are the Liberal Party, the Social Democrats and the Danish People’s Party. There is a long tradition in Denmark of minority governments consisting of two or three parties. The current Government, which has been in power since 2001, is made up of a coalition between the Liberal Party and the Conservative Party, and is supported by the Danish People’s Party. It has replaced a coalition government consisting of the Social Democrats and the Social Liberals. The regional political level includes five regions. One of the main responsibilities of this level of government is the health care sector. The local level consists of 98 municipalities. The municipalities are accountable for schools, social services, prevention and health promotion, as well as health care services. Denmark has been a member of the European Union (EU) since 1973. It is also a member of the United Nations, the World Health Organization (WHO), the World Trade Organization (WTO) and the Council of Europe. 5
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Denmark participates in the following international conventions: the Convention against Torture and Other Cruel, Inhuman and Degrading Treatment or Punishment; the International Covenant on Civil and Political Rights; the Convention on the Elimination of All Forms of Discrimination against Women; the International Convention on the Elimination of All Forms of Racial Discrimination; the International Covenant on Economic, Social and Cultural Rights; the International Convention on the Protection of the Rights of All Migrant Workers and Members of Their Families; and the Convention on the Rights of the Child, with the Optional Protocols on the involvement of children in armed conflict and on the sale of children, child prostitution and child pornography.
1.5
Health status
From an international perspective, health status in Denmark can generally be characterized as good in terms of morbidity and mortality indicators. However, over recent decades, the population health status has progressed at a lesser rate than in other European countries. Nevertheless, life expectancy trends show that there was a marked improvement in the population’s health status during the latter half of the 1990s. Life expectancy As Fig. 1.3 and Table 1.3 show, the average life expectancy in Denmark has increased substantially during the 20th century, albeit with somewhat different developments for men and women. Historically, male life expectancy has remained almost stagnant since the early 1950s, only beginning to grow again during the 1990s. Female life expectancy, however, rose rapidly until the 1970s, with smaller increases from then on. Until 1995, the overall average life expectancy in Denmark increased at a slower pace than in other western European countries. However, from 1995 onwards, the average life expectancy increased significantly and at a higher pace than in most other western European countries. Table 1.4 shows that, when including the whole period between 1995 and 2002, the average life expectancy increased by 1.7 years for women and by 2.1 years for men. During these eight years the increase in Danish life expectancy was equivalent to that experienced in the previous 25 years. The increase in life expectancy is mostly noticeable among men, which could be primarily attributed to a decline in the infant mortality rate over the same period of time (Ministry of the Interior and Health 2004c). 6
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Fig. 1.3
Denmark
Average life expectancy (in years) for men and women, 1901–2003
85
80
75
70
65
60
55
Men
2001–2003
1996–2000
1991–1995
1986–1990
1981–1985
1976–1980
1971–1975
1966–1970
1961–1965
1956–1960
1951–1955
1946–1950
1941–1945
1936–1940
1931–1935
1926–1930
1921–1925
1916–1920
1911–1915
1906–1910
1901–1905
50
Women
Sources: DIKE, 1997; Statistics Denmark, 2005.
Table 1.3 Average life expectancy at birth in Denmark, Norway, Sweden and the United Kingdom in 1970–1994 and 1995–2000 Country Denmark Norway Sweden United Kingdom EU average
1970 73.3 74.2 74.8 72.0 –
1994 75.4 77.9 79.0 76.9 –
Change 2.1 3.7 4.2 4.9 –
1995 75.3 77.9 79.1 76.8 76.6
2000 76.9 78.8 79.9 78.1 77.9
Change 1.6 0.9 0.8 1.3 1.3
Sources: OECD, 2004; WHO, 2005. Note: EU: European Union.
In 2000 the Ministry of the Interior and Health carried out an extensive survey to reveal the less favourable health developments in Denmark. The survey concluded that the health status of women is lagging. For example, mortality rates, especially among women aged 35–64, have been less favourable in Denmark. Middle-aged women in Denmark have, on average, a 40–50% higher mortality rate than women in other EU countries. In particular, the increase in the incidence of cancer in women (primarily that of the breast and the lung) gives cause for concern. However, cardiovascular diseases and 7
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Table 1.4 Mortality and health indicators, 1960–2002 (selected years) 1960 1970 1980 1990 1995 1997 1998 2000 2001 2002 Life expectancy at birth (female) Life expectancy at birth (male) Life expectancy at birth (total) Mortality rate, adult female (per 1000 female adults) Mortality rate, adult male (per 1000 male adults) Mortality rate under 5 (per 1000 live births) Infant mortality rate (per 1000 live births)
74.4
75.9
77.3
77.7
77.8
78.4
78.6
79.3
79.3
79.5
70.4
70.7
71.2
72.0
72.7
73.3
73.7
74.5
74.7
74.8
72.2
73.3
74.3
74.9
75.3
78.9
76.2
76.9
77.0
77.2
–
–
9.9
11.4
12.0
11.4
10.9
10.9
11.0
–
–
–
11.9
12.3
12.1
11.3
11.0
10.6
10.5
–
–
16.9
10.4
8.9
6.3
6.2
5.7
5.7
–
–
21.5
14.2
8.4
7.5
5.1
5.3
4.7
5.3
4.9
4.4
Sources: OECD, 2004; National Board of Health, 2005b.
alcohol-related diseases in women have also contributed to this lagging health status. By contrast, the evolution of the mortality rate amongst Danish men is parallel to that of men in other EU countries (Ministry of the Interior and Health 2004c). Mortality and morbidity Most of the decline in Danish mortality rates during the 20th century has been among infants, children and young people. Infant mortality rates are now among the lowest in Europe. While life expectancy for a newborn boy has increased by 20 years over the last century, it rose by 4 years for a man aged 50 years or older. Declining mortality rates among children, young and middle-aged people are largely due to a decline in infectious diseases, including tuberculosis (TB). In the 1930s, 60% of those dying from TB were aged between 15 and 44 years. During the 1960s, people aged over 65 mainly died from cancer and cardiovascular diseases, which is still the case today. Causes of death have also differed according to gender, with mortality rates increasing among men due to cardiovascular diseases until the mid-1960s and decreasing among women since the early 1950s. During the late 1980s, Denmark had a lower mortality rate caused by cardiovascular diseases than Norway and Sweden, although the rate was still high compared to the rest of the EU. Smoking, especially among women, is more common in Denmark than in many other EU countries and alcohol 8
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consumption is higher than that of other Scandinavians, but lower than that of the French and the Austrians. Danes also have the highest calorie intake of all EU citizens (according to figures based on the amount of food sold) (Ministry of Health 1998). Taken together, however, these lifestyle factors still do not sufficiently explain Denmark’s poor progress in increasing longevity. Figure 1.4 illustrates the mortality trends for five age groups during the period 1985–2005. Mortality for the age group under 24 years has decreased substantially during the 1990s. The number of deaths in this age group was reduced by almost a third during this period. Since 1995, the mortality rate for all age groups has decreased, including for those 70 years and older, which experienced a slight increase in the first half of the 1990s. In 1999, the mortality rate for this age group (70+) was very similar to that of 1990 and 6% lower than that in 1995. In the first half of the 1990s, the mortality rate was unchanged for the age group 30–49 years and thereafter began to decrease significantly – approximately 20% from 1995 to 2001. The mortality rate decreased by 23% over the entire period, and it decreased significantly in the last few years of the 1990s for the age group 50–69 years. Mortality rate differences between social classes are much less pronounced among women. If the average mortality rate is 100, male mortality varies by occupational group from approximately 72 to 125 (with some outliers, such as merchant seamen and fishermen at approximately 2000), whereas the range of variation for women only lies between 90 and 110. In fact, female skilled workers and white collar workers have a lower mortality rate than women in the highest occupational groups (Ministry of Health 2000). See “Inequalities in health” later in this chapter for further elaboration on these findings. Recent research into general morbidity amongst Danish citizens (see Table 1.5) shows a rise within the population in the last few years. This rise has been demonstrated in both women and men, and across all age groups. The percentage of the population reporting to be suffering from one or more longstanding illnesses is also increasing. The most common of the long-standing illnesses are musculoskeletal diseases, respiratory diseases, cardiovascular diseases, diseases of the nervous system and sensory diseases. The most common complaints and symptoms reported during a 14-day period are pains or aches in the neck, the shoulders, the back, the limbs, the hips or the joints, headaches, tiredness, and colds, including head colds or coughing (Ministry of the Interior and Health 2002b). Two groups of illnesses stand out from the others. First, asthma, hay fever and other allergies and head colds, and, second, musculoskeletal diseases (Ministry of the Interior and Health 2002b). Regarding prevention, both of these 9
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Fig. 1.4
Denmark
Mortality for different age groups, 1985–2005
120
110
100
90
80
70
60
50
40 1985
1990 0–24
1995 25–44
2000
45–64
65–74
2005 75+
Source: National Board of Health, 2005b. Notes: 2005 data are provisional; Index 1985=100. Table 1.5 Main causes of death, 1995, 1997 and 1999 (ICD 10 Classification)
I. All causes II. Perinatal conditions (P00-P96, A33) III. Communicable diseases Infectious and parasitic diseases (A00-B99) Tuberculosis (A17-A19) IV. Noncommunicable conditions Circulatory diseases (I00-I99) Malignant neoplasms (C00-C97) Trachea/bronchus/lung cancers (C33-C34) Mental disorders (F01-F99) Other diseases of the digestive system (K00-K92) V. External causes (V01-Y88)
1995 62 815 176 656 637 19 46 045 24 926 15 701 3 506 935
1997 59 606 168 383 376 7 42 945 22 003 15 254 3 427 1 234
1999 58 722 124 469 465 4 43 122 21 459 15 444 3 376 1 751
977
1 027
1 092
2 464
2 425
2 453
Source: WHO, 2005. Notes: ICD; WHO International Classification of Diseases. 10
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Table 1.6 The 10 most common diagnoses on discharge from hospital, 2000 1 2 3 4 5 6 7 8 9 10
Diagnoses Diseases of the circulatory system Neoplasms Injury, poisoning and other consequences of external causes Pregnancy, childbirth and puerperal conditions Diseases of the digestive system Diseases of the respiratory system Symptoms and other ill-defined conditions Diseases of the musculoskeletal system Diseases of the genitourinary system Diseases of the nervous system and sense organs
Total 141 926 105 152
% 12.7 9.4
101 203
9.0
90 724 88 167 85 647 68 833 55 145 54 566 25 928
8.1 7.9 7.6 6.1 4.9 4.9 2.3
Source: National Board of Health, 2005c.
groups have been given priority in recent years. The main diseases diagnosed in hospitals are cardiovascular diseases, tumours and injuries (see Table 1.6). Morbidity rates were reported by the National Institute of Public Health in 1987, 1994 and 2000. The Danish Health and Morbidity Survey (SUSY) in 2000 was based on a representative sample of approximately 22 500 people over the age of 16. As many as 78% of those surveyed considered their individual health status to be “good” or “very good” (the top two grades in a 5-grade scale) (Kjøller & Rasmussen 2002). The earlier surveys show a similar trend, with a positive health response ranging from 78% to 80%. These figures are found to be greater in Denmark than in most other EU countries. Approximately 5% more men than women considered themselves to be in “good” or “very good” health. A pronounced difference was also found between individuals, depending on their level of education. A total of 60% of Danes with fewer than 10 years of formal education considered themselves to be in “good” or “very good” health, compared to 86% with 13 or more years of formal education. Almost 40% of Danes suffered from a long-standing illness in 2000, compared to 33% in 1987. In 2000 approximately 12% suffered to such an extent that the illness seriously restricted their daily activity. Approximately 20% reported experiencing emotional problems that adversely affected their daily routine in terms of work or leisure during the four weeks prior to the survey (National Institute of Public Health 2002). Table 1.7 shows details of the population’s healthy life expectancy (HALE) and disability-adjusted life expectancy (DALE) at the turn of the century.
11
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Table 1.7 Healthy life expectancy and disability-adjusted life expectancy, 2000–2002 Indicator/Years Expectation of lost healthy years at birth (females) Expectation of lost healthy years at birth (males) HALE at birth (years, females) HALE at birth (years, males) HALE at birth (years, total population) Percentage of total life expectancy lost (females) Percentage of total life expectancy lost (males) DALE (years)
2000 8.4 5.3 70.1 68.9 69.8 10.7 7.2 69.8
2001 8.7 5.5 70.8 69.3 70.1 70.9 7.3 70.1
2002 8.4 6.3 71.1 68.6 69.8 10.5 8.4 69.8
Sources: WHO, 2005 ; WHO Regional Office for Europe, 2005. Notes: HALE: Health-adjusted life expectancy; DALE: Disability-adjusted life expectancy.
Factors affecting health status Several factors affect the health status of the Danish population. Among these are diet and obesity, tobacco use, alcohol consumption and a lack of physical activity. Diet and obesity The 2000 SUSY survey shows differences in diet between age groups and gender (Kjøller & Rasmussen 2002). More women than men have a daily consumption of steamed vegetables, salad/raw vegetables and fruit, while more men than women include potatoes in their diet. Daily intake of salad is most common within the age group 45–66. The consumption of fish at least once a week is equally distributed between the sexes. The survey concludes that variety in diet is proportionally associated with age, that is, the older a person is the more variety they have in their diet. Between 1955 and 1999 the amount of protein in the average Danish diet generally increased, and the consumption of carbohydrates and dietary fibre has decreased. The dietary fat content increased from 36% in 1955 to 43% in 1989 and then decreased to 38% in 1995. The dietary fat content is, however, still too high according to national dietary guidelines (National Institute of Public Health 2002). Between 1987 and 2000 the proportion of people over the age of 16 who were severely obese (body mass index, BMI ≥30) increased from 6% to 9.5% (National Institute of Public Health 2002). As illustrated in Fig. 1.5, the share of people living in Denmark that are moderately overweight (BMI≥25) has also increased, with 40% of men and 25% of women characterized as overweight in 2000. By comparison, only 35% of men and 17% of women were overweight in 1987. The increase in those who are severely overweight is especially high 12
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amongst men between 16 and 24 years old and women between 25 and 44 years old. It has been shown that the level of education has an impact on obesity. Fig. 1.5 50
Number of men and women who are overweight or severely overweight, 1987, 1994, 2000
40
30
20
10
0
Women
Men
Women
Overweight
Men
Severely Overweight 1987
1994
2000
Source: Ministry of the Interior and Health, 2004b. Notes: Overweight: BMI ≥25; Severely overweight: BMI ≥30.
Those with a lower level of education are associated with a higher incidence of being severely overweight. Those who have less than 10 years of education are more than twice as likely to be severely overweight than those with a minimum of 15 years of education. Tobacco use Tobacco use in Denmark is the cause of 12 000 deaths per year (Juel 2001). Approximately 4 500 people die from smoking-related cancer each year. This corresponds to approximately one third of all cancer deaths in Denmark per year (Peto, Lopez, Boreham, Thun 2006). Figure 1.6 illustrates the evolution of daily smokers among men and women in Denmark from 1950 to 2004. In 2004, 25% of the Danish population above the age of 13 were daily smokers, with smokers accounting for 23% of females 13
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and 28% of males. These figures have decreased in comparison to 1997 figures, where 29% of the population were female smokers and 35% were male smokers. Overall, a decrease is observed for both sexes throughout the entire period. However, from the 1950s until the 1970s the percentage of female smokers increased (PLS Rambøll 2004). Approximately nine out of ten Danish smokers smoke on a daily basis. While Danish males smoke at a comparative rate to the EU average, Danish females have one of the highest proportions of daily smokers in the EU (Ministry of the Interior and Health 2004c). The share of daily smokers is largest in the age group 45–66 years, where 40.6% of the men and 36% of the women are smokers. The overall share of daily smokers is highest in groups with less education and lowest in groups with more education (National Institute of Public Health 2002). The use of tobacco has not decreased at the same rate that the number of smokers has. Smokers with a low level of tobacco use, in particular, have given up smoking, and those with a high level of tobacco use (more than 15 cigarettes daily) continue to smoke. However, the number of heavy smokers has decreased in the period 1994–2000, especially for the age group 25–44 years.
Fig. 1.6
Share of daily smokers as a percentage of the total population, 1953–2004 (selected years)
90
80
70
60
50
40
30
20 1953
1963
1970
1975
Source: PLS Rambøll, 2004.
14
1980
1985
1990
Men
Women
1992 Total
1993
1997
2002
2003
2004
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Alcohol consumption Statements based on sales have shown that the Danish population’s average alcohol consumption increased rapidly through the 1960s. From the middle of the 1970s, the increase stagnated and, since then, the average alcohol consumption has stabilized. Since 1975, Danish men and women aged 14 and above drink, on average, 12 litres of pure alcohol per person per year. In 1999, the average intake was 11.3 litres of pure alcohol per person per year (National Institute of Public Health 2002; WHO 2005). A large share of the Danish population drink alcohol on a regular basis. In a survey conducted by the National Institute of Public Health for the year 2000, almost eight out of ten (78.1%) adults reported drinking alcohol within the previous week. The weekly alcohol consumption among Danish men and women differs. A total of 85.1% of male respondents reported an intake of alcohol within the previous week, while only 71.8% of the females surveyed reported a similar intake (National Institute of Health 2002). The recommended maximum level of alcohol units set by the National Board of Health (21 units per week for men and 14 for women) is exceeded by 14.8% of men and 8.7% of women. Compared to other age groups, both men and women in the 16–24 years age group have a relatively large percentage of alcohol intake beyond the recommended maximum level. The drinking pattern within this age group also differs from the other age groups because they consume three quarters of their alcohol at the weekend. The intake of alcohol on weekdays increases with age. People with a higher level of education tend to drink more alcohol during the weekdays. The shares of people drinking on weekdays and exceeding the recommended maximum level of alcohol have generally increased compared to 1994 data, but a decrease has been observed among those who are 25–44 years old (National Institute of Health 2002). Physical activity Among the Danish population, 16.3% have sedentary spare time activities and 23% reported being physically active at a moderate to hard level in 2000. It is primarily the older groups and those with the lower levels of education that take part in sedentary activities, and the younger and more highly educated that are more physically active. The share of people engaging in sedentary activities has, however, decreased among the elderly population and has not changed among the younger population. The percentage of the population engaging in moderate to hard physical activity in 2000 remains unchanged compared to that of 1994 but is slightly higher than that of 1987. Among the working population, the percentage of the population with sedentary work as their main occupation 15
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has increased by 36.9% from 1987 to 2000, while the share engaging in hard physical work has decreased by 32.3% during the same period. This decrease is reported strictly for men only (National Institute of Public Health 2002). Inequalities in health Inequalities in health have received increasing attention in Denmark in recent years. A comprehensive national study of mortality and life expectancy between 1987 and 1998 found that Danes with no vocational training had a mortality rate that was almost 80% higher than that of Danes with a higher level of education. Even when smoking, drinking and lack of exercise were adjusted for, the mortality rate of those with no vocational training was still 50% higher. This is largely due to less favourable living conditions, unhealthier work environments and a much higher mortality rate for permanently unemployed people (Juel 1999). Surveys of the expected number of years lived without long-standing illness reveal a similar trend to that found with mortality and education. A comprehensive study of illness patterns among Danes aged 30–64 was carried out between 1986 and 1991. Among women, managers (typically office personnel in key positions) can expect to spend as much as 83% of their working life without long-standing illness. Women who are salaried employees, white-collar workers, the self-employed and unskilled workers can all expect to spend between 72% and 74% of their working lives without a long-standing illness. The percentage for unemployed women is only 45%. Male managers can expect to be without a long-standing illness for 76% of their working life, salaried employees and white-collar workers between 72% and 74%, and skilled and unskilled workers for 62%. The percentage for unemployed men is as low as 39%. The proportion of working life spent without a long-standing illness, therefore, varies significantly with occupational status, across occupational groups and according to gender, whereby women experience good health for a longer time than their male colleagues (Ministry of Health 2000). Decayed, missing and filled teeth at age 12 years The trend of decayed, missing and filled teeth (DMFT) at the age of 12 years has decreased steadily since 1975, as illustrated in Table 1.8. In 2003, the share of children of 12 years of age with DMFT was 0.9% compared to 5.2% in 1975. The relatively small percentage of DMFT, compared to international figures, is partly explained by free access to dental care for those aged 18 years or younger (either at a Municipal Dental Health Service or at a private practice dentist on a fee-for-service basis, paid by the municipalities). The effort to promote health education has also strengthened the daily use of a toothbrush 16
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Table 1.8 Decayed, missing and filled teeth (DMFT) at age 12 years, 1975–2003 (selected years) DMFT (%)
1975 5.2
1980 5.0
1985 2.1
1995 1.2
Sources: von der Fehr, 1994; National Board of Health, 2005a.
2000 1.0
2003 0.9
Note: DMFT: Decayed, missing and filled teeth.
and fluoride toothpaste in children. Surveys have shown that good oral hygiene habits in childhood are retained in adolescence (Lissau, Holst & Friis-Hasche 1990). For more information on Dental health care see Section 6.11. National vaccination programmes and levels of immunization General vaccination programmes are carried out by GPs and financed by the regions on a fee-for-service basis. Primary vaccinations for children are given in conjunction with health examinations, which are offered as part of the prevention programme for children. These vaccinations are financed by the regions and are free of charge for children between five weeks and five years of age. Coverage for diphtheria, tetanus, pertussis, polio and Hib-infection (Haemophilus influenzae type b) is relatively high in Denmark. However, there have been problems with the measles, mumps and rubella (MMR) vaccination due to parents’ doubts about adverse effects and complications as a result of the vaccine. In 1996, 85% of all children aged 15 months received the MMR vaccination in Denmark, but this figure was less than 80% in the City of Copenhagen. In 2003, the percentage of children receiving the combined vaccination reached 96% in Denmark as a whole and 95% in the City of Copenhagen (National Serum Institute 2005). This improved coverage can be explained by the fact that half of the Danish counties have taken initiatives to increase coverage since the mid-1990s, including public information programmes and postal invitations to parents from GPs. In 1997, 16% of children in Denmark were not immunized against measles (see Fig. 1.7 for further details). By international standards, this is a high proportion, and was a cause of concern for the Danish health authorities. In 2005, however, only 5% were not immunized against measles, which is a relatively small proportion by international standards.
17
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Fig. 1.7
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Levels of immunization for measles in the WHO European Region, 2005
Western Europe Monaco (2004) Andorra (2004) Finland Spain Netherlands Israel Sweden Luxembourg Denmark San Marino Germany Portugal Turkey Austria Norway Iceland Greece (2004) Belgium Italy Cyprus Malta France (2004) Ireland United Kingdom Switzerland Central and south-eastern Europe Hungary (2004) Poland Slovakia Lithuania Albania Czech Republic (2004) Romania The former Yugoslav Republic of Macedonia Bulgaria Estonia Serbia Croatia Latvia Slovenia (2004) Bosnia and Herzegovina CIS Kazakhstan Uzbekistan Belarus Turkmenistan Kyrgyzstan Russian Federation Azerbaijan Republic of Moldova Ukraine Armenia Tajikistan Georgia Averages CIS average EU average EU Member States before May 2004
99.0 97.6 97.0 96.8 96.3 96.0 95.4 95.4 95.0 94.1 93.3 92.6 91.0 91.0 90.0 90.0 88.0 88.0 87.2 86.3 86.0 86.0 84.2 82.1 82.0 99.9 98.2 98.0 97.2 97.2 96.9 96.7 96.4 96.2 95.9 95.6 95.5 95.0 94.0 90.0 100.0 99.3 99.0 99.0 98.9 98.6 98.2 96.9 95.7 94.1 94.0 91.6 98.0
91.3 89.7 70
80
Percentage
Source: WHO Regional Office for Europe, January 2007. Notes: CIS: Commonwealth of Independent States; EU: European Union.
18
90
100
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2
Denmark
Organizational structure
M
ost of the activities carried out by authorized health professionals are organized and financed by the public sector, with free access to health services for all residents in the country. A large part of the public health care system is organized and financed by the regions, which are responsible for hospitals and health care professionals that are self-employed but mainly financed through taxes. The central State’s role is almost exclusively regulatory, supervisory and fiscal. The municipalities are responsible for health and social care, including dental care for children and the disabled; and, from 2007, for a large share of rehabilitation, disease prevention, health promotion and treatment of alcoholism and drug users. Besides the self-employed health professionals, who are reimbursed by taxes and user charges, there are a few private hospitals and clinics, which are reimbursed by taxes, private insurance and user charges, and pharmacies licensed by the State. The activities of the non-authorized health sector are not well documented.
2.1
Historical background
In Denmark there is a long tradition of public welfare politics (Vallgårda 1989; Vallgårda 1999b; Vallgårda 1999a). This also applies to a decentralized management of welfare tasks. Before the 18th century, landlords, or the artisan masters, were responsible for providing care for their subordinates when they were ill or in need of help in other respects. However, this did not mean that help was always given. Gradually, changes in societal behaviour occurred as a result of the dissolution of the feudal social relations and the increasing power of the central State. A new political ideology, namely cameralism, which stressed the importance of a big and industrious population, gained ground in 19
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the 18th century and created an impetus towards improving the health of the population. Most of the tasks aimed at health care and relief for the poor were taken over or established in the 18th and 19th centuries by towns and counties, not the central State. The central State laid down the guiding principles, but most welfare measures were carried out by the local authorities, and this is still the case. The Danish health care sector was financed mainly by taxes, which were raised by parishes, towns and counties and governed by the same authorities. Philanthropy and charity, organized through the church, only played a relatively minor role in welfare provision in Denmark and the other Nordic countries, compared to many other European countries. The fact that the public authorities also played the role of benefactors is probably one of the reasons why people’s attitudes toward the State are much more positive in Scandinavia than in other western European societies. The roots of the Danish welfare state date back to the 18th century, long before the establishment of the social democrats and other pro-welfare state parties, and the rise of organized philanthropy. With the introduction of public relief for the poor at the end of the 18th century, limiting the number of citizens entitled to help due to poor health became an issue. Improving the population’s health was considered both to improve the national economy in general and to reduce public spending. A number of measures were implemented to improve the population’s health, such as the education of midwives; inoculation for smallpox; the improved education of physicians and surgeons; and the undertaking of public health and the treatment of poor people by state-employed district doctors. The first hospitals were built by counties and towns. The hospitals were very small and their purpose was to provide the sick (mainly patients with venereal and other contagious diseases) with care and shelter. An exception was the state hospital, Frederiks Hospital, in Copenhagen (300 beds) where patients with contagious diseases were not admitted. It was established in 1757 as a teaching hospital for surgeons and physicians. During the 19th century, the number of private medical practitioners increased. Everyone who could afford it was treated by doctors in their homes, and even extensive surgery was performed in private homes. Trained midwives were employed all over the country and they helped the poor, free of charge. Public health measures were taken, such as improving sewerage and water supply, housing improvements, food control and control of working conditions. Public health boards were set up from the middle of the 19th century. From that point on the state regulation of health care increased and in 1803 the predecessor of Sundhedsstyrelsen (the National Board of Health) was established. From 1838, all Danish doctors were educated in both surgery and medicine, which previously had been separate entities. Thus, all doctors were trained in the same way and by the same teachers, creating a unified and homogeneous 20
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profession, where all were educated at the University of Copenhagen. In 1936, a medical school was opened in Ă…rhus and in 1966 another one was established in Odense. In 1857, the Danish Medical Association was founded, and the proportion of doctors enrolled soon increased. Approximately 60% of medical doctors were members of the Association in 1900 and practically all doctors were members by 1920. Since GPs constituted the largest section of the profession until the late 1930s, they did so as part of the Association as well. However, the influence of the GPs in the Association has been smaller than their numbers would indicate. The Association has been increasingly influential over time and, until the 1980s, it participated in almost all governmental committees on health care. With politicians becoming increasingly interested in, and having different opinions on, health care politics, the Danish Medical Association lost some of its influence (VallgĂĽrda 1992). Many doctors working on the National Board of Health also held posts within the Association, thus strengthening the link between the Association and the Government. Nurses have been an organized entity since 1899 and have often been represented in committees, too. The Danish medical profession has been a part of the State, rather than a policy-making body outside of it. Several measures developed by the profession have since been taken over by the State, such as the system of approving medical specialties. Public hospitals were built during the 19th century in almost all Danish towns by the towns and counties themselves and financed primarily by real estate (property) taxes and, to a lesser extent, charity and use charges (which were sometimes paid by the patients themselves but more often by their employers or the authorities for relief for the poor). Originally, the hospitals were intended for and used by the poor, but this gradually changed at the end of the 19th century. While the lower social classes still constitute the majority of hospital patients, it seems that currently this is mainly due to poorer health among the lower social classes (Steensen & Juel 1990). Specialized hospitals have been rare in Denmark, with the exception of psychiatric, fever and TB hospitals. From the 1930s onwards, the State has subsidized hospitals to an increasing degree. Yet, county councils continued to be responsible for the hospitals and to make decisions on hospital policy. The State has exerted only little formal influence in this area. Of the private hospitals, a few Catholic hospitals existed on a non-profitmaking basis; however, they have been gradually taken over by the counties. During recent decades, a few private hospitals have been established on a profit-making basis. The presence of this new type of private hospital and clinic has increased since the beginning of the 1990s. There are less than 500 beds in private hospitals; approximately 2% of the hospital beds are private. The private hospitals, however, have caused political conflict and been discussed numerous 21
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times in the Danish Parliament. They are considered by some to be a threat to the equity principles of the Danish health system, while others claim that they offer a good supplement and provide an innovative element to it. Health insurance developed during the second half of the 19th century. Health insurance organizations were created by a combination of artisans and other groups. The artisans organized their own help funds as a continuation of the guilds funds, which were established by members to provide mutual help. Other groups organized health insurance funds for the poorer people within the population, established either by themselves or by those who were financially better off. Philanthropic activities were motivated by the desire to prevent illness and thereby prevent labourers and crofters becoming dependent on relief for the poor. State subsidies were given to insurance schemes from 1892. However, detractors maintained that state subsidies would reduce the motivation for philanthropic support. The late 19th century in Denmark was characterized by the establishment of associations, consisting of workers organizing themselves into labour unions and the social democratic party; farmers establishing cooperatives; and smallholders and day labourers organizing themselves into groups. Health insurance schemes covered the insured and their children. Married women were independent, contributing members from the start. Members of the insurance schemes were initially required to pay half of their hospital user charges; however, this payment was later reimbursed by the insurance scheme. Accordingly, for insurance scheme members, hospital admissions were free at the point of use. User charges were only a small part of hospital expenditure, with the rest financed by taxes. The insurance schemes also paid for the care provided by GPs, which is one of the reasons for the high number and equal distribution of GPs in Denmark. Historically, there were more doctors in Denmark per 1000 inhabitants than in any other Scandinavian country. In fact, in 1930, there were twice as many doctors in Denmark than in Sweden. It was not until the late 1960s and 1970s that Norway and Sweden reached the Danish level. Initially, membership of the health insurance schemes was taken up exclusively by the lower income classes. In 1900, these schemes only covered 20% of the population, whereas in 1925 they covered 42%. In 1973, however, when the insurance schemes were abolished, the coverage was at 90%. What is more, contributions to the schemes could be considered an earmarked tax. Social insurance schemes of this type did not exist in other public service areas, such as social security and pensions, as they did in Germany. From 1973 onwards, health care was financed by taxes, with the exception of those services or products paid by the patients themselves; these included dentist bills (in part), optical lenses and a share of the costs of prescription drugs. 22
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During the 1930s and 1940s – not least as a reaction to the falling birth rate – free health examinations were introduced for pregnant women, infants and preschool children. School medical services, which had previously only existed in cities and towns, were implemented throughout the country. Today, all of these examinations still exist. General health examinations have not been introduced for other groups; however, some specific examinations, such as systematic screening for cervical and breast cancer, are offered in most regions. Danish welfare politics in general, and especially health care policies, have been characterized by a consensus regarding the basic institutional structure (Vallgårda 1999b). Since the 1940s, there has been an agreement among the political parties that access to health care should be independent of where one lives and of economic resources. From 1945 to 1970, health care policy was characterized by a strong medical influence and consensus. Health care matters were discussed in technical rather than political terms. Since the 1970s, however, controversies have been much more frequent, as in several other countries over this period. Differences between the political parties also became more visible in this area, as they began to include specific health policies in their programmes. Thus, the authority of the medical profession was weakened. The 1970 reform of the political and administrative structure reduced the number of counties and municipalities. It also placed the responsibility for the largest part of the health care sector on the counties, whereas previously this responsibility had been divided between the towns, counties, the State and the health insurance schemes. In 2007, a reform has been implemented reducing the number of municipalities to 98 and establishing five regions with the responsibility for providing hospital and outpatient care for citizens. The acts on health care mainly set out the general legislative framework, letting the local and regional authorities decide on matters relating to actual performance. Ensuring local self-governance has for a long time, and in many different respects, been given a higher priority in formal legislation than ensuring an equal level of quality and provision of health care. This, however, has changed with this most recent reform, which holds equal standards of care throughout the country as one of its main priorities. In the 1970s public awareness of rising public expenditures began to increase (Vallgårda 1992). Public expenditure as a share of gross national product (GNP) rose from 28% to 42% between 1960 and 1971, a period when general economic growth was rapid. Concern about the increase in public expenditure promoted a reorientation of health care politics, where more attention was subsequently given to primary health care, disease prevention and health promotion. The effect of health care on mortality was questioned as well. From the middle of the 1970s, cost-containment became a political issue and the increase in health care expenditure slowed. New management methods were introduced 23
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in hospitals and, with them, more nonmedically trained managers were hired, which reduced the influence of the increasing number of doctors to some extent. From the 1980s, the politics of care for the diseased and disabled elderly changed from an institutional system to a home care-based one. The number of home nurses and other facilities increased substantially, while beds in nursing homes decreased, in spite of a rising number of elderly inhabitants in Denmark. Then, a slower increase in resources to health care led to an intensified debate about prioritizing. No national model or priority plan has ever been discussed, but different counties elaborated their own prioritizing criteria during the 1990s. During the same period, health technology assessment (HTA) and, largely, quality assurance were taken up in the health care sector and supported by the national authorities. Gradually, disease prevention and health promotion have received more political focus at both the central government level – with government programmes in 1989, 1999 and 2002 – and at local levels, in counties and local communities, which have launched campaigns against heart disease and employed people with the task of promoting prevention activities. For more information on the 2002 government health programme, see Section 6.1 on Public health. Since the 1990s, health care expenditure has risen again. Also, the debate on prioritization has subsided and the focus has shifted to efficiency and quality. Since the early 1990s, more economic incentives have been gradually introduced into the hospital sector. In 1993, free choice of hospital was introduced and in 1998 it was decided that hospitals should be reimbursed according to diagnosis-related groups (DRGs) for patients living in other counties. Since 1973, hospitals have received resources according to their budgets; however, in 1999 it was decided that only 10% of resources would be allocated in relation to activities based on DRGs and from 2004 this figure changed to 20% (Ankjær-Jensen & Rath 2004). Quality assurance methods and accreditation have played an increasing role in hospital management. Patient rights have also been strengthened through legislation on rights and complaint systems (see Subsection 2.5.2 on Patient rights and empowerment). Additionally, waiting times have been a big political issue since the mid-1990s. As such, a maximum 2-month waiting guarantee was introduced in 2002 and then reduced to one month in 2007. Thus, if the patient cannot be guaranteed treatment within one month, he/she may chose to be treated at another hospital, including privately and in other countries. Table 2.1 shows some trends of the health care sector, including a decrease in the number of hospitals and hospital beds and in the length of stay; an increase in the number of doctors and nurses; a slight increase in admissions; and a steep increase in outpatient visits, both to hospital outpatient departments and 24
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Table 2.1 Trends in the evolution of the health care sector, 1936–2003 (selected years) Indicator Number of general hospitals Number of psychiatric hospitals Number of doctors per 1000 Number of hospital nurses per 1000 Number of hospital beds per 1000 (general hospitals) Number of hospital beds per 1000 (psychiatric hospitals) Hospital admissions per 1000 (general hospitals) Outpatient visits per 1000 (general hospitals) Average length of stay in days (general hospitals) Number of GP consultations per 1000
1936 160 – 0.8 1.1
1960 142 17 1.2 2.0
1981 113 16 2.2 3.2
2003 57 10 3.6 5.6
6.0
6.0
6.0
3.7
–
–
–
0.3
69 – 28 –
114 – 16 –
178 656 10 4 500
218 1 025 5.5 6 500
Sources: Ministry of the Interior and Health, 2004a; National Board of Health, 2005d; Vallgårda, 1992. Note: GP: General practitioner.
GPs. Overall, these trends indicate a change in the role of hospitals towards one providing more diagnosis and treatment and less care. The purpose of the 2007 reform was to ensure greater equality in hospital treatment across the country, by increasing the influence of the National Board of Health on hospital planning. The number of regional authorities was reduced from 14 counties to 5 regions, which do not have the right to levy taxes. The municipalities received more responsibility for rehabilitation, disease prevention and health promotion, as well as the care and treatment for disabled people, and alcohol and drug users. Communities contribute to the regions through payments both per capita and by activity, the latter according to citizens’ utilization of the regional health services.
2.2
Organizational overview
The defining feature of the Danish health system is its decentralized responsibility for primary and secondary health care. However, important negotiation and coordination channels exist between the State, regions and municipalities, and the political focus on controlling health care costs has encouraged a trend towards more formal cooperation. See Fig. 2.1 and Table 2.2 for an overview of the organization of the system. 25
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State level Responsibility for preparing legislation and providing overall guidelines for the health sector lies with the Ministry of Health. Each year the Ministry of Health, the Ministry of Finance and the regional and municipal councils – represented by the Danish Regions and the National Association of Local Authorities – take part in a national budget negotiation to set targets for health care expenditure. These targets are not legally binding. The National Board of Health, a central body established in 1803 and now connected to the Ministry of Health, is responsible for supervising health personnel and institutions, and for advising different ministries, regions and municipalities on health issues. Regional level The five regions are governed by councils, which are elected every four years. They are financed by the State and the municipalities. The regions own and run hospitals and prenatal care centres, and they also finance GPs, specialists, physiotherapists, dentists and pharmaceuticals. Reimbursements for private practitioners and salaries for employed health professionals are agreed through negotiations between the Danish Regions and the different professional organizations. The Ministry of Health, the Ministry of Finance and the National Association of Local Authorities also participate in these negotiations. Municipal level The 98 municipalities are also governed by councils elected every four years (at the same time as regional council elections). They are responsible for providing services such as nursing homes, home nurses, health visitors, municipal dentists, prevention and health promotion, and institutions for people with special needs (i.e. people with disabilities, treatment for drug- and alcohol-related problems and school health services). These activities are financed by taxes, with funds distributed through global budgets, and carried out by salaried health professionals. Salaries and working conditions are negotiated by the National Association of Local Authorities and the different professional organizations.
2.3
Decentralization and centralization
With the exception of a few central state hospitals, health care in Denmark has been the responsibility of the towns and counties since the beginning of the 18th century, so there is a long tradition of decentralized administration in the health sector (see Section 2.1 on Historical background). The 1970 reform 26
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Fig. 2.1
Denmark
Organizational chart of the statutory health system
State level Parliament Government Ministry of Health National Board of Health
Regions
a
Regional level 5 Regions Regional councils
National Association of Local Authorities
a
Municipal level 98 Municipalities Municipal councils Subcommittees
Sources: National Association of Local Authorities, 2005; Vallgårda & Krasnik, 2007. Note: a The Danish regions and the National Association of Local Authorities are not part of the formal political and administrative system. The associations provide counselling for their members and negotiate with professional organizations and the central Government.
of the public administrative structure, which reduced the number of counties from 24 to 14 and the number of municipalities from over 1300 to 275, led to both centralization and decentralization of responsibilities. While many state tasks were transferred to the counties, responsibility for the hospitals moved from local hospital boards to the county councils. Ironically, though, since this reform, the State’s tendency to intervene in the administration of the health care sector has increased over time. Consequently, tension has been rising with regard to the counties’ autonomy. The 2007 reform allocated new tasks and responsibilities to both the State and the municipalities, and thereby involved a certain level of both centralization and decentralization. In 1976, responsibility for psychiatric hospitals and care for disabled people was decentralized from the State to the counties as part of an effort to develop closer coordination between somatic and psychiatric care, and, more generally, to establish smaller units that would be closer to the population. The counties also developed closer coordination with municipal social services, which gradually led to their handling the special needs of psychiatric patients. The process of decentralizing psychiatric treatment is continuing today, with the aim of delivering flexible and well-coordinated services. Deconcentration of state functions in health care is rare. One of the few examples of this is the case of public health officers, who have been employed by the State from the beginning of the 18th century and who work at the regional level. GPs were initially 27
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Table 2.2 Political bodies, administrative bodies and health care responsibilities Political bodies
Administrative bodies
State Parliament and its health committee
Regions 5 regional councils with committees
Municipalities 98 municipal councils with subcommittees
Government represented by Ministers of Health, Finance, Welfare and Labour Ministry of Health
Hospital administration
Social and health administration
National Board of Health and a number of other boards and institutions
Private
Administration for the reimbursement of private practitioners
Ministry of Finance Ministry of Welfare
Activities
Ministry of Labour Regulation and legislation
Hospitals
Nursing homes
Prenatal centres Home nurses Surveillance of the health sector Special Health visitors and health institutions for hazards disabled people Children’s dentists Public health District officers psychiatry Home dental service for the Annual budget physically/ negotiations mentally with the Danish disabled Regions and the National School health Association of services Local Authorities Home help Source: Vallgårda & Krasnik, 2007.
28
General practitioners Specialists Physiotherapists Dentists Pharmacies Chiropractors Private hospitals Occupational health units
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paid through the many local health insurance schemes; these were, however, gradually centralized and finally taken over by the counties in 1973. A serious consequence of decentralization is the unequal access to health care across the different counties. Danish politicians appear to consider local self-governance (and its potential for innovation) to be more important than geographical equity. Decentralization in Denmark has been shown to lead to differences in waiting times, in the availability of medical technology and in the rates of specific diagnostic and curative activities, such as systematic screening for breast cancer or the use of expensive drugs for ovarian cancer. One of the goals of the 2007 reform is to ensure equal standards of care throughout the country by increasing the power of the state bodies in planning and quality management.
2.4
Population coverage
Denmark has a tax-based, decentralized health care system providing universal coverage for all residents in the country. However, to be entitled to free access to health care an individual must be registered as a resident for more than six weeks. All those who have the right to tax-financed health care receive a health certificate card. The right to health care services is regulated by law with no option of opting out of the publicly funded system. People over the age of 16 who have the right to tax-financed services can choose between Group 1 and Group 2 coverage (see Subsection 2.5.2 on Patient choice). With regard to many services, a person’s rights depends on which group they have chosen (see Section 2.5 on Entitlements, benefits and patient rights). Children under the age of 16 are covered by the same form of coverage as their parents. A considerable proportion of the Danish population is covered by additional voluntary health insurance (VHI) (see Subsection 4.1.4 on Voluntary health insurance). Special rules for accessing health services apply for tourists, foreigners, legal immigrants, asylum seekers and illegal immigrants. Tourists and foreigners temporarily staying in Denmark must pay for health care services on a feefor-service basis. To receive reimbursement, a European Health Insurance Card or evidence of private health insurance must be shown at the point of use (Ministry of the Interior and Health 2004d). Legal immigrants are covered by the tax-financed system and they have the same rights as residents with Danish citizenship. Asylum seekers are not residents and do not have these entitlements; they may be treated by basic primary services and emergency hospital services, but they would have to apply for specialized treatment in the case of lifethreatening and painful chronic diseases, which are all financed by the Danish 29
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Immigration Service. Illegal immigrants are only entitled to acute treatment and are not otherwise covered by the tax-financed system (see Section 6.14 on Health care for specific populations).
2.5
Entitlements, benefits and patient rights
2.5.1
Entitlements and benefits
All Danish residents have free access to GPs, ophthalmologists, ear, nose and throat specialists, and emergency wards. Access to specialists and hospital care is free at the point of use with a referral from a GP. Free access includes ambulance transport and palliative care. In Denmark, treatment is left up to medical judgement and there is no minimum package of care. There have been some efforts to establish a list of priorities but an explicit priority-setting system has not been implemented. Formal restrictions on access are decided by the Parliament and the individual hospitals, and they only exist for a few treatments (i.e. infertility treatments). Entitlement to some vaccinations, health examinations for children and pregnant women, and health visits to elderly residents are also regulated by law. Co-payments exist for long-term nursing home care, dentists, physiotherapists, pharmaceuticals, and so on. Eyesight tests and glasses are paid for by patients; however, hearing tests and aids are free. People with low income may be reimbursed for co-payments by the social security system. An increasing number of Danes buy private insurance to cover these co-payments, to gain access to private hospitals and clinics and as an extra financial safeguard in case of sickness. Many employers offer private insurance to their employees, which is a contributing factor to the overall increase in private insurance (see Subsection 4.1.4 on Voluntary health insurance). Treatments not authorized by the National Board of Health are not reimbursed by the public system or by most private insurance companies. Sickness pay is the responsibility of the employer during the first two weeks of absence and the responsibility of the municipality thereafter. Many employees have a collective agreement which entitles them to their salary for a longer period, although sickness pay from the municipality generally stops after 54 weeks. It is more common for salaried people to have an agreement with their employer that entitles them to their salary during sickness and maternity leave, than wage earners. All pregnant women are entitled to maternity benefits from the municipality for four weeks before the expected birth and 14 weeks after the birth. The 30
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following 32 weeks of benefit may be shared between the father and the mother. For maternity leave, many employees have an agreement to be paid their salary for 26 weeks or more. Relatives of chronically or terminally ill patients are entitled to salary or compensation from the community. In the case of disability and reduced working capability, a national supplementary disability pension is granted. This type of pension may be temporary or permanent and it is co-financed by the State and the municipalities. Insurance bodies and pension funds often offer their members supplementary benefits in case of disability and acute serious disease. Health checks are often required before taking out insurance or entering a pension fund and membership may be denied. Insurance companies are not allowed to ask for or to see predictive genetic testing. However, they are allowed to ask and should be informed about serious diseases in the family, including those that are hereditary. They cannot request HIV testing, but if the HIV status is known the person must inform the insurance body about it. Currently, there are no plans for changing the entitlements and coverage of publicly financed health care and benefits. The rules about entitlement are decided by the Government and their implementation is decided by health care institutions and individual health professionals. The role of HTA and other forms of evidence guiding these decisions are not regulated by the authorities. When it comes to health care, it is principally a medical judgement that decides entitlement. Private insurance coverage is decided through contracts between the companies and the policy-holders. 2.5.2
Patient rights and empowerment
Patient rights In 1998, the Danish Government agreed on an act regarding a patient’s legal position. The act set out comprehensive legislation, regulating the fundamental and general principles for the individual patient’s rights (Legal Information 1998). The aims of the act are to help ensure that the patient’s dignity, integrity and self-determination are respected; and to support the trust relationships between the patient, the health system and the various personnel involved. The act also contains rules on information about consent and life testimonials, and information regarding patient cases and professional confidentiality, along with access to health information (Vallgårda & Krasnik 2004).
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Patient choice Since 1973 residents over the age of 16 have been able to choose between two coverage options known as Group 1 and Group 2. The default is Group 1 and approximately 99% of the Danish population were in this group in 2004 (Association of County Councils 2005). In Group 1, members are registered with a GP of their own choice, practising within 10 km of their home (5 km in the Copenhagen area); otherwise, a GP’s written acceptance of their willingness to carry out home visits during the day is needed. Group 1 members have free access to general preventive, diagnostic and curative services. Patients may consult emergency wards, dentists, chiropractors, ear, nose and throat specialists or ophthalmologists without prior referral, but their GP must refer them for access to all other medical specialties, physiotherapy and hospital treatments. Consultation with a GP or specialist is free of charge, while dental care, podiatry, psychology consultations, chiropractice and physiotherapy are subsidized. Patients seeking care from specialists other than ear, nose and throat specialists or ophthalmologists, and without a GP referral, are liable to pay the full fee. An individual in Group 1 has the possibility to change GPs after six months and after contacting the local authority. In Group 2, individuals are free to consult any GP and any specialist without referral. The region will subsidize the expenses up to the cost of the corresponding treatment for a patient in Group 1. The same rules apply to treatment by podiatrists, psychologists, dentists, chiropractors and physiotherapists. Hospital treatments are free. Only a minority of the population (1%) chooses this group, probably due to the level of general satisfaction with the referral system. Changing group is possible once an individual has been in either Group 1 or 2 for 12 months (Association of County Councils 2005). The majority of hospitals in Denmark are general hospitals. There are very few specialized hospitals other than psychiatric hospitals. A legislative reform in 1993 gave patients the freedom to choose to be treated at any hospital in the country as long as treatment takes place at the same level of specialization. This is in accordance with the fundamental principle that health services should be provided at the most appropriate level of specialization (i.e. less specialized cases should not be referred to more highly specialized units). This legislative reform was a key step towards allowing patients more influence over their care and treatment. However, according to a national study, which assessed the impact of the reform, patients prefer treatment close to their place of residence, which contradicts the original intention of the reform (Birk & Henriksen 2003). In 2002, a new piece of legislation regarding waiting time guarantees was implemented. Patients who are not offered treatment at public hospitals within two months of referral are free to choose treatment at private hospitals or clinics anywhere in the country and at hospitals abroad. In 2007, this guarantee was 32
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changed to one month as of 1 October. The non-public treatment expenses are paid by the patient’s region. As a precondition for the use of the extended free choice, the chosen non-public hospital or clinic has to have an agreement with the region (Association of County Councils 2005). In the case of cancer and certain other diseases (i.e. coronary heart disease), waiting time guarantees are defined for specific procedures, and, if the hospital is not able to treat the patient locally within the case time limits, it is obliged to look nationally or even internationally for alternative hospitals. If the hospital is unable to do this, then the case is referred to the National Board of Health for assistance in seeking alternative solutions within the case time limits, which are defined by the waiting time guarantees. However, due to heavy public and political criticism of the lack of fulfilment of these procedures, the Director of the National Board of Health resigned from his post in November 2006. Since 2003, referral to highly specialized services can be carried out on a direct referral basis by a medical doctor, independent of his/her place of work. The new legislation states that the patient must be referred to a highly specialized health service, if a qualified medical judgement is carried out and considers accordingly that the patient needs such treatment. Before this legislation, the county was required to produce an economic guarantee prior to referral to a highly specialized health service, including a secondary examination of the case by the county’s own hospital service. Currently, only patients with strictly defined needs for specialized treatment are accepted at the highly specialized health services. Information for patients Patients are informed about the age and gender of GPs before choosing a doctor, but other than this, no information is available. A patient that needs hospital treatment has a few different options available for them to obtain information about hospital characteristics (e.g. waiting lists). When the patient is referred to a hospital, the hospital is obliged to send a notice letter to the patient. This letter should inform the patient of his/her specific examination and treatment and of the hospital’s possibility to examine and treat the patient within one month. If the waiting time exceeds one month, then the hospital provides patients with information about the option of choosing another hospital, including those that are private or based abroad. Patients can also obtain information and guidance on hospital choice and waiting times through their GP and through patient offices, which exist in every region. A number of web sites have been established by the National Board of Health, the Danish Regions and the Ministry of Health in order to give patients further access to information. The sites provide information regarding public and 33
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private hospitals, specialists and clinics as well as selected hospitals abroad, which have existing arrangements with the regions. The typical content of the information includes waiting times in weeks to examination, treatment and after-care in the different hospitals and the number of operations conducted at specific hospitals (Ministry of the Interior and Health 2007). Information on quality aspects of hospitals has been published on the home page of the Ministry of Health since November 2006. This information includes ratings (1–5 stars) based on patient satisfaction, and standards of hygiene, safety, and so on. This rating system, however, has been criticized for its limited scope, unclear weighting of the different elements, and its ratings of hospitals as a single unit rather than as individual departments. A number of initiatives have been introduced to strengthen patient rights in the health system. The National Board of Health is in charge of securing the patients’ dignity, integrity and right of self-determination (National Board of Health 2005a). In 1992, a law was passed on patient rights, which obliges doctors to inform patients of their condition, treatment options, and the risk of complications. It also prohibits doctors from initiating, or proceeding with, any given treatment that is against the will of the patient (unless mandated by law). In addition, the patient has the right not to receive information. This law was extended in 1998, regulating the basic and general principles of the individual patient’s right of self-determination and public security related to the health system and regarding medical examination, treatment and care. Issues covered are the patient’s right to continuous information, which is adapted according to age and the disease(s), given throughout examinations and treatment and communicated with respect to the patient. Furthermore, the rules also determine doctors’ rights to share information with third parties, to give patients right of access to documents, to hold case records and to have total professional confidentiality (Legal Information 2005a). Complaint procedures A complaint system has been established regarding professional treatment in the health service: the Patients’ Complaints Board is a public authority that has the role of expressing patient criticism about the professional conduct of medical staff and submitting particularly serious cases to the public prosecutor with the purpose of taking such cases to court. The board deals with complaints about treatment and care, information and enquiries about consent, the drawing up of medical certificates, the compiling of case records, decisions about the right of access to documents and violations of professional confidentiality rules. The board also attends to the reports about professional activities from such agencies as the National Board of Health and the Danish Medicines Agency. 34
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Finally, the board deals with complaints made about previous decisions by the local psychiatric patient’s board of complaints regarding grievances other than the loss of liberty (Patients’ Complaints Board 2005). For decisions based on criticism, the Patients’ Complaints Board assesses whether the individual health personnel have fulfilled the commonly acknowledged professional standards. In 2003, the Patients’ Complaints Board received 2850 complaints, compared to 2949 in 2002 and 2721 in 2001. Compared to the number of patient contacts in the health care system, these are relatively few complaints. In round figures, there are more than 1.1 million discharges from hospitals per year, more than 4 million outpatient treatments and more than 34 million patient contacts in public practices. A large proportion of complaints are concerned with doctors, corresponding to 85% in 2003. The board settled 2219 cases in 2003, of which every fourth case ended with criticism of one or more health professionals. Ten cases were sent to the prosecution with the request to charge for a criminal offence (Patients’ Complaints Board 2003). Patient safety and compensation In June 2003, an Act on Patient Safety was agreed on, with effect from January 2004. The Act aims at promoting patient safety by establishing a system of reporting adverse events. The system was at first based on three types of occurrence: (1) serious occurrences; (2) surgical and invasive operations; and (3) use of medicine (Danish Society for Patient Safety 2007). However, this has been changed, and all occurrences are now to be reported. It is quite an extensive process to develop and there are still many challenges to be overcome. Patients can receive compensation for health care-related harm from treatment at public hospitals through the Patient Insurance Scheme, which was set up in 1992. The insurance provides compensation to patients or a patient’s relatives as well as subjects or donors for somatic damages and some psychiatric damages caused during treatment in the health care system. In 1995, this insurance was expanded to include damages caused by biomedical experiments in the primary health care sector. In 1999, the insurance was extended again, to cover treatment at all public and private hospitals (but not private profit-making hospitals) as well as specialists and selected hospitals abroad, which the regions use in accordance with the Law on Health of 2005 (Legal Information 2005a). The Patient Insurance Scheme is based on the following principles. • A patient’s right to compensation does not depend on a doctor or any other health person to incur personal responsibility for the damage. 35
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• Compensation is provided through an obligatory insurance scheme, which is financed by the hospital owners. • The size of compensation is regulated through the Law of access to complaint and compensation within the health services (Legal Information 2005b). Other compensation schemes include the Danish Dentist Society Insurance Schemes and the Danish Chiropractor Society Insurance Schemes. The Council for Adverse Drug Reactions offers general guidance to the Danish Medicines Agency and proposes recommendations and solutions to the Agency for improving the prevention and monitoring of adverse reactions. The main task of the Council is to monitor and assess the reporting of adverse reactions in practice. Further, it proposes recommendations and inspires the Danish Medicines Agency’s information and communication tasks with regard to adverse reactions for consumers, patients and health care professionals. The most important source of information on adverse drug reactions is spontaneous reports. The Agency recommends that all patients who experience adverse drug reactions not mentioned on the package leaflet should contact their GP. GPs are then required to report all presumably serious or unexpected adverse drug reactions or reactions to medical products to the Danish Medicines Agency. Moreover, GPs are obligated to report any known and non-serious adverse drug reactions for the duration of the first two years a medicinal product is on the market. It is also possible for the patient or the patient’s relatives to report adverse drug reactions directly to the Agency. In Denmark, direct-to-consumer advertising of prescription drugs is permitted under strict legislation. In an announcement in 2003, it was stressed among a long list of restrictions that advertising of drugs should not give the impression that it is not necessary to consult a GP; that there are no sideeffects; that the product is better than another drug; that it is recommended by scientists; that it mainly or solely addresses children; that it contains references to examinations; or that a person’s well-being depends on their use of the drug. These advertising restrictions do not include advertising for vaccination campaigns, which are approved by the Danish Medicines Agency (Danish Medicines Agency 2005b). Patient participation/involvement Patients’ participation takes place in three ways in Denmark: (1) through organized patient groups, nationally, regionally or locally; (2) through patient counsellors; and (3) indirectly, through feedback from national surveys. A number of patient groups exist, which were formed around concerns about particular diseases or health problems, such as heart disease, cancer, arthritis, diabetes, or sclerosis. Since the mid-1990s, many of these groups 36
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have explicitly taken on policy advocacy as an important function. The groups are very active and they influence public debate. Approximately 200 active patient groups exist in Denmark. They act as the patients’ voices in the media towards the authorities and politicians, frequently giving input on the health debate so that patients’ views are not neglected. They also provide information, help and support related to health and sickness, and dialogue with the relevant authorities at all levels. The largest, best-known and most well-funded groups have a strong track record of involvement in health policy. This is often achieved through the formation of coalitions with doctors or across patient groups. Patient organizations that are entirely at the grassroots level and work independently of the health care professional sector tend to be much smaller, with non-paid volunteer staff. It is therefore a far greater challenge for them to navigate the different decision-making structures at the national, regional and municipal levels, and to have a greater influence. The larger groups are backed by larger membership numbers and operating budgets, which enable them to maintain a professional staff. These organizations are generally invited to participate in parliamentary hearings that are relevant to their causes and concerns, while this is quite rare for the smaller organizations. In every region, a patient guidance system exists. The system’s primary task is patient guidance on provider and treatment choice, complaint and compensation rules, and waiting lists, and so on. Patient guidance also assists in clearing up misunderstandings, which in many cases could otherwise lead to a complaint being filed. Nurses primarily act as guidance counsellors and function as problem solvers in a close dialogue with patients, relatives and the hospital personnel. Guidance counsellors are obligated to be neutral and impartial (Association of County Councils 2005). A survey conducted by the Danish Ministry of Finance in 2000 analysed the population’s view of the public sector, including satisfaction with health care services. In general, Danish citizens are mostly satisfied with GPs (4.2 on a scale from 1 (very dissatisfied) to 5 (very satisfied)) and less satisfied with emergency medical services (3.5) (Ministry of Finance 2001). This survey is carried out every second year. Results from the 2004 survey show that 90% of patients are satisfied with their stay in hospital, 93% are satisfied with doctors and 95% are satisfied with the health personnel. This is a small increase compared to results from 2000 and 2002. Patients report great trust towards the doctors and health personnel professionalism, good communication between the patient and health personnel and there is evidence of a strengthened dialogue between hospitals and GPs since previous surveys. Other results have shown changes that are even more significant. From 2000 to 2004, there was a significant increase in patients’ evaluation of the content of written materials: 96% of the patients receiving the written material evaluated the content to be “very good” 37
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or “good” in 2004, compared to 87% in 2000. Furthermore, patients answered more positively in 2004, compared to 2000 and 2002, to questions regarding the waiting times (which prolonged the hospital stay) between referral and admission and during admission. Patients also increasingly believe that their GPs are informed to a “very good” or “good” level by the hospital regarding their admission. There was an increase of 6.7%, from 71% in 2000 to 77.7% in 2004. More specifically, the only statistically significant decline (from 60.2% to 58.0% (The Counties, Copenhagen Hospital Co-operation (H:S) & Ministry of the Interior and Health 2005)) between 2000 and 2004 was found in the responses to the question on whether patients were told whom to contact with any questions during admission.
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Planning, regulation and management
P
olicy development takes place at central, regional and local levels. The 2007 reform implies a more important role for the central level. With the reform, the influence of the National Board of Health on hospital planning was strengthened with the purpose of ensuring more equal treatment across the country. Implementation of policies and provision of services still take place at the regional and local levels. The National Board of Health has an advisory function over the political bodies at all levels, and it has a supervisory function over all authorized health professionals and institutions, except practitioners of complementary and alternative medicine (CAM). The Parliament and the Government, with few exceptions, outline the general policies, and make decisions on the overall organizational structure, financial framework of activities and responsibilities of the health care sector. Most health care institutions, hospitals, nursing homes and school health clinics are owned and managed by the regions or municipalities. GPs, specialists, dentists and physiotherapists are self-employed and reimbursed by the regions based on taxation. Pharmacies are privately owned but strictly regulated, and pharmaceuticals are subsidized by the regions.
3.1
Regulation
There is no national health plan for the development of the health care sector. 3.1.1
Regulation and governance of third-party payers
The main financing of the health care sector comes from municipal and central state taxation. The central State subsidizes the regions and municipalities and 39
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does not act as a purchaser or directly finance the providers. The municipalities contribute taxes comprising 20% of the overall regional income. The subsidies, and a counterbalancing system that transfers money from richer to poorer municipalities, are calculated according to formulas, which are based on allocated resources and needs. The role of the central State is mainly to regulate and contain expenditure and to provide some general guidelines for the health care sector. An increasing number of citizens take out private health insurance, which is organized by profit-making companies, in order to receive reimbursement for medical expenses, such as their utilization of private clinics. A rising number of companies offer private health insurance with variable coverage and the market is not particularly transparent for the average consumer. The private profit-making health insurance market is unregulated. 3.1.2
Regulation and governance of providers
In terms of organization, the five regions are responsible for providing hospital, somatic and psychiatric care, and for financing private practitioners (such as GPs, practising specialists, dentists, physiotherapists, chiropractors, and so on) for their public sector work. Private practitioners are self-employed but reimbursed for their services by the regions. However, only those who have a prior agreement with the regions are reimbursed, based on a negotiated number of doctors per 1000 inhabitants. Very few doctors work without such an agreement. A few private profit-making clinics and small hospitals are also paid by the regions for attending to patients, according to contracts or waiting time guarantees. Furthermore, the municipalities employ health care providers, who mainly take care of children and the elderly. Regarding stewardship and regulation, the central Government sets the overall direction of health care and increasingly – but still only to a limited extent – defines specific targets for the health care sector. For some decades it has tried to regulate the establishment of highly specialized departments and functions (such as heart transplants), and during recent years has set targets for waiting times, introduced screening programmes, improved treatment for cancer patients, and so on. With the recent reform, the central authorities have been given the means to govern these activities more efficiently. The Ministry of Finance negotiates the level of taxation with the municipalities, thus setting the financial framework of the activities. It also participates in negotiations between professional organizations and unions about salaries, working conditions, fees and the number of practitioners with regional contracts. 40
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There is a licensing system for health care professionals but not for health care facilities. Instead, health care facilities are supervised by the National Board of Health. The National Board of Health has a system of locally based medical officers, which supervise health professionals. Medical doctors (physicians and surgeons) have been licensed since the 17th century, midwives since the early 18th century, and nurses since 1933. During recent decades, a number of new health provider groups have achieved authorization such as laboratory technicians, physiotherapists, opticians, surgical appliance makers, and so on. The National Board of Health grants the licences and, in case of malpractice or other undesired behaviour, has the authority to withdraw them. There is no relicensing system. Education of doctors, specialists, nurses and other health professionals is regulated and supervised by the central State as a means to secure highquality care. Undergraduate education of medical doctors, psychologists, pharmacists and other academic staff is the responsibility of the Ministry of Science, Technology and Innovation. Postgraduate training of doctors is the responsibility of the National Board of Health. Education of most other health professionals is the responsibility of the Ministry of Education (see Section 5.2 on Human resources). Drugs are licensed by the Danish Medicines Agency. This body also supervises pharmacies and is responsible for licensing medical equipment, according to the EU regulations. A number of state agencies are responsible for securing the safety of the citizens. The National Institute of Radiation Hygiene under the National Board of Health is responsible for supervising utilization of X-ray machinery and radioactive substances. The Danish Working Environment Authority is responsible for supervising the working environment and prevention of occupational hazards. The Danish Environmental Protection Agency is responsible for environmental safety. Finally, the Danish Veterinary and Food Administration is responsible for supervising food safety. A national model for quality assessment and improvement, the Danish Health Care Quality Assessment Programme, was established in 2002. Its main objective is to monitor all publicly financed health care activities. In 2005, it was established as an independent institution. Its principal task is to provide ongoing feedback to individual health care institutions, including processed indicator data. The programme also promotes periodic accreditation, publication and benchmarking of assessments and indicators. National strategies for quality improvement have been published since 1993. The 2004 Law of authorization of health professionals and of health care activities made the reporting of adverse events compulsory, with the purpose 41
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of preventing consequential events. These reports do not allow the sanctioning of health care personnel or institutions. According to a 2004 law, organizations of CAM providers may – provided they fulfil certain requirements – obtain permission from the Minister of the Interior and Health to let their members describe themselves as registered CAM providers. Otherwise, the activities of CAM providers are regulated by the Law of authorization of health professionals and of health care activities, which forbids anyone other than authorized doctors to perform a number of activities. 3.1.3
Regulation and governance of the purchasing process
There is practically no division between purchasers and providers in hospitals. Hospitals receive 80% of their funding from budgets and 20% from activitybased remuneration according to a DRG system. The Government is planning to increase the activity-based proportion to 50% over the coming years. Thus, the regional councils influence hospital activities through budgets and direct political decisions concerning the establishment of activities, departments or hospitals. Self-employed private practitioners are reimbursed according to their activities and GPs are also reimbursed through capitation. The levels of reimbursement and capitation are negotiated between the practitioners’ organizations and the Danish Regions. The regions limit the number of providers through an agreement, but cannot generally limit the activities of providers.
3.2
Planning and health information management
Planning is an integrated part of the Danish health system. The planning system reflects the decentralized nature of the Danish health system, with the regions and municipalities as planners and providers of health care services and the State as the provider of the overall framework of the system. Decisions regarding the supply of different health services are mainly made at the regional level but with State involvement in certain areas. For example, services such as health examinations for children and pregnant women along with the provision of highly specialized services are determined by the State, whereas the supply of other hospital facilities in various areas is determined at the regional level. Further, the number of GPs practising in each region is agreed on between the regions and the Organisation of General Practitioners in Denmark (PLO) through annual negotiations. 42
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As health care is largely a regional responsibility, most national legislation concerning the health sector does not specify how the system should be organized or which services should be provided. Legislation concerning health care at the local level is slightly more specific. The more specific rules given by the central Government pertain mostly to preventive activities such as vaccination schemes and health check-ups for children and pregnant women. The decentralized structure requires careful coordination between the municipalities, the regions and the State in order to secure coherence in the long term and to strengthen prevention and health promotion as well as quality development within the health care sector. The goal of coherence was formalized through legislation enacted in 1994, which required counties and municipalities to develop a joint health plan every four years for the coordination of all preventive and curative health care activities within the health care sector, and, to some extent, between the health care sector and other public sectors (e.g. the social sector) (National Board of Health 2005a). The health plans were required to include a statement on the health status of the population, a description of the available services and an indication of the nature and extent of cooperation with municipalities and with other counties. The coordination process varied from county to county, but was often based on meetings, seminars and jointcommittee work, and focused on specific subjects, such as children, the elderly and mental health. All health plans should be submitted to the National Board of Health for comments. The plans have contributed to an increased awareness of intra- and intersectoral coordination and to the establishment of new relations within the sector. However, the health plans have been criticized for being solely an administrative task, and disconnected from functional levels (Seemann 2003; Strandberg-Larsen, Nielsen & Krasnik 2007). With the recent structural reform and redrawing of geographical and administrative boundaries within the Danish health system, the risk of unintended fragmentation of the system is present. Furthermore, the post-reform organizational structure increases the demand for careful coordination between the municipalities and the regions since the responsibilities for providing health services have been divided to an even greater extent than before. Fragmentation is thought to be avoided mainly by strengthening the principal agent’s obligation to cooperate through mandatory health agreements. Following the reform, the Health Act was revised. A statutory cooperation between municipalities and regions was established in the form of mandatory regional health care agreements to try to ensure the required coherence between treatment, prevention and care. The obligatory health care agreements include arrangements regarding hospital discharges for weak and elderly patients, on the social service available for people with mental disorders, and on prevention and rehabilitation. The health care agreements are anchored in the regional consultative committees consisting of representatives from the 43
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region, the municipalities within the region, and private practices. The regional consultative committees can be used to resolve disputes (e.g. about the service level, professional indications and referral criteria in the area of training) and to create the basis for a continuous dialogue about planning. The health care agreements should comply with centrally defined requirements, and tangible proof that the cooperation lives up to the requirements should be made publicly available. Overall, there have been substantial improvements with the new health agreements in terms of formalizing a more coordinated care system. Moreover, the health agreements have been planned to a greater degree, treating the process as one of continuous learning and adaptation. However, the same pitfalls from the previously used health plans can not be said to have been avoided with the new system (Strandberg-Larsen, Nielsen & Krasnik 2007). Economic management and planning of the health sector take place within a framework of negotiation between the different political and administrative levels. The annual national budget negotiation results in agreement on resource allocations, such as the recommended maximum level of municipal taxes, the level of state subsidies to the regions and municipalities, the level of redistribution or financial equalization between municipalities, and the size of additional grants earmarked for specific areas that need additional resources (see Chapter 4 on Financial resources). The annual national budget negotiation has been increasingly used by the central Government as a means of reaching an agreement on the development of the health sector and setting the overall economic framework. The central Government has some influence over the direction of the health sector by highlighting priority areas, such as heart surgery, cancer treatment and waiting lists, and making earmarked grants available to assist the regions and municipalities in achieving targets, such as reducing waiting times for surgery, increasing the number of heart bypass operations and expanding psychiatric services. Although these targets are not legally binding, the practice of earmarking funds reduces local autonomy to set priorities. The regions have, therefore, frequently expressed dissatisfaction with this practice, claiming that it contradicts the fundamental principle of decentralized health care in Denmark. The decentralized structure of the health system allows the regions to influence the planning and management of the system in a way that reflects local preferences. The regions can broadly influence the provision of health care in three ways. First, the regions collectively regulate the number of people employed by hospitals and the number of private practitioners entitled to reimbursement from the regions. The agreements arising from negotiations between the regions 44
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and GPs contain detailed rules regarding the number of doctors per 1000 inhabitants. In this way, the regions are able to limit access to practitioners and exert some control over expenditure. The Danish Regions, further, act as one body in negotiations for hospital management, thus limiting the influence of any individual regional council. Hospital management has changed in recent years following the appointment of more professional managers such as economists, lawyers and other university-educated administrators. This has affected hospital power structures and it is claimed to have reduced the influence of clinical practitioners. Economic rationale plays a more prominent role in the system today, both as a result of the focus on cost-containment and the introduction of new managers. Second, the regions’ collective negotiations with professional organizations are a key means of controlling the activities of private practitioners. Giving priority to an activity by associating it with a fee appears to be an effective incentive. An example of this is the recent introduction of special fees for preventive advisory talks. Third, the regions can determine the size, content and costs of hospital activities through detailed budgets. These budgets enable them to specify which treatments should be offered and which technical equipment should be bought. The regions’ planning capacity is reduced by: (1) choice, which allows hospital patients access to treatment in other regions; (2) waiting list guarantees, which force them to prioritize these goals; and (3) various initiatives, which have been introduced by centrally conceived legislation or agreements (Vrangbæk 1999). 3.2.1
Health technology assessment
HTA in Denmark is oriented toward public opinion, in that various public interest groups have participated in the development of the HTA over the years and, particularly, in formulating the 1996 national HTA strategy. Statements from Danish consensus conferences are directed mainly towards the public and decision-makers in politics and administration. In Denmark, HTA is decentralized. This corresponds with the national strategy for HTA, which explicitly states that HTA should be applied at all levels of the health service as a systematic process in planning and operational policy, and as an underlying process for the routine clinical decisions of health professionals (National Board of Health 1996). The purpose of HTA is to obtain a relevant basis for decision-making – from politics to clinical practice – regarding the use of new technologies in the health 45
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system. Decisions for the general use of technologies in the health system should be made with a broad-based, systematic and well-documented information. Staff at all levels of the health service are responsible for identifying and drawing attention to areas where HTA is needed. This responsibility includes the need for new technology assessments as well as the evaluation of existing technologies. In areas where an independent national intervention is necessary, HTA projects are to be undertaken as a basis for planning and operational decision-making. Implementation of independent national projects should take place in cooperation with research councils, health authorities and professional organizations (Jorgensen, Hvenegaard, Kristensen 2000). On 1 April 2001, the Danish Institute for Health Technology Assessment (DIHTA) and the Danish Hospital Evaluation Centre merged to form the Danish Centre for Evaluation and Health Technology Assessment (DACEHTA) (National Board of Health 2005a). The Centre is situated as a separate entity within the framework of the National Board of Health, and receives advice from two boards. The Centre’s Advisory Board is made up of 23 members representing the main stakeholders of the Danish health system at political, administrative and industry levels. The Scientific Advisory Board, which has 12 members, gives multidisciplinary advice to the Centre. The DIHTA annual budget of DKK 25 million is part of the Ministry of Health’s budget framework. The key aims of DACEHTA include: (1) to carry out HTAs and evaluations of public health services with the aim of improving quality, standards and value for money; (2) to integrate HTA principles into the running and planning of the public health service at all levels; (3) to realize the intentions behind the National Strategy for Health Technology Assessment which was issued by the National Board of Health; and (4) to follow the strategic plans within the field of evaluation. DACEHTA has created a strategic plan, which describes the overall visions and guidelines for the work carried out by the Centre (Danish Centre for Health Technology Assessment 2005). DACEHTA collaborates with the health authorities at regional level in evaluating and analysing medical equipment, pharmaceutical products, investigations, treatment and care methods, methods for rehabilitation, health education and prevention. The Centre initiates and carries out HTA in cooperation with clinical departments, GPs, health administrators, clinical scientists, health services researchers and representatives from the medical industry. DACEHTA has a small multidisciplinary staff of 11 full-time experts and 8 external part-time experts, who are mainly occupied with advising, administration and coordination of projects. Between 1997and 2003, DACEHTA (DIHTA before 2001) published 48 reports or assessments, 21 external reports, 46
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6 PhDs, 3 graduate theses, 38 scientific articles, and 44 articles, letters and other materials (National Board of Health 2005a). The reports cover topics including beta-interferon treatment for multiple sclerosis; incidence, treatment and prevention of back pain; influenza vaccination of elderly people; colorectal cancer; arthritis; and the treatment of gallstones. Several of these reports have helped to create an ongoing and lively public debate on priorities in health care. There is no regulatory mechanism in the Danish health service requiring the use of HTA in policy decisions, planning or administrative procedures. At the national level, however, a number of comprehensive assessments of health technology have formed the basis for health policy decisions. However, the conclusions of HTAs are often disregarded due to political or an individual health professional’s priorities. A primary concern regarding HTAs is that assessments are time-consuming and thorough tasks, which can be difficult to fit into a short-term political process that often demands quick decisions. 3.2.2
Information systems
A number of public registers exist within the health care field concerning the population’s use of health care benefits, disease incidence and prevalence, causes of death, and so on. The registers are mainly compiled for administrative purposes and the information regarding individuals is used for treatment and statistical research purposes. More specifically, the data can be used for the management of health expenses or the planning of activities within the health system. The registers and their data are very important for both epidemiological and health services research in Denmark. The most commonly used registers are labelled according to a personal identification number (CPR) and contain information on individuals, including their family relations, education and income status (Vallgårda & Krasnik 2007). This provides researchers with the opportunity to collect and combine information at an individual level from different registers for the analysis of statistical associations. Such coupling of registers is under strict regulation, due to data sensitivity. Data validity in the major registers is generally high; however, problems can occur when, for example, health professionals have to register diagnosis or treatment codes. The key registers that can be identified in Denmark are listed here. (a) Registers based on contact with the hospital system are the National Patient Register (LPR), the Psychiatric Central Register, the Medical Birth Register and the National Board of Health Register for Legal Abortions. The LPR is a 47
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unique register containing all hospital admissions, outpatient treatments, and casualty department visits across all of the public and private hospitals in the country (National Board of Health 2005a). (b) Specific disease registers are the Cancer Register, the Malformation Register and the Artificial Insemination Register (for in vitro fertilization (IVF)). (c) Registers concerning the population’s health status in general are the Causes of Death Register and the Work Accident Register. (d) Administrative registers with relevance to the health sector are the CPR Register, the Health Reimbursement Register and the Sickness Benefit Register. The Health Reimbursement Register contains information about health services that are provided by GPs, practising specialists, dentists, physiotherapists, psychologists, and so on. However, it does not include information about symptoms or diagnoses of patients. All information in the registry is connected to the citizens’ unique CPR numbers, which makes it possible to link information from this registry with information from the LPR and the Causes of Death Register. In this way, it is possible to analyse complex health-related matters relating to specific population groups (Vallgårda & Krasnik 2007). (e) Other registers of importance for public health science include: the Demographic Database (DDB), the Prevention Register (FBR), the Hospital Use Statistics Register (SBR) and the Fertility Database (FTDB). The DDB is focused on registering when changes take place, for example, moving home, marriage or migration. The FBR is established in coordination with Statistics Denmark, the Ministry of Health and the National Board of Health with the aim of highlighting the health conditions in Denmark. This information is gathered from several different registers, such as the LPR, the Causes of Death Register and the Health Insurance Statistics Register from Statistics Denmark. The SBR contains information regarding people who have been admitted to somatic hospital departments. This information is also coupled with information on social conditions. Finally, the FTDB includes information regarding demographic and social data of the population during their fertile years (12–49 years for women and 12–64 years for men) (Statistics Denmark 2005). See www.dst.dk, www.im.dk, www.sst.dk and www.regioner.dk for further information on registers. To conduct research projects based on register data, permission from the Scientific Ethical Committee and the Data Protection Agency is required. The Danish Law of a scientific ethical committee system and biomedical research projects (Legal Information 2003) sets out the legal framework for the scientific ethical assessment of research projects in overall terms. Consent is required and is fundamental to the rules governing the scientific ethical assessment of research projects and to the committee system. The implementation of the 48
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Law on professional confidentiality and handling of personal information, etc. (Law on Health of 2005) is monitored by the Data Protection Agency. It is the Agency’s task to ensure that data are used in agreement with the Act and with the rules issued in pursuance of the Act. Therefore, data collected in relation to a project must be reported to the Data Protection Agency when the project involves handling of sensitive personal information. According to the Act this entails collection, registration, systematization, storage, adjusting, selecting, searching, use of data, passing on, promoting or coordinating without blocking, erasing or terminating data. 3.2.3
Research and development
Denmark has a rich tradition of medical research. Training for researchers has been formalized and the funding system includes the growing use of independent quality assessments. However, the Government encourages more international partnerships, broader research cooperation and extended information technology (IT) networks. A number of public institutions carry out research in Denmark. There are nine universities, which occupy a central position in the research system and whose tasks include carrying out research, providing higher education, responsibility for training PhD students as well as disseminating knowledge. Government research institutions, including a broad, varied group of institutions placed under nine ministries, comprise another element of public research. During the period 2006–2007, the number of such institutions has been reduced dramatically due to a governmental plan to fuse these types of institutions with the universities. The State finances 75% of public sector research. The rest is financed by private organizations, regional and local governments and international sources, such as the EU (Danish Council for Research Policy 2005). Research is also conducted at university hospitals. Denmark, however, is still lagging behind in terms of the objectives of the Barcelona Declaration regarding the total share of the country’s GDP to be invested in research. Some of the most important governmental research institutions involved in health-related research are listed here. • Statens Serum Institut (SSI) (National Serum Institute) is a research organization partly integrated within the Danish health service and involved in prevention and control of infectious diseases and congenital disorders (National Serum Institute 2005). • The National Institute of Public Health (SIF) has become part of the University of Southern Denmark. Its primary purpose is to research the health 49
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and morbidity of the Danish population and the functioning of the health system, as well as to educate (National Institute of Public Health 2005). • The Danish National Centre for Social Research conducts research and carries out commissioned projects in the area of welfare state policies, and disseminates the results (Danish National Centre for Social Research 2005). • The Danish Institute of Health Services Research (DSI) is an independent non-profit-making research institute. It aims at providing an improved basis for the planning and management authorities within the health services. This is achieved through collection, examination and dissemination of information, by carrying out research and development tasks, and through theoretical and practical counselling (DSI 2005). Besides these national research institutions, some smaller institutions are financed by individual regions in order to carry out health research at regional level. One example is the Research Centre for Prevention and Health in Glostrup. In 2007 there were more than 27 000 academically trained researchers in Denmark. Since the mid-1990s the number of researchers, including PhD students, has increased by approximately 7000. The reform of researcher training was an important factor behind these increased numbers. Researcher training in Denmark is a 3-year postgraduate programme, leading to a PhD Degree. Universities have formal responsibility for researcher training, but training can also be carried out in cooperation with a government research institution or a hospital. The number of enrolled PhD students has tripled to more than 5000 since the mid-1990s. Approximately one third of all university research is carried out by research students. The reform of researcher training has made a decisive contribution to the internationalization and renewal of Danish research (Ministry of Science, Technology and Innovation 2005). The number of peer-reviewed journal articles is not registered and gathered by a single institution. The Regional Councils and the National Board of Health have requested the establishment of such an institution but this has not yet been implemented. However, each university and governmental research institution records its own publications.
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4
Denmark
Financial resources
T
he Danish health system is mainly financed by state and municipal taxes. Other sources of finance include user charges for some health goods and services and VHI, which is taken out to partially cover user charges. Figure 4.1 gives an overview of the system’s financing arrangements. The most significant resource allocation mechanisms are listed here. • National level: the national budget negotiation takes place once a year between the Ministry of Health, the Ministry of Finance and the regional and municipal councils, which are represented by the Danish Regions and the National Association of Local Authorities. • Regional/local level: political budget negotiations take place within the regional and municipal councils within nationally specified ceilings. In 2003, the total health expenditure per capita was US$ 2763 in purchasing power parity (PPP), of which 83% was public expenditure. The main portion of health-related public expenditure is spent on hospitals. The average growth rate of the total expenditure on health between 1998 and 2003 was 2.8%. Total health expenditure as a percentage of GDP has risen moderately during the period 1995–2003, corresponding to an average yearly increase of 0.1%. This rise was preceded by a decline in total health expenditure as a percentage of GDP during the period 1980–1995. The public proportion of total health expenditure was fairly stable between 1995 and 2003 (OECD 2006).
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Fig. 4.1
Denmark
Financing flow chart State taxes
State government
Block grants
Activity-based subsidy
Regional councils Co-payment for health services (per capita and activity-based)
Municipal taxes
Municipal councils
Voluntary premiums
Voluntary health insurance Global budgets
Municipal health services Disease prevention and health promotion Social psychiatry School health care and dental care for children and disabled Treatment of drug and alcohol abusers
Regional health services
Out-of-pocket payments
General practitioners Specialists
Fee-for-service
Pharmaceuticals
Subsidies
Dentists Hospitals Prenatal and maternity care District psychiatry
Population Private hospitals Private health goods Direct payments
Patients
Source: Authors’ compilation.
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Capitation and fee-for-service
Fee-for-service Global budgets and activity-based financing
Global budgets Fee-for-service (special agreements)
Reimbursement
Taxes
Care for elderly and disabled
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4.1
Denmark
Revenue mobilization
The historical evolution of public and private expenditure on Danish health care is described in Section 2.1 on Historical background. The current revenue mobilization is dominated by public taxation at both state and municipal levels. The Local Government Reform and the Financing Reform, which came into effect on 1 January 2007, had some important implications regarding income tax distribution between the municipalities and the central Government. Most significantly, the number of taxation levels was reduced from three to two; this is because the previous 14 counties were merged into 5 new regions, which were not given power to levy taxes. As of 1 January 2007, the municipalities took over the portion of the county revenue that does not correspond to the new state health contribution of 8% of income. This means that the municipalities have been allowed to raise their tax revenue by four percentage points. State taxes are henceforth a combination of personal income tax, valueadded tax (VAT) (a single rate of 25%), energy and excise duties, labour market contributions (8% on all personal income), corporate income tax and the abovementioned health contribution (8%). Personal income tax accounts for almost half of the State’s total tax revenue and is payable on wages and almost all other forms of income, including profits from personally owned businesses. It is calculated according to a progressive scale, with a basic rate of 5.5%. The medium and top rates (6% and 15%, respectively) are levied on earned and capital income. A tax ceiling ensures that income taxes collected at state and municipal levels cannot exceed 59% of income. Aside from the state health contribution, some taxes are partly motivated by health concerns (e.g. excise duty on motor vehicles, energy, spirits and tobacco products). In the 1990s, the national Government introduced a green excise duty that is levied on pollution and the consumption of scarce goods, such as water, oil, petrol and electricity. In 2007, the average municipal tax rate was 24.6%. Municipal taxes are levied proportionately on income and real estate (property). Every year, the central Government agrees on maximum municipal taxation rates with the National Association of Local Authorities. The central Government also distributes additional resources to the municipalities through block grants, if municipalities raise their service level or take over tasks from the state subsidies based on the size of their tax revenue. Because the population’s income and need for public services vary from area to area, a certain amount of redistribution or financial equalization is necessary to compensate for discrepancies and to make sure the tax rate is associated with the municipal council’s chosen service level and not the tax base or the population’s need for 53
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public services. Redistribution between municipalities is devised according to a formula, which accounts for the following objective criteria: age distribution; the number of children in single parent families; the number of rented flats; the rate of unemployment; the number of people with only basic or no education; the number of immigrants from non-EU countries; the number of people living in socially deprived areas; and the proportion of elderly people living alone. Likewise, the size of the State’s block grant to each region depends on sociodemographic criteria. In 2001, the Government introduced a tax freeze as a central part of its economic policy. 4.1.1
Main source of finance
See Section 4.1 on Revenue mobilization. 4.1.2
Second most important source of finance
State and municipal taxes are the main sources of health care financing in Denmark, but patients also make substantial out-of-pocket payments at the point of use. Private expenditure mainly covers the costs of pharmaceuticals, vitamins, dentists, spectacles, unauthorized or alternative treatments, VHI and accident insurance. 4.1.3
Out-of-pocket payments
Patients pay out-of-pocket payments for part of the cost of dental care and physiotherapy. For dental care, the reimbursable amount depends on the procedure performed, but it is usually only a small part of the total cost. High co-payments for dental care have caused some controversy in Denmark, as it is claimed that they are reducing equity of access to these services. Expenditure on pharmaceuticals in hospitals is reimbursed in full, whereas pharmaceutical expenditure in the primary health care sector is subject to different levels of co-payment. Under the new reimbursement system, an individual’s annual pharmaceutical expenditure is reimbursed at the following levels: below DKK 520 – no reimbursement; DKK 520–1260, 50% reimbursement; DKK 1260–2950, 75% reimbursement; above DKK 2950, 85% reimbursement (Danish Medicines Agency 2005a). Chronically ill patients with permanent or high drug utilization levels can apply for full reimbursement for any expenditure above an annual ceiling of DKK 3805 (Danish Medicines Agency 2005a). Special rules for pensioners have been abolished, although 54
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pensioners who find it difficult to pay for pharmaceuticals can apply to their municipality for financial assistance. Patients with very low income can receive partial reimbursement, on a case-by-case basis, under the Ministerial order of Law on social security pension (Legal Information 2007a) and the Ministerial order of Law on social service (Legal Information 2007b). In addition, many individuals purchase VHI to cover the cost of paying for pharmaceuticals (see Subsection 4.1.4 on Voluntary health insurance). Pharmacists are required to substitute the most inexpensive, or close to the most inexpensive, generic medicine for the medicine prescribed by the physician to help reduce the burden of out-of-pocket payments (and the burden on public expenditure) related to pharmaceuticals. This should take place if the prescriber has not clearly stated to the contrary. It is not known how much is spent on unauthorized or alternative treatments and pharmaceuticals in Denmark. According to a national survey carried out in the year 2000, 21% of respondents had used unauthorized or alternative treatments during the previous year; women aged between 25–44 and 45–66 were the most frequent users of alternative treatment, and zone therapy, massage, herbal medicine and acupuncture were the most frequently used treatments (National Institute of Public Health 2003) (see Section 6.12 on Alternative/ complementary medicine). User charges for GP and hospital visits have been discussed as a means of reducing unnecessary utilization of health services, but they have so far been rejected for fear of reducing utilization by poor individuals who are most in need of health care. Out-of-pocket payments are not tax deductible. 4.1.4
Voluntary health insurance
For the past century, a large proportion of health care in Denmark has been financed through a system of VHI schemes (see Section 2.1 on Historical background). The counties took over these schemes in 1973 and, since then, most health care has been financed through taxation. However, a small VHI scheme still exists, which covers treatments that are only partially reimbursable or not publicly reimbursable at all. The purchase of such VHI is becoming increasingly popular. In 2002, the contribution of VHI to total expenditure on health was 1.6%: a 0.2% increase from 1998. Private (out-of-pocket) expenditure on health care accounted for 17% of total health expenditure in 2002, compared to 16.6% in 1998 (OECD 2004). Since opting out of the tax-based financing of the public health care services is not possible, VHI is mainly used as a complementary or supplementary scheme alongside the statutory health care system in Denmark. 55
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Complementary VHI provides full or partial coverage for services that are excluded or only partially covered by the statutory health care system. For example, it provides coverage for the reimbursement of pharmaceuticals, dental care, physiotherapy and corrective lens co-payments. Approximately 28% of the population purchased complementary VHI in 1999, making complementary VHI the most common type of VHI in Denmark (Thomson & Mossialos 2004). The purpose of supplementary VHI is to increase consumer choice and access to different health services. Traditionally, this means guaranteeing superior accommodation and amenities in hospital – rather than improved quality of care – and faster access to treatment that generally has long waiting times, such as elective surgery. This type of VHI is of growing importance in Denmark and mainly covers access to private hospitals in Denmark and abroad. The demand for supplementary VHI in Denmark is fuelled by general conditions in the Danish labour market (including strong competition for employees and high levels of personal income tax) and the fact that companies benefit from tax deductions when purchasing VHI for employees (Mossialos & Thomson 2002). Over the past few years, demand may also have been fuelled by the critical tone of public debate on the statutory health care system. Quality and waiting times are perceived to be problems in Denmark and, although these perceptions are not always accurate or evidence based, insurers have been able to benefit from these concerns. Supplementary VHI in Denmark favours those who are employed, as many policies are tied to job contracts. In general, supplementary VHI has less significance for children, unemployed people, students, the elderly and those with pre-existing conditions or chronic illnesses. For these reasons, supplementary VHI introduces greater inequality into the health system (which is, otherwise, unacceptable in Denmark) and stimulates the demand for private health care, which has generally been very limited (Mossialos & Thomson 2002). The VHI market is dominated by Health Insurance “denmark”, a mutual (non-profit-making) association that covers approximately 29% of the total population and had a 99% share of the VHI market in 2004 (Health Insurance “denmark” 2007). Health Insurance “denmark” offers individual insurance policies; however, premiums are not tax deductible. The role of Health Insurance “denmark” is primarily to cover co-payments, and, in some cases, it pays for non-publicly reimbursed health care. Four different types of coverage are offered (Health Insurance “denmark” 2007). The first type of coverage, Group 1, provides coverage for expenses related to private hospital care, medication, medical aids, chiropractice, chiropody, physiotherapy, dental treatment, eye care, glasses, contact lenses, funeral aid and visits to sanatoria. Approximately 7.1% of the total Danish population were covered in Group 1 in 2004. Group 2 is designed for people who choose to pay a greater amount of their health expenses 56
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in exchange for a freer choice of both GPs and specialists. Group 2 members are reimbursed for expenses relating to GPs and specialists, in addition to receiving Group 1 coverage. Only 0.8% of the total Danish population were covered by this scheme in 2004. The third type is called Group 5. It covers medication, dental care, glasses and contact lenses. This group is mainly aimed at young people, who generally have less need for coverage. Thus, the coverage and the premium are lower compared to the two types already mentioned. Group 5 is by far the largest, comprising 22.6% of the total Danish population in 2004. The fourth type is a basic insurance, designed for people with no acute need for medical care. As a member of the Basic Insurance group, medical costs will not be refunded; however, members may switch to one of the other types of coverage whenever necessary, without having to requalify. A total of 3.6% of the Danish population are members of this type (Health Insurance “denmark” 2005). VHI is provided through annual or long-term contracts and benefits are paid in cash. Applications for coverage may be rejected if applicants do not fulfil the requirements, which mainly regard health status and are set out by Health Insurance Denmark. In recent years, private profit-making insurance companies have gained access to the market. Similar to Health Insurance “denmark”, these companies offer coverage for private hospital care in Denmark or abroad. According to the trade organization, Insurance & Pension, the number of private insurance contracts more than doubled from approximately 120 000 in 2002 to almost 300 000 in 2004 (Mandag Morgen 2005). Private health insurance is primarily distributed through company agreements in the form of group insurance. Schemes that provide a lump sum in case of “critical illness” have been the biggest successes for these insurance companies. Such schemes can be used for private hospital care or any other purpose and often form part of collective and business arrangements between employers and employees. Interest in private insurance comes from a combination of the employees pressuring employers for an agreement and companies seeing it as a modern personnel and pension policy. Insurance varies depending on the company, according to the content and degree of coverage. The typical minimum coverage includes some private hospital treatments plus preliminary examinations and after-care. If treatment cannot be conducted in a private hospital in Denmark, then it is offered abroad. The five largest private profit-making insurance companies in Denmark are Codan Care, Danica, PFA, Topdanmark and Tryg (Danish Association of the Pharmaceutical Industry 2005). Three types of private health insurance exist in Denmark: user-payment insurance, critical illness insurance and hospital insurance. User-payment 57
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insurance is individual insurance offered by Health Insurance “denmark”. Critical illness insurance is accident insurance, which can be subscribed to with Health Insurance “denmark” but it is also a part of several collective agreements between employers and employees. Hospital insurance is usually paid by employers. Several commercial insurance companies offer this kind of insurance. Generally, it covers all hospital treatment expenses. The premiums of VHI policies, which are sold by the dominant mutual association Health Insurance “denmark”, are usually group-rated and vary according to the level of coverage chosen. Commercial premiums are based on age and employment status. The maximum age limit for coverage is 60 and pre-existing conditions are excluded from the coverage. There is no regulation of premiums and no tax relief for policies purchased by individuals. Employers purchasing policies on behalf of their employees may deduct the cost of these premiums from their taxes. Almost all policies sold by Health Insurance “denmark” are purchased by individuals, while over 80% of the commercial policies are purchased by employers or groups (Thomson & Mossialos 2004) Employer tax relief for employer-paid insurance policies is likely to fuel demand for VHI in future. There are no cross-subsidies with the statutory health care system. Generally, the Danish population is not concerned with the growth of private health insurance. Approximately two thirds of the population find the act of companies offering health insurance to their employees to be positive. Only one third of the population finds it troubling and sees it as a potential risk for privatization to damage the Danish welfare model in the long run. The part of the population in favour of private health insurance is equally distributed in gender, age, education and type of work. People in the age group 15–29 years, people with less education and people earning yearly wages that are greater than DKK 500 000 are, in particular, very positive towards the growth of private health insurance (Mandag Morgen 2005). Although the level of private insurance coverage in Denmark is relatively low today, the market for VHI is expected to grow in the long run. This may undermine people’s willingness to contribute to the public health care system and it may increase inequity in access to health care, especially if the poor or unemployed cannot afford to subscribe to VHI schemes.
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4.2
Denmark
Allocation to purchasers
Resource allocation decisions are made at several levels. The most significant resource allocation mechanism at national level is the national budget negotiation that takes place once a year between the Ministry of Health, the Ministry of Finance and the regional and municipal councils, which are represented by the Danish Regions and the National Association of Local Authorities. At this annual negotiation, the following allocations are decided upon: • the recommended maximum level for municipal taxes; • the level of state subsidies to the regions and municipalities, in the form of general block grants, whose size depend on several objective factors, with the most important factors being the population’s demographic characteristics (regions and municipalities) and the size of municipal tax revenues (the municipalities only) (a minor part of the grants is distributed between the regions, based on the productivity of their hospitals, which is measured in DRG-points produced). • the level of redistribution or financial equalization between municipalities, which compensates for variations in the tax base of different areas; • the size of the one-off or permanent grants, which are earmarked for specific initiatives that require additional resources (e.g. the Second National Cancer Programme or other initiatives including heart surgery and mental illnesses). Although the regions and municipalities are responsible for providing the majority of health services in Denmark, they must stay within the health care expenditure limits that were agreed on during annual negotiations. Since most regional and municipal health care spending is financed through income taxes (81%) or real estate (property) (6%) taxes, the central Government’s strongest economic control instrument over the municipalities is their opportunity to limit or extend these revenues. If expenditure exceeds the limits – even though the municipalities are not legally bound by the annual negotiations – the national Government may penalize individual or all municipalities or regions by withholding grants, which account for 13% of total municipal health care financing. In practice, however, there are few instances of significant tax increases beyond agreed levels. Room for negotiation during the annual negotiations has been very limited since the introduction of the tax freeze on all taxation levels in 2001.
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4.3
Denmark
Purchasing and purchaser–provider relations
Financial resource allocation between the integrated purchasers and providers in the hospital sector of the Danish health care system has been subject to major changes. In the past, many county politicians and managers were very sceptical of activity-based financing, probably because their counties experienced massive deficits before the introduction of global budgeting in the 1970s. Another possible reason for this scepticism is the combination of unlimited demand for health care (which is provided free at the point of delivery) and very limited extra tax revenue (which is provided to the counties for treating a greater number of patients). However, activity-based financing was eventually introduced in the 1990s. Since the counties experienced massive deficits in the 1970s, the predominant method for allocating resources to hospitals has been prospective global budgets, which were fixed by the county councils. These budgets were based on past performance and modified when new activities were introduced, which included changes in tasks and areas of specific need. During the 1980s and 1990s, counties developed their budgetary process by increasingly including non-economic measures, such as activities (e.g. discharges, bed-days and the number of ambulatory visits) and service levels (e.g. standards for various gauges of waiting time). Some counties also wanted to include clinical quality and performance measurement management in this target, but did not succeed as the proposed measures were considered too simple. These performance measures supplemented global budgets, which continued to make up the main component, and were mostly intended to raise awareness of the relationship between costs and activity, and to create incentives for increased activity and improvement in hospital services. They were not intended to introduce competition between hospitals, and little emphasis was placed on publishing the hospitals’ results to the public. This was probably due to the fear that hospital administrations might manipulate performance data or that below-standard performances might create anxiety among voters and encourage patients to choose hospitals in other counties. Performance measures varied from county to county and, in some cases, even from hospital to hospital. Although hospital budgets are “soft” in the sense that they are not legally binding and do not include specific sanctions if targets are not achieved, persistent failure to fulfil a budget may result in replacement of managers. Another initiative to improve effectiveness has been to delegate management and financial responsibility to lower levels (e.g. from hospital to department 60
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level). It is hoped that this will increase cost-awareness and allow the better utilization of information at each organizational level. Department-level budgets are fixed through annual negotiations between the regions, hospital administrators and departments. The procedure varies across the regional level. Individual hospitals may make contracts with each department. If an inhabitant has utilized regional services such as heart transplants, or exercised his/her right to a free choice of hospital, the county or region where these services were delivered is reimbursed by the inhabitant’s own region. Before the introduction of activity-based financing, this reimbursement was passed on to the hospitals involved or, more often, kept by the regions as part of their general income. For this reason, hospitals usually did not regard reimbursement for treatment of patients from other counties as an incentive. The system of politically controlled global budgeting and contracts, combined with cost-containment efforts at the regional level, has proven to be an effective way of controlling expenditure on hospital services. However, the system provides limited economic incentives to increase efficiency at the point of service delivery and limited general incentives to increase activity if demand rises, which possibly contributes to waiting list problems for some treatment types (Pallesen 1997). Finally, global budgeting encourages hospitals and departments to view their economic budget as a “right”. It also makes it difficult to establish whether the current resource allocation mechanism is efficient or not, and to reallocate resources between hospitals and departments. A number of different initiatives, at both state and regional levels, have been introduced to counter the negative consequences of global budgeting. These initiatives are characterized by adding increasingly more performance measures in hospital budgets or by gradually introducing more market-oriented steering mechanisms into the health care sector. Activity-based financing has been gradually introduced as a resource allocation mechanism in Denmark. In 1997, extra funds were allocated to the counties so that they could experiment with activity-based financing. As part of the budget agreement for 1999, and in conjunction with the “free choice of hospital” scheme introduced in 1993, full DRG payments for patients treated at hospitals outside their home region were introduced. This has increased the incentive for regions to treat patients from other regions since, in many cases, DRG rates are higher than the deliberately low rates that were initially applied to the “free choice” scheme. At first, only marginal rates were used, for fear that this element of activity-based financing may lead to increases in health care costs; however, this has turned out not to be the case. It is still not clear to what extent this change has led to greater competition between regions. However, a survey conducted in 2002 concluded that 70% of hospitals reported having 61
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launched initiatives to attract patients from other regions to their services. The survey also showed that the share of patients from other regions that were treated in hospital departments increased by 32% between 1996 and 2000 (AnkjærJensen & Rath 2004). Since 2004, the global financing system, which is based on an adaptation of the DRG system, has been combined with negotiated activity targets for each hospital. Under this system, each hospital receives an upfront budget corresponding to 80% of the DRG rates related to the case mix in the negotiated activity target (the “baseline”), with the remaining 20% being allocated according to actual activity. Hospitals and departments that produce less DRGs than their baseline will thus receive less funds. Departments and hospitals that produce more DRGs than their baseline will experience a rise in income; however, there is a limit as to how much the extra income can exceed the baseline. This thereby combines the advantages of global budgeting with the advantages of activity-based financing. Implementation of the new scheme has varied between counties (Ankjær-Jensen & Rath 2004). The Government is planning an increase in the activity-based financing from 20% to 50% of the hospital budgets during the coming years. This increase means that the economic consequences of producing less DRGs than the baseline will become stronger for the individual hospital or department. In order to avoid hospitals and departments from discriminating against patients on the basis of their place of living, their activity is measured in DRGs independent of where patients live.
4.4
Payment mechanisms
4.4.1
Paying health care personnel
Salaries for staff employed by hospitals, nursing homes and municipal health schemes are fixed through negotiation between trade unions, professional organizations, the Danish Regions and the National Association of Local Authorities. Approximately 60% of Danish doctors work in hospitals as salaried employees. A further 10% are involved in nonclinical work such as administration, teaching and research. Approximately 23% of doctors work as GPs (Ministry of the Interior and Health 2005b). GPs licensed by a region derive almost all of their income from that region, according to a scale of fees that is agreed on by the Organisation of General Practitioners and the Danish Regions. Their remuneration is a mixture of capitation, which makes up on 62
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average a third of their income, and fee-for-service payments for services rendered (per consultation, examination, operation, etc.), including special fees for out-of-hours consultations, telephone consultations and home visits. This combined fee system has been developed over the last century. Its objective is to create incentives for the GPs to treat patients by themselves rather than to refer those who could be treated in general practice to hospital. At the same time, it provides economic security and remuneration for general services, for which fees are not paid otherwise. While the fee-for-service mechanism should increase GPs’ productivity, capitation aims at preventing GPs from providing unnecessary treatment. In 1987, the city of Copenhagen changed from an area using a mostly capitation-based system to one using the combined fee system used in the rest of the country. As a result of this change, the volume of activities which were specifically remunerated increased and referrals to specialists decreased (Krasnik et al. 1990). Priority setting also influences the contract between the GPs and Danish Regions. For example, a comparatively high fee for preventive consultations is supposed to encourage GPs to offer longer consultations focusing on broader health and prevention activities such as education regarding smoking or dietary habits, weight control, and so on. Before the introduction of this quite high fee, GPs who used extra time to discuss such topics with their patients were “punished” compared with GPs who stuck to a quick examination of each patient. Practising specialists licensed by the regions are also remunerated by region, although they only receive fee-for-service payments. In order to visit a specialist a patient must be referred by a GP; that is, unless the patient is willing to pay for the treatment on their own. Almost all specialists’ income is paid by the region. Very few doctors are employed in the private profit-making sector, but those that are work either at clinics or small hospitals or in the pharmaceutical industry. Paying providers a fee for the services rendered is intended to promote productivity, but there is little evidence concerning the efficiency of this payment mechanism. It has proven very difficult to control the regional expenditure for these services and it has, during some periods, even increased more rapidly than hospital expenditure – probably due to the strong activity-based financing element. There are limits on GPs’ and specialists’ income from the counties, but these limits are much weaker than those in the hospital sector. Health care personnel employed by the municipalities (nursing home staff, home nurses, health visitors and municipal dentists) are paid a fixed salary. Public health professionals are employed at public (at both state and municipal levels, and within research institutions) and private institutions involved in the administration, planning and provision of health care. Public health professionals are mainly paid on the basis of fixed salaries. For details 63
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of the payment of dentists and dental auxiliaries, see Section 6.11 on Dental health care.
4.5
Health care expenditure
The national data on health care expenditure differ from the approach applied by the Organisation for Economic Co-operation and Development (OECD) in terms of method of measurement and the extent of services included. In this section, OECD data are primarily used to improve the possibility of crosscountry comparison, and despite recognition of the methodological difficulties that are also embedded in this approach. Danish health care expenditure as a percentage of GDP is slightly lower than the EU average for the Member States belonging to the EU before May 2004 (see Fig. 4.2, Fig. 4.3 and Fig. 4.4).
Table 4.1 Trends in health care expenditure, 1980–2003 (selected years)
Total health expenditure, US$ PPP per capita Total health expenditure as a % of GDP Public expenditure on health as a % of total expenditure on health Private expenditure on health as a % of total expenditure on health Out-of-pocket payments, US$ PPP per capita Out-of-pocket payments as a % of total expenditure on health Private insurance – % of total expenditure on health Mean annual real growth rate in total health expenditurea Mean annual real growth rate in GDP
1980
1985
1990
1995
2000
2002
2003
943
1 275
1 554
1 843
2 353
2 583
–
9.1
8.7
8.5
8.2
8.4
8.8
9.0
87.8
85.6
82.7
82.5
82.4
82.9
8.0
12.2
14.4
17.3
17.5
17.6
17.1
17.0
107
173
249
300
373
396
–
11.4
13.6
16.0
16.3
15.9
15.3
–
0.8
0.8
1.3
1.2
1.6
1.6
–
–
–
–
2.3
4.3
2.0
–
–
–
1.0
2.8
3.0
1.7
2.3
Sources: Ministry of Finance, 2001; Ministry of the Interior and Health, 2005b; OECD, 2004. Notes: a 2003 prices; PPP: purchasing power parity; GDP: gross domestic product. 64
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Fig. 4.2
Denmark
Health care expenditure as a share (%) of GDP in the WHO European Region, 2004, WHO estimates Western Europe
11.6 10.9 10.8 10.0 9.9 9.9 9.8 9.8 9.8 9.5 9.3 9.2 9.0 8.7 8.7 8.1 7.8 7.8 7.7 7.5 7.5 7.2 7.1 6.9 6.2
Switzerland Germany Iceland France Norway Monaco Portugal Netherlands Greece Sweden Belgium Malta Denmark Italy Israel United Kingdom Spain San Marino Turkey Finland Austria Ireland Andorra Luxembourg Cyprus
Central and south-eastern Europe
Bosnia and Herzegovina Slovenia Hungary Croatia Bulgaria Czech Republic The former Yugoslav Republic of Macedonia Albania Lithuania Poland Latvia Slovakia Romania Estonia
9.3 8.7 8.4 7.9 7.7 7.2 7.0 6.6 6.5 6.4 6.4 5.8 5.7 5.5
CIS
7.5 6.3 5.8 5.6 5.4 5.4 5.3 4.5 4.0 3.9 3.8 3.7
Republic of Moldova Belarus Ukraine Armenia Uzbekistan Kyrgyzstan Russian Federation Tajikistan Georgia Kazakhstan Turkmenistan Azerbaijan Averages EU Member States before May 2004 EU average CIS average
9.3 8.7 5.3 0
5
% of GDP
10
15
Source: WHO Regional Office for Europe, January 2007. Notes: CIS: Commonwealth of Independent States; EU: European Union.
65
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Fig. 4.3
Denmark
Trends in health care expenditure as a percentage of GDP in Denmark and selected other countries, 1998–2004, WHO estimates
12
11
10
9
8
7
6
5 1998 Denmark United Kingdom
1999
2000 Germany EU average
2001
2002 Norway EU15
2003
2004
Sweden EU12
Source: WHO Regional Office for Europe, January 2007. Notes: EU: European Union; EU15: European Union Member States before May 2004; EU12: countries that joined the EU in May 2004 and January 2007.
In Denmark, health care expenditure as a percentage of GDP fell in the 1980s; however, it has slowly risen since 1995 (see Table 4.1). The relatively high health care expenditure as a percentage of GDP in 1980 was largely due to a change in the definition and calculation of health care expenditure to include expenditure on nursing homes. In the 1980s, there was a trend towards rising private expenditure as well, which was driven by a political effort to contain public expenditure (see Section 2.1 on Historical background). The public proportion of total health expenditure, however, has been fairly stable during the period 1995–2003 (OECD 2004).
66
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Fig. 4.4
Denmark
Health care expenditure in US$ PPP per capita in the WHO European Region, 2004, WHO estimates Western Europe
Monaco Luxembourg Switzerland Norway Iceland San Marino Netherlands Germany France Belgium Sweden Denmark Ireland Andorra United Kingdom Italy Austria Finland Greece Israel Spain Portugal Malta Cyprus Turkey Central and south-eastern Europe Slovenia Hungary Czech Republic Croatia Slovakia Lithuania Poland Estonia Latvia Bulgaria Romania The former Yugoslav Republic of Macedonia Albania Bosnia and Herzegovina CIS Belarus Russian Federation Kazakhstan Ukraine Armenia Turkmenistan Republic of Moldova Georgia Kyrgyzstan Uzbekistan Azerbaijan Tajikistan Averages EU Member States before May 2004 EU average CIS average
4 797 3 992 3 954 3 862 3 508 3 172 3 056 3 052 3 016 2 922 2 875 2 838 2 619 2 581 2 531 2 424 2 365 2 275 2 106 1 972 1 908 1 903 1 686 972 589 1 760 1 334 1 333 897 829 816 810 776 751 635 566 411 409 359 740 571 393 361 321 224 202 193 177 169 160 82 2 645 2 268 444 1 000
2 000
3 000
4 000
5 000
US$ PPP Source: WHO Regional Office for Europe, January 2007. Notes: PPP: Purchasing pwer parity; CIS: Commonwealth of Independent States; EU: European Union.
67
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5
Physical and human resources
5.1
Physical resources
T
Infrastructure and capital investment
5.1.1
Denmark
he regions are responsible for providing hospital care and they own and run hospitals and prenatal care centres. They also finance GPs, specialists, physiotherapists, dentists and pharmaceuticals. Health care is largely a regional responsibility, and most national legislation concerning the health care sector does not specify how it should be organized or which services should be provided (see Section 3.2 on Planning and health information management). The number of beds in somatic and psychiatric hospitals in Denmark has declined substantially since the 1990s (see Tables 5.1 and 5.2), reflecting a trend in almost all western European countries (see Fig. 5.1). Somatic activity has increased since the mid-1990s, parallel with a reduction in the number of hospitals. The number of discharges increased from 1996 to 2005, with an average yearly rise of 1.3%. This should be looked at along with the average length of stay, which has decreased by 1.6 days during the same period. There has been a fall in the number of bed-days from approximately 6 million in 1996 to approximately 5 million in 2005, which corresponds to an average annual fall of 2% (Ministry of the Interior and Health 2006). The number of discharges from psychiatric hospitals increased during the period 1997–2003, with an average yearly rise of 2.2%. The number of psychiatric hospitals was stable from 1997 until 2001, where it began to vary noticeably; from 2000 to 2001, the number of psychiatric hospitals was reduced from 12 to 9 and then subsequently increased to 10 and 14 hospitals in 2002 and 2003, respectively (Ministry of the Interior and Health 2006). 69
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Table 5.1 Activity in somatic hospitals, 1996–2005 (selected years) Hospitals Discharges Bed days Beds Average length of stay (days) Bed occupancy rate (%)
1996 1998 2000 2002 2004 2005 79 76 61 58 52 – 980 000 996 000 1 029 000 1 062 000 1 089 000 1 102 000 5 990 000 5 738 000 5 567 000 5 471 000 5 111 000 4 998 000 20 476 19 472 18 484 18 166 16 668 16 410 6.1
5.8
5.4
5.2
4.7
4.5
80.1
79.5
81.7
79.0
82.2
83.5
Sources: Ministry of the Interior and Health, 2004b; Ministry of the Interior and Health, 2006.
Table 5.2 Activity in psychiatric hospitals, 1997–2003 1997 1998 1999 2000 2001 2002 2003 Hospitals 12 12 12 12 9 10 14 Discharges 35 526 36 769 38 626 38 982 40 691 40 815 40 423 Bed days 1 440 000 1 433 000 1 442 000 1 406 000 1 373 000 1 330 000 1 280 000 Beds 4 029 3 999 4 022 3 894 3 886 3 799 3 676 Bed occupancy 97.9 98.3 98.2 98.9 96.8 95.9 95.4 rate (%) Outpatient 450 000 483 000 532 000 564 000 567 000 746 000 643 000 visits Source: Ministry of the Interior and Health, 2006.
The relative reduction in the number of beds is most significant in psychiatry, largely due to a policy of deinstitutionalization. During the period 1980–1990, the number of psychiatric beds was dramatically reduced from 8182 to 4906. The general decline in the number of beds in both somatic and psychiatric hospitals is associated with a large increase in the number of outpatient visits. Many diagnostic and therapeutic procedures can take place without inpatient admission, or before and after an inpatient stay. Capital investment The regional and local authorities are responsible for conducting estate condition surveys. There is no central assessment of overall estate conditions. In the primary health care sector, the GPs and practising specialists own or rent their practice as independent contractors. No central or regional estate condition surveys are conducted at this level. 70
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Fig. 5.1
Denmark
Beds in acute hospitals per 1000 population in Denmark, selected countries and EU averages, 1990–2005
9
8
7
6
5
4
3
2 1990
1991
1992
1993
Denmark Sweden EU15
1994
1995
1996
1997
1998
Germany United Kingdom EU12
1999
2000
2001
2002
2003
2004
2005
Norway EU average
Source: WHO Regional Office for Europe, January 2007. Notes: EU: European Union; EU15: European Union Member States before May 2004; EU12: countries that joined the EU in May 2004 and January 2007.
The task of ensuring functional sustainability and appropriate space utilization of existing buildings is the responsibility of the decentralized levels and the State is rarely involved. Supervision over fire and safety compliance in hospitals lies with the local authorities. Regional capital investments are funded through general revenue with the exception of occasional grants, which are provided as direct transfers from the central Government to earmarked investments in health areas with special political focus, such as medical equipment to improve cancer care services. The financing of large-scale buildings is accomplished through a combination of general revenue, savings and loans. However, the central administration sets limitations on the economic activities of the regions, regarding the level of expenditure and borrowings. These limitations vary over time and they are generally based on political considerations. From 2007, the Ministry of Health must approve investments above a certain level. A redistribution of funds between municipalities has been implemented to ensure equitable geographic distribution of capital. The redistribution is devised according to a formula that accounts for the following factors: age distribution; the number of children in 71
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single parent families; the number of rented flats; the rate of unemployment; the number of people with a low level of education; the number of immigrants from non-EU countries; the number of people living in socially deprived areas; and the proportion of elderly people living alone. The influence of the private health care sector is marginal and its size is not regulated. 5.1.2
Information technology
Denmark, with 22 fast Internet connections per 100 inhabitants in 2005, was among the countries in Europe with the highest number of fast Internet connections, despite the relatively high user costs (Ministry of Science, Technology and Innovation 2005). In 2002, within a 3-month study period, 55% of the population had made contact with the public administration services using the Internet. Most commonly, people sought information from a public sector web site (40%), or engaged in other activities, such as downloading forms (16%) and sending information to authorities (13%) (Statistics Denmark 2004). In recent years, access to the Internet has generally increased. In 2004, 83% of the population had access to the Internet from home and/or work compared to 73% in 2001. The increase in home-based connections was particularly significant, reaching 70% of the population in 2004 compared to 59% in 2001. Access to the Internet from work was at 58% in 2004, compared to 53% in 2003 (Statistics Denmark 2004). Access to the Internet has increased for all age groups during the period 2001–2004. The most significant increase was among those aged 60–74 years, from 31% in 2001 to 53% in 2004 (Fig. 5.2). However, those in the group aged 16–39 years continue to have the highest percentage of access, with 96% in 2004. Concerning educational status, access to the Internet increases with the level of education. In the group with “higher education”, 96% had access compared to 71% within the group with “basic school” education. Students, white-collar workers and self-employed individuals all have a high degree of access to the Internet, with 96% for the first two groups and 91% for the latter. The unemployed group has significantly less access to the Internet (51%) compared to the other groups (Statistics Denmark 2004; Ministry of Science, Technology and Innovation 2005). In Denmark, a National Strategy Group has been established for the development of an IT strategy in health. This group is made up of the Ministry of Health, the National Board of Health, the Danish Regions and the National Association of Local Authorities. A National Strategy (2000–2002) for implementing IT in the hospital system was first published in 1999 and 72
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Fig. 5.2
Denmark
Internet access by the Danish population, 2004 (%) Women Men
Higher education Upper (secondary) school Lower (primary) school 60–74 years 40–59 years 20–39 years 16–19 years Unemployed Self-employed White-collar worker Blue-collar worker Student 0
10
20
30
40
50
60
70
80
90
100
Sources: Statistics Denmark, 2004; Ministry of Science, Technology and Innovation, 2005.
then subjected to hearings. Subsequent revisions of this document produced a National IT Strategy for the Danish health care service, which provided a common framework for the full computerization of the health sector during the period 2003–2007 (Ministry of the Interior and Health 2003b). These initiatives included the implementation of electronic health records (EHRs) in the Danish health care sector, and the spread of EHRs within the health system has taken place in recent years. However, the implementation process of the full strategy has not been very successful and available information suggests that the objectives have not been met so far. Exploiting the possibility of sharing data among systems that are already in use in the health care sector, through integrated information systems and EHRs and using common standards, is a major priority of the IT strategy. In 1998, the Danish Electronic Health Record Observatory was launched by the Ministry of Health, with the purpose of supporting the national health IT strategy by monitoring and assessing the development, implementation and application of EHRs in hospitals. The EHR Observatory is also part of the National IT Strategy 2003–2007. Explicit goals of the Strategy were: to install EHRs in all hospitals by January 2006; to ensure EHRs are based on the national information model for EHRs; to implement large-scale national eXtensible Markup Language (XML) communication between and within hospitals by 2005; and to establish an Internet-based secure health network by 2005 (BrunnRasmussen, Bernstein, Vingtoft, Andersen & Nohr 2003). Health professionals 73
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and IT experts have criticized the fact that the former counties have established different EHR systems and approaches, which they regard as a serious drawback, due to waste of resources and lack of coordination. Considering the complexity of the problems and the decentralized approaches that have been taken during the initial phases, full and functional EHR coverage of the Danish health care sector is not expected any time in the near future. A central initiative of the National IT Strategy is the creation of a common public health portal. Such a portal is intended to provide a common basis for communication and information in a cooperating health care sector. In addition, it is meant to provide citizens with an electronic access point to the health care sector (Lippert & Kverneland 2003). Currently, IT has been introduced to and, to some extent, used in all parts of the health care sector. Denmark ranks among the countries with the most widespread use of electronic communication within the health care sector. This is particularly attributable to collaboration between the central and regional health authorities on the establishment of the Danish health care data network for the communication of clinical messages, such as medical prescriptions from a GP to the pharmacy and referrals from a GP to the hospital. In 2002, approximately 2.4 million messages per month were exchanged among more than 2500 parties including hospitals, pharmacies, laboratories, GPs, and so on. Furthermore, IT is expanding within each part of the health care sector. In 2002, more than 87% of GPs used electronic medical patient records (Ministry of the Interior and Health 2003b). Within hospitals, IT systems are used to register patient data such as patient files, patient administrative systems, laboratory systems, blood bank systems and diagnostic imaging and booking systems. The patient administrative systems, which are extended throughout the entire health system, deliver data to central registers (such as the National Patient Registry). More than half of the local authorities have introduced electronic care systems, supporting the tasks of health recording, administration of drugs, and documentation and planning. 5.1.3 Medical equipment, devices and aids There is very limited national information available from hospitals and primary care facilities on existing medical equipment and its use in the Danish health system. The only available data include the number of magnetic resonance imaging (MRI) units, computed tomography scanners (CT), and radiation therapy equipment. The number of MRI units increased from 13 units in 1990 to 55 units in 2004, corresponding to a 423% increase. During the same period, the number of CT scanners increased from 22 to 79 scanners corresponding 74
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to a 359% increase. Finally, from 1981 to 2004 radiation therapy equipment increased from 25 to 35 units (OECD 2006). 5.1.4
Pharmaceuticals
Pharmaceutical expenditure Pharmaceutical expenditures for Denmark and selected European countries are illustrated in Table 5.3. As shown, Denmark’s per capita consumption of pharmaceuticals is well below that of other western European countries (measured as sales in ex-factory prices and including both prescription and non-prescription medicines and in both the primary care and hospital sectors). Pharmaceutical consumption in Denmark is lower than in any other western European country as well, at only 0.4% of the country’s GDP. Pharmaceutical expenditure in the primary health care sector in 2005 was DKK 11 935 million (calculated in terms of pharmacy retail price, including prescription charge and VAT) and in the hospital sector this was DKK 4398 million (calculated in terms of hospital pharmacy settling price, including VAT). Expenditure on over-the-counter (OTC) pharmaceuticals was DKK 1876 million. OTC pharmaaceuticals are also was sold through authorized retail outlets (DKK 205 million) (Danish Medicines Agency 2006). Table 5.3 Pharmaceutical consumption in Europe, 2002
Country
Austria Denmark Finland France Germany Greece Ireland Italy Luxembourg Spain Sweden
Pharmaceutical expenditure per inhabitant, US$ (PPP)
Share of public health care expenditure on medicine, %
Public health expenditure on medicine as a % of GDP
358 239 309 570 408 278 259 484 355 354 329
17.3 5.8 11.1 18.4 18.8 20.7 12.3 15.4 11.2 22.2 10.6
0.9 0.4 0.6 1.4 1.2 1.0 0.7 1.0 0.6 1.2 0.8
Public sector’s share of medicine expenditure (reimbursement share), % 74.9 52.5 53.0 67.0 74.8 71.5 84.2 52.1 82.5 73.6 69.3
Source: OECD, 2004. Notes: PPP: Purchasing power parity; GDP: Gross domestic product. 75
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In 2005, sales of medicinal products in the hospital sector accounted for 27% of total sales. In the primary care sector, pharmaceutical expenditure was financed by the regional health authorities (56%), patient co-payments (39%) and municipalities (4%). Pharmaceutical consumption was DKK 1137 per 1000 inhabitants per day in 2003 (DKK 1092 from the primary health care sector and DKK 45 from the hospital sector). Figure 5.3 shows the number of people being treated with prescribed medicinal products in the primary health sector (by sex and age). The constant increase in pharmaceutical consumption, which was observed throughout the 1990s, is still prevalent in Denmark today. This is partly due to the growing elderly population. During the last decade of the 20th century, a considerable number of new medicines were marketed; of these, most were either modifications of existing drugs, or pharmaceuticals for the treatment of previously untreatable ailments. This has attracted new consumer groups. Furthermore, it is increasingly common to use a combination of several drugs instead of single substances in the treatment of many diseases (e.g. hypertension, rheumatoid arthritis and gastric ulcers). Fig. 5.3
Number of people treated with prescribed medicinal products in the primary health care sector, by sex and agea
Source: Personal communication from Ellen Westh Sørensen (Department of Social Pharmacy, University of Copenhagen), 2006. Note: a Population as of 1 January 2006. 76
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The steady rise in the level of pharmaceutical expenditure has focused political attention on the pharmaceutical market for many decades, but particularly since the late 1980s. In spite of several initiatives to control costs (such as price freezes, price cuts, generic substitution and reference pricing), the level of pharmaceutical expenditure continues to rise today. Price levels In Denmark, the pricing of medicinal products is not controlled. Figure 5.4 shows the price index for medicines in some European countries in 2003. These indexes were calculated based on an assortment of Danish medicines, by comparing the package prices of a medicine in Denmark to those in another country where the same packages were available. Denmark, Finland and Sweden all have the same level, whereas Italy and Norway’s price indexes are lower. Iceland, together with Ireland, Great Britain, Germany and Liechtenstein, all pay a higher price than Denmark for the same medicines. Pharmaceutical cost–containment methods Generic substitution is one of the tools used to contain the growth of pharmaceutical expenses. Pharmacists are required to substitute the least expensive, or close to the least expensive, generic medicine for the medicine Fig. 5.4
Price index for medicines, 2003
Source: Jørgensen & Keiding, 2004. Note: Index: Denmark=100. 77
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prescribed by the physician, when that the prescriber has not clearly stated to the contrary or the patient has not refused the substitution. Generic substitution slows down increasing drug costs 2-fold: by the actual change to a less expensive generic drug; and by stimulating price competition among interchangeable medicines. Generic substitution is possible among products containing the same quantity of the same active substance, if their biological equivalence has been proven and marketing authorizations granted. During recent years, some important medicines (including citalopram, simvastatin, omeprazol and felodipin) have lost their patent protection. This, along with generic substitution, has led to heavily decreased prices and a relatively small increase in pharmaceutical expenditure. Another approach to controlling pharmaceutical expenditure is parallel imports of pharmaceuticals, which has been practised since the beginning of the 1990s. Denmark has a high proportion of generic and parallel import products on the market. Parallel importing of pharmaceuticals has been permitted since 1990. Generics (including leading brand name (original) products make up 10–11% of the total pharmaceutical market. In 2003, the number of packages prescribed with generic competition was 27% of the total number of packages. In 1999, this figure was 23%. The use of generic and parallel-imported products was promoted from 1993 through a reference pricing system for reimbursement. Under this system, reimbursement was based on the average price of the two least expensive versions of a specific product. In 2005, the basis for reimbursement was changed to the lowest price paid in the EU. In 1999, the Institute for Rational Pharmacotherapy was founded to guide doctors in rational prescribing. It also has the function of elaborating treatment guidelines with respect to cost. Each region employs local groups of pharmacists and GPs to monitor prescription patterns and advise GPs on rational prescribing. The Institute for Rational Pharmacotherapy coordinates educational activities for local-level groups as well. It also established a national formulary for medical doctors for rational choice of treatments in 2003. Practice guidelines are produced by the medical colleges for various specialties and by the Danish College of General Practice. The Institute for Rational Pharmacotherapy aims to provide objective information and guidelines on the rational use of pharmaceuticals, both in pharmacological and economic terms. However, marketing authorization is based on chemical, pharmaceutical, clinical and safety criteria, without any assessment of need or cost–effectiveness; this means that there is no essential 78
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drugs list in the Danish pharmaceutical sector. Instead, consumption is partly regulated through the reimbursement system. Reimbursement In Denmark, reimbursement for an individual medicine is based on its main indication; however, other secondary indications also warrant reimbursement. Some pharmaceutical products are only reimbursed for certain diseases. The medicine’s therapeutic effect, value added, and side-effects are also factors considered when deciding on reimbursement. Price comparisons and economic evaluations also form part of the decision-making process. The Danish Medicines Agency decides on the reimbursement status of each pharmaceutical product. The Danish Medicines Agency is a parallel board to the National Board of Health under the Ministry of Health. It is responsible for legislation concerning pharmaceuticals and medical devices, the approval of new products, clinical trials, deciding which drugs should be reimbursed, and licensing companies that produce and distribute pharmaceuticals. The regional health authorities advise the Danish Medicines Agency before they make any decision on whether or not to reimburse a particular drug. In general, reimbursement is granted for drugs that have a definite and valuable therapeutic effect and when they are used for a well-defined indication. The total trade of medicinal products assigned reimbursement in 2005 equalled DKK 9.3 million (Danish Medicines Agency 2006). For pharmaceutical products without general reimbursement, an individually based subsidy may be obtainable by submitting an application, through a patient’s own physician, to the Danish Medicines Agency. The cost of public reimbursement for medicines in the primary health sector has increased steadily over the years. Complementary VHI covering the cost of medication is quite common in Denmark: approximately 1.9 million Danish citizens (29% of the population) are members of the non-profit mutual insurance company Health Insurance “denmark” (Health Insurance “denmark” 2007). Usually, only pharmaceuticals subject to prescription are eligible for reimbursement. Drugs available without a prescription may be included in the list of reimbursable pharmaceuticals, but in such cases reimbursement is only granted to pensioners and patients suffering from a chronic illness that requires continuous treatment with the drug. A prescription would have to be issued for the pharmaceutical in question as well. Even if a drug meets the criteria for reimbursement, certain characteristics of the pharmaceutical, its specific use or the way in which it is prescribed may lead to a non-reimbursement decision. There are no fixed percentages for the reimbursement of medicines but reimbursement relates to the patient’s annual pharmaceutical expenses. From 79
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April 2005 reimbursement is calculated according to the least expensive generic product. Patients with high pharmaceutical expenses are reimbursed for a higher percentage of their expenses. As of 2006, percentage groups were 0%, 50%, 75% and 85%. Expenses below DKK 520 per year are not reimbursed. If the patient’s payment exceeds approximately DKK 3900, the patient can apply for 100% reimbursement for the rest of the year.
5.2
Human resources
5.2.1
Trends in health care personnel
Public health professionals In Denmark, public health was established during the 1980s as a separate medical specialty with a standardized theoretical and practical training programme, including health management, occupational medicine and social medicine. In 1996, the first Danish postgraduate Master of Public Health programme was established and, in 1999, the University of Copenhagen launched a 5-year university programme in public health (Bachelor/Master (Candidatus) Education in Public Health Sciences). This was followed by the University of Southern Denmark in 2001. The first Masters of Science in Public Health from the University of Copenhagen graduated in 2004. Masters of Science in Public Health are qualified to work in public and private companies in the areas of health service planning, administration and case processing as well as in health care analysis, development, guidance, training and research that focuses on disease prevention and health promotion. Private employers include consulting firms working in the areas of social welfare and health, and companies in the pharmaceutical industry. To this may be added national and international organizations such as the Danish Cancer Society, the Danish Heart Foundation, the Red Cross, WHO, the OECD and the World Bank. Universities and institutes of higher education are also employers of Masters of Science in Public Health. The Danish Graduate School in Public Health offers a national PhD education within public health sciences. The Graduate School involves cooperation between 13 institutions comprising the University of Copenhagen, University of Southern Denmark, University of Aarhus, government research institutes, hospital research units, and private research organizations. The Graduate School is organizationally anchored in the Institute of Public Health of the University of Copenhagen.
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Doctors Approximately 11 000 doctors were employed at hospitals in 2003, which is 600 more doctors than in 2001. The average yearly growth rate of doctors employed full time at hospitals increased by 2.8% for the entire country during the period 2000–2003. Approximately 45% of doctors employed in hospitals have permanent positions (Danish Medical Association 2005). The rest are employed in temporary positions as part of their postgraduate educational programme. Temporary positions are set up in specific hospitals and departments by the National Board of Health in an attempt to distribute newly qualified doctors between specialties and geographic areas, according to need and capacity. In this way, the National Board of Health is able to control the number of doctors trained in different specialties. Approximately 3680 doctors are GPs, which corresponds to one per 1575 inhabitants. Recruitment of young doctors into general practice has been supported by an increasing recognition of general practice as a formalized specialty with growing scientific activity, improved social and professional environments (with group practices) and a fair income compared to hospital doctors. Whereas GPs are fairly well distributed across the country, the 1387 Fig. 5.5
Number of physicians per 1000 population in Denmark, selected countries and EU averages, 1990–2005
4
3
2
1 1990
1991
1992
Denmark United Kingdom
1993
1994
1995
1996
Germany EU average
1997
1998
1999
Norway EU15
2000
2001
2002
2003
2004
2005
Sweden EU12
Source: WHO Regional Office for Europe, January 2007. Notes: EU: European Union; EU15: European Union Member States before May 2004; EU12: countries that joined the EU in May 2004 and January 2007.
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full-time practising specialists are concentrated in the capital and other large urban areas (Danish Medical Association 2005). Approximately 1100 doctors do not work in a clinical setting but they are fully employed as medical public health officers or researchers and teachers at public and private institutions. Medical public health officers are responsible for monitoring health conditions in their respective regions and for supporting public authorities by counselling, along with the supervision of health care professionals on behalf of the National Board of Health. The number of doctors in Denmark is increasing, albeit at a slightly lower rate than in other EU countries. This can be attributed to the limited access to medical training programmes in Denmark during the 1970s and 1980s (see Fig. 5.5 and Fig. 5.7). At the time of writing, the recruitment of doctors is becoming increasingly difficult, especially in rural areas that are far from the urban centres.
Fig. 5.6
Number of nurses per 1000 population in Denmark, selected countries and EU averages, 1990–2005
20 18 16 14 12 10 8 6 4 1990
1991
1992
Denmark EU average
1993
1994
1995 Germany EU15
1996
1997
1998
1999
Norway EU12
2000
2001
2002
2003
2004
2005
Sweden
Source: WHO Regional Office for Europe, January 2007. Notes: EU: European Union; EU15: European Union Member States before May 2004; EU12: countries that joined the EU in May 2004 and January 2007.
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Fig. 5.7
Denmark
Number of physicians and nurses per 1000 inhabitants in the WHO European Region, 2005 or latest available year (in parentheses)
Monaco (1995,1995) Greece (2004,2004) Belgium (2003,2004) Switzerland (2005,2000) Italy Iceland (2005,2004) Israel Netherlands Norway Denmark (2004,2004) Austria Malta Portugal France Germany (2005,2004) Andorra Sweden (2004,2002) Spain (2003,2000) Finland (2003,2004) Ireland Luxembourg (2004,2004) San Marino (1990,1990) Cyprus United Kingdom (2002, –) Turkey (2003,2004) Central and south-eastern Europe Lithuania Bulgaria Czech Republic Estonia (2004,2004) Latvia Slovakia (2004,2004) Hungary Serbia Croatia Slovenia (2004,2002) Poland (2004,2004) The former Yugoslav Republic of Macedonia Romania Montenegro Bosnia and Herzegovina Albania (2004,2005) CIS Belarus Georgia Russian Federation Kazakhstan Azerbaijan Armenia Republic of Moldova Ukraine Uzbekistan Turkmenistan (2004,2004) Kyrgyzstan Tajikistan Averages CIS average EU Member States before May 2004 (2004,2004) EU average
6.6 4.9 3.5 4.4 13.4 3.9 8.3 3.9 7.0 3.7 9.4 3.7 6.1 3.7 14.5 3.7 15.3 3.6 9.8 3.5 6.1 3.5 5.5 3.4 4.6 3.4 7.5 3.4 7.7 3.4 3.4 3.2 10.2 3.2 3.7 3.2 7.6 2.8 15.4 2.8 9.5 2.5 5.1 2.4 4.0 2.1 1.4 2.6
16.2
4.0 7.4 3.6 4.0 3.6 8.5 3.2 6.4 3.2 5.4 3.1 6.6 2.8 8.8 2.6 5.4 2.5 5.2 2.3 7.2 2.2 4.6 4.8 2.2 3.7 1.9 1.9 4.9 1.4 4.4 1.2 3.6 4.7 4.5 4.2 3.7 3.6 3.5 3.1 3.0 2.7 2.6 2.5 2.0
3.9
4.1
4.7 5.8 4.4
3.7 3.4 3.2 0
Physicians Nurses
11.9
8.0 6.4 7.2
7.1 7.8 10.2
7.9 7.5 7.0 5
10
15
20
25
Number per 1000 inhabitants Source: WHO Regional Office for Europe, January 2007. Notes: CIS: Commonwealth of Independent States; EU: European Union.
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Fig. 5.8
Denmark
Number of dentists per 1000 inhabitants in Denmark, selected countries and EU averages, 1990–2005
2
1.5
1
0.5
0 1990
1991
1992
Denmark United Kingdom
1993
1994
1995
Germany EU average
1996
1997
1998
1999
Norway EU15
2000
2001
2002
2003
2004
2005
Sweden EU12
Source: WHO Regional Office for Europe, January 2007. Notes: EU: European Union; EU15: European Union Member States before May 2004; EU12: countries that joined the EU in May 2004 and January 2007.
Nurses In Denmark, the total number of nurses was 59 055 in 2003, which is 6578 more than in 1994, corresponding to a 12.5% increase during the period 1994–2003. In 2003, 35 281 nurses worked in full-time positions at hospitals, which is 5666 more than in 1994. The share of nurses working at hospitals has steadily increased during the period 1994–2003. In 2003, 11 210 nurses worked in the outpatient care sector (that is, not in hospitals) and in the social sector and 4209 worked at nursing homes and other institutions (Ministry of the Interior and Health 2005b). According to WHO data (see Fig. 5.6 and Fig. 5.7), the number of nurses in Denmark is relatively small compared to those in neighbouring countries (namely, Sweden and Norway). National data show that there are approximately 750 nurses per 100 000 inhabitants compared to approximately 1440 nurses per 100 000 inhabitants in Norway. Such comparisons, however, are not straightforward due to differences in the classification systems of nurses and other groups of caregiving personnel.
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Dentists and dental auxiliaries In 2004, two thirds of Denmark’s 5272 dentists worked in private practice, while the other third were employed by the municipalities. There was a decline (-2.6%) in the number of dentists during the period 1995–2004 (Fig. 5.8). 1537 dental auxiliaries were employed or available for the labour market in 2004, which corresponds to a 47.9% increase from 1995 figures. Dental auxiliaries now perform some of the tasks previously carried out by dentists (Ministry of the Interior and Health 2006). Psychologists In 1993, psychologists gained public professional authorization from the former Ministry of Social Affairs and a special committee was set up to evaluate psychologist qualifications. This authorization gave private practice psychologists access to public reimbursement for referred patients suffering from mental disorders related to serious illness, violence, attempted suicide, bereavement, and so on. The Danish Association of Psychologists had 7315 members in 2004, of whom 6064 were registered psychologists and the rest students (Danish Association of Psychologists 2005). Physiotherapists, chiropractors, pharmacists and midwives Physiotherapists are either private practitioners, who are partly reimbursed by the regions, or public employees at hospitals and other public health institutions. In 2004, 7580 physiotherapists were employed or available for the labour market, corresponding to a 48.9% increase during the period 1995–2004 (Ministry of the Interior and Health 2006). The Association of Danish Physiotherapists had approximately 8000 members (as reported in 2005), up from 7000 in 2001 (Association of Danish Physiotherapists 2005). Chiropractors have had public authorization since 1992. They are primarily self-employed in the primary health care sector; however, in the last couple of years, they have also been employed at hospitals and as consultants within the regions. Members of the Danish Chiropractors’ Association can also receive partial reimbursement from the regions. In 2004, 380 chiropractors were employed or available for the labour market, corresponding to an increase of 43.4% during the period 1995–2004 (Ministry of the Interior and Health 2006). The Association had 507 members (as reported in 2005), compared to 337 in 2001 (Danish Chiropractors’ Association 2005). Most pharmacists work in private pharmacies under strict government regulation. In 2004, there were 3574 pharmacists (Fig. 5.9). Since 1995, this group has increased by 17.4% (Ministry of the Interior and Health 2006) (see Section 6.5 on Pharmaceutical care). 85
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Fig. 5.9
Denmark
Number of pharmacists per 1000 population in Denmark, selected countries and EU averages, 1990–2005
1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 1990
1991
1992
1993
1994
1995
1996
Denmark Sweden EU15
1997
1998
1999
Germany United Kingdom EU12
2000
2001
2002
2003
2004
2005
Norway EU average
Source: WHO Regional Office for Europe, January 2007. Notes: EU: European Union; EU15: European Union Member States before May 2004; EU12: countries that joined the EU in May 2004 and January 2007.
Midwives in Denmark are mainly employed by obstetric departments in hospitals, including decentralized outpatient clinics. In 2004, there were 1463 midwives compared to 1095 in 1995 (Ministry of the Interior and Health 2006). Table 5.4 Health care personnel per 1000 population, 1980–2003 (selected years)
Active doctorsa Active nursesb Active dentists Active pharmacists Active midwives
1980 1.8 4.9 0.8 0.3 0.1
1985 2.3 6.2 0.8 – 0.2
1990 2.5 5.7 0.8 – 0.2
1995 2.6 6.4 0.8 0.5 0.2
2000 2.8 6.9 0.8 0.5 0.2
2001 2.8 7.0 0.8 0.5 0.2
2002 2.9 7.1 0.8 0.5 0.2
2003 3.0 7.0 0.8 – 0.2
Sources: WHO, 2005; WHO Regional Office for Europe, 2005. Notes: a The number of physicians at the end of the year includes all active physicians working in health services (public or private), including health services under ministries other than the Ministry of Health. Interns and residents (i.e. physicians in postgraduate training) are also included. The number of physicians excludes: physicians working outside the country; physicians on the retired list and not practising or unemployed; physicians working outside health services (e.g. employed in industry, research institutes, etc.); dentists (stomatologists), who should be defined as a separate group; b The number of nurses includes: qualified nurses; first- and second-level nurses; feldshers; midwives; and nurse specialists. It excludes nursing auxiliaries and other personnel, who do not have formal education in nursing.
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The number of health personnel in 2004 was estimated at 122 651, which is 17 000 more than in 1995, corresponding to a 16% increase. Table 5.4 provides further details of health care personnel numbers since 1980. In 2004 there were 86 914 full-time employed individuals working at Danish hospitals, compared to 83 691 in 1995. Approximately 80% of these had a formal health-related education. Nurses comprised the largest group, with 35% of the total personnel, while doctors comprised 13%. There was a 1.8% increase in full-time employed health personnel during the period 2001–2004 (Ministry of the Interior and Health 2006). 5.2.2
Planning of health care personnel
As it is difficult to foresee the future need for health care personnel, periods of unemployment among doctors in Denmark have been followed by periods of staff shortage. The number of doctors increased dramatically during the 1960s and 1970s due to a large intake of medical students. This led to temporary unemployment among doctors during the 1980s, although expansion of the health sector and a reduction in working hours made it possible for the system to absorb most doctors. At present, there is a shortage of nurses and doctors, particularly in rural areas, which is forcing some regions to recruit doctors from neighbouring countries. To meet the shortages of doctors, the procedure for authorization of doctors not born or raised in Denmark (non-native) has been made more effective. In 2002 and 2003, 215 non-native doctors were granted authorization. However, the intake of medical students is rising, which is in turn increasing concern about the health system’s capacity to ensure an adequate number of postgraduate training posts in the coming years. The intake of medical students has been increasing throughout the 1990s. In 2003, the intake of students was 1139, which corresponds to an average yearly increase of 3.3% from 1995 to 2003. Further, the number of educated doctors in the entire health system is expected to increase by 18% during the period 2000–2025 (Ministry of the Interior and Health 2004b). The recruitment of nurses is currently the most serious staffing problem in the Danish health sector. The lack of nurses is mainly due to low salary levels and heavy workloads. However, this trend is changing and the number of nursing students increased from 2334 in 2001 to 2565 in 2002 (Ministry of Education 2005a).
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The number of students admitted for dental education in 2003 was 163, which is very similar to the number admitted in 2002. In 2002, only 37 dentists were unemployed. Only 142 dental auxiliaries attended educational programmes in 2002, compared to 153 in 2001, with 33 unemployed (National Board of Health 2005a). In Table 5.5, the intake of pharmacists, psychologists, physiotherapists, chiropractors and midwives is illustrated for the years 2001 and 2002. For all five types of health education, the number of students accepted has been relatively stable. The State has an element of control over the supply of health professionals, since the training of authorized health professionals (with a few exceptions) is public. This is the case when there are applicants for all places, which has not always been the case for nurses. The State can also influence health professionals’ qualifications by determining the content of their training. The National Board of Health has particular influence over postgraduate training. The State also decides which professions are to be reimbursed by the regions. There are certain quotas, for example for physiotherapists, and in order to buy a general practice, authorization as a GP is required from the National Board of Health, along with a licence from the regions. Dentists, however, can establish a practice wherever they choose and still be reimbursed by the regions. Table 5.5 Intake of other health care personnel for 2001 and 2002 Education Pharmacists Psychologists Physiotherapists Chiropractors Midwives
2001 204 452 609 50 90
2002 213 461 642 53 102
Source: Ministry of Education, 2005.
5.2.3
Training of health care personnel
Training is regulated centrally by the Ministry of Science, Technology and Innovation, together with a number of councils, such as the Health Training Council and the Social and Health Training Council, which work in cooperation with the Ministry of Health, the National Board of Health and others. Further training in the health sector for specialists is the responsibility of the Ministry 88
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of Health, and it is adjusted continually to meet the needs of the health sector as regards subjects, content and capacity. Undergraduate medical education takes place at the Faculty of Health Sciences at the Universities of Copenhagen, Århus and Southern Denmark. The training programme is six years long. Training takes place at the three universities and hospitals. After completing the final medical examination, medical doctors have to undergo 1.5 years of practical clinical education to obtain permission to practise independently. This consists of six months in both medical and surgical departments and six months in general practice. From 2008 a reform of medical education will reduce the length of the practical clinical education to one year. Postgraduate training programmes for medical specialties, including general practice, are defined by the Ministry of Health based on advice from the National Board of Health and the National Council for Postgraduate Education of Physicians, which replaced the former Danish Board of Medical Specialties in 2001. Members of the National Council represent the regions, the professional associations and colleges, the universities and the regional Councils for Postgraduate Education of Physicians. The Councils are responsible for the regional planning and coordination of physicians’ clinical training. The National Council gives advice on the number and type of specialties, the number of students admitted to postgraduate training programmes, the proportion of students studying each specialty, the duration and content of postgraduate training programmes, and international collaboration programmes. At the time of writing there are 37 specialties in Denmark compared to 42 in 2001. Each specialty has its own specific requirements and objectives, including practical training in hospitals and general practice. The medical colleges and the National Board of Health also run training courses. Because the quality of clinical training, particularly regarding surgical skills, has been heavily criticized, the National Board of Health has set up an inspection system including surveillance and the advising of the individual departments responsible for training (Ministry of Education 2005b). Basic nurse training takes 3.5 years, and training is carried out at public schools of nursing in collaboration with hospitals. The training alternates between theoretical and clinical education. Clinical education is located at hospitals and in municipalities. Two shorter theoretical education courses for health and social helpers (14 months) and health and social assistants (extra 18 months) have been established to provide training for basic nursing care functions in hospitals and nursing homes. The Centres for Advanced Education (CVUs) offer a number of mid-range training education programmes such as, nursing, midwifery and physiotherapy. 89
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CVUs offer basic, supplementary and advanced education as well as development activities, which have become an obligation for every CVU. The main objectives of the CVU’s health care education programmes are to educate people with secondary school education to a professional or Bachelor’s Degree level and to provide further training within the health care fields up to diploma level (University College Øresund 2005). In 2000, a new act regarding mid-range training introduced the “professionalbachelor” level and related “professional-bachelor” title at the mid-range training universities and institutions. The aim was to create a common framework for the mid-range training education programmes and to add to the qualitative development of health education by strengthening the professional level and by placing mid-range education more clearly in the overall picture. Nurses and physiotherapists are only two of the groups that can now obtain a professional Bachelor title (Ministry of Education 2005b). In recent years there has been an increase in Master’s-level education within the field of health, as a supplement to the advanced education system. Among these types of education programmes are the Master of Public Health, Master of International Health, Master of Industrial Medicine Development, Master of Health Pedagogy and the Master of Rehabilitation. These educational training programmes are offered at the Universities of Copenhagen, Århus, Southern Denmark, and the University of Education in Denmark. Several Masters’ courses have also been developed within the field of management and administration in the health system. These are, for example, the Master of Public Administration, the Master of Business Administration and the Master of Hospital Management, and they are offered at the University of Ålborg and Copenhagen Business School. Dentists and dental auxiliaries are trained at the Faculty of Health Sciences at the universities of Copenhagen and Århus. Dentists are offered a 5-year independent undergraduate training programme, while dental auxiliaries are trained in two and half years. Pharmacists and psychologists are all trained at universities. 5.2.4
Registration/licensing
The National Board of Health registers and supervises qualified practitioners and other health care personnel. It is in charge of granting and, if necessary, removing authorization. The Board addresses questions regarding authorization revocation and activity reduction, according to the Law of authorization of health professionals and of health care activities passed by central Government. The Act states that authorization can be revoked or activity can be reduced, 90
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if a qualified health care worker takes an unnecessary risk regarding the patient’s health or has shown serious or repeated unsafe professional activity (see Subsection 3.1.2 on Regulation and governance of providers). The final licence withdrawal occurs in court. This system of authorization helps protect health care professions, while at the same time reassuring the population and the responsible health authorities by ensuring minimum qualifications for health personnel. Further, through regulation of the capacity available for education, it is possible, to a certain degree, to control the number of authorized personnel within the different professional categories and specialties. During recent years an increasing number of professional groups have obtained authorization/ licensing by the National Board of Health. The groups that are able to obtain authorization/licensing today are doctors, nurses, dentists, dental auxiliaries, clinical dental technicians, physiotherapists, chiropractors, midwives, prosthetists/orthotists, radiographers, opticians and contact lens optometrists, clinical dieticians, occupational therapists, medical laboratory technologists, and chiropodists. The regions limit the number of GPs entitled to receive reimbursement as a means of controlling costs. The number of GPs, measured per 1000 population, is negotiated by the regions and the Organisation of General Practitioners. Training for nurses in the Danish education system conforms to EU standards and there is mutual recognition of nurses’ education. The standards are meant to ensure that all nurses in the EU have a certain level of knowledge and experience in medical health care, surgical health care, psychiatric health care, paediatrics and obstetrics health care, health care for the elderly and home health care. Authorization is generally applied for in the country of work. Nurses’ education has been internationalized in order to meet with standards set by the Higher Education Area in the Bologna process. More English language teaching has been introduced in nursing schools and students now have the opportunity to complete some of the requirements of their educational curriculum abroad. Nursing schools in Denmark receive exchange students as well: previously, most students came from Nordic countries but more recently there has been an increase in students of other nationalities (e.g. Chinese students). The number of full-time non-native students, however, is limited due to Danish language demands. Efforts are being made to be able to offer complete entire nursing education in English for Chinese students, but currently only certain modules, or one full semester, are offered in English. However, these gradual changes are not expected to have a significant influence on the number of full-time non-native students in Denmark in the foreseeable future.
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At the time of writing, an EU project, “Tuning Educational Structures in Europe�, is being developed. The project is intended to increase transparency and understanding in nursing education across Member States, to strengthen qualifications and to increase mobility. The project is not meant for the harmonization of nursing education across Europe. Since the 1980s it has been increasingly recognized that management and public health skills are lacking in the Danish health sector. As such, an increasing number of economists, professional managers and lawyers have been employed in health administration. Health professionals with postgraduate management training are also increasingly employed in health administration, which perhaps reflects a tendency towards the diminishing status and influence of the medical profession. Many health professionals have criticized this trend, claiming that economics and management targets are becoming more important than quality of care. Administrative expenses in the Danish health system are moderate compared to health systems that are based on VHI or other, more complex systems of health care organization.
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6
6.1
P
Denmark
Provision of services
Public health
ublic health services are partly integrated with curative services and partly organized as separate activities run by special institutions. The main responsibility for surveillance and control of communicable diseases rests with medical public health officers employed by the Ministry of Health. Public health medicine officers work at the regional level, and they must be notified when instances of certain communicable diseases occur. GPs who treat patients for communicable diseases are obliged to report these incidences. Public health medicine officers are also in charge of individual and community interventions to control communicable diseases. While their function is largely advisory, they do have the power to prevent infected children from entering institutions or even to close institutions to avoid the spread of infection. Other measures to prevent epidemics are in the hands of a special regional commission for epidemic diseases or, in the case of infectious foodborne diseases, local food control agencies. For information on immunization services and national vaccination programmes, see Section 1.5 on Health status. Schools provide sex education, including the use of contraceptives, as part of their general education programme. This education often includes a visit to a special clinic offering advice on family planning. Since 1973, all women have had access to free-of-charge pregnancy terminations on request within the first 12 weeks. All pregnant women have direct access to antenatal services provided by GPs, midwives and obstetricians in hospital obstetric departments. Rates of utilization of these antenatal services are very high overall, although some social and ethnic differences have been detected, indicating a lower utilization rate among lower socioeconomic groups and immigrants. Women can choose 93
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to give birth at home or in hospital, free of charge. Almost 99% of deliveries take place in hospital. In 1986, the National Board of Health issued guidelines for the screening of cervical cancer. These guidelines are still implemented at the time of writing. In 2001, 94% of Danish women in the age group 25–59 years were covered by the programme. Systematic breast cancer screening (mammography) has been recommended for women aged 50–69 years by the National Board of Health, but only introduced in some parts of the country. While no other general screening programmes have been launched, local programmes, such as colon cancer screening, have been established on an experimental basis. A key principle of Denmark’s AIDS policy is that prevention should be carried out without compulsory measures and, if necessary, based on anonymity. The AIDS prevention programme involves close collaboration between the National Board of Health, the regions, the municipalities and private organizations, such as the National Danish Organisation for Gays and Lesbians. The main elements of this programme are general information campaigns on safe sex, psychological assistance to those who are HIV positive and information targeting specific risk groups. From January 2005 a new and more effective HIV surveillance system, called SOUNDEX, was implemented. This new system decodes last names to letters or numbers and helps to prevent duplicate information. This, thereby, allows better information to be obtained on the incidence of HIV and the spread of infection in Denmark. The number of infected people has increased during recent years, which could indicate that the population and particularly the groups at greater risk have been paying less attention to the issue. National responsibility for the prevention of drug abuse lies with the National Board of Health, which develops information and educational material and carries out national campaigns against drug abuse. Local activity is considered more effective, however, and the State therefore provides financial support for local initiatives that are carried out by health, social and educational authorities as well as private organizations. The National Board of Health runs training programmes for key local people involved in tackling drug abuse. A special state agency, the National Working Environment Authority, is responsible for surveillance of, and control and maintenance standards of, occupational health and safety. The Authority provides advice, sets standards and inspects work sites. In 2003, the National Board of Health launched a national action programme aimed at severe obesity. During the period 2005–2008, DKK 83 million has been allocated towards this effort. Further, in 2003 the Government presented a programme called “Better Health for Children and Adolescents”, which is 94
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intended to ensure a greater focus on a healthy children culture (Ministry of the Interior and Health 2003a). A network of health promoting hospitals has been established as a platform for developing preventive activities related to hospital services. This network has developed a health strategy, which includes a number of targets and elements aiming to improve the health status of its citizens. The members of the WHO Healthy Cities Programme include the city of Copenhagen and the smaller city of Horsens in Jutland. A number of institutions regularly perform safety inspections of workplaces, food provision services. and the condition of roads and accommodation, among other things. The most common institutions performing these inspections are the National Food Agency, the Ministry of Housing and Urban Affairs, the Ministry of Transport and Energy, the Ministry of the Environment and the Danish Working Environment Authority. These inspections are largely environmental interventions, but they help to prevent diseases by reducing health risks and by making sure that these places or items are not damaging the health of citizens. Over the past few decades, Denmark has seen the development of unfavourable trends in average life expectancy in comparison to other OECD countries (see Section 1.5 on Health status). These trends became a major health policy issue in 1993. Although it is not possible to explain fully these trends, there are at least three contributing factors. First, unhealthy lifestyles, as major determinants of premature death, are partly responsible: there is a high prevalence of smoking and alcohol consumption, an intake of too many calories and fatty foods and a lack of physical activity. Second, a low investment in health care development such as technology for cancer treatment and heart disease rehabilitation may also be to blame: evidence to support this, however, is not very strong. Finally, socioeconomic factors are likely contributors, and they may explain the very low life expectancy in the city of Copenhagen, and the large socioeconomic inequalities in health and lifestyle factors affecting health status. In response to a low increase in average life expectancy, the Government initiated a 10-year national target-oriented programme of public health and health promotion in 1999. This programme has many similarities to WHO’s target-based strategy for the 21st century (Ministry of Health 1999). It is the second of its kind and the result of close cooperation between the Ministry of Health, other relevant ministries and experts in public health, epidemiology and prevention. The overall aim of this programme is to improve public health and reduce social inequality in health in Denmark. It has 17 targets, which are based on the following criteria: they must concern the dominant health problems in 95
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Denmark; there should be reasonable evidence concerning causes, risk factors and the effectiveness of interventions; and there should be a need to strengthen the effort beyond existing activities. The 17 targets concern specific risk factors (e.g. tobacco, alcohol, nutrition, exercise, obesity and traffic accidents); age groups (e.g. children, young people, elderly people); health promoting environments (e.g. primary schools, places of work, local communities, health facilities); and structural elements (e.g. intersectoral cooperation, research and education). The goals of this initiative are to increase average life expectancy by at least two years, for both males and females, and to extend the number of healthy life years through a reduction in chronic diseases. In autumn 2002, the new Government launched the health care programme “Healthy throughout life 2002–2010”. “Healthy throughout life” retains important goals and target groups from the Government Programme on Public Health and Health Promotion 1999–2008. Nevertheless, “Healthy throughout life”, in contrast to the 1999–2008 Programme, specifically focuses on reducing the major preventable diseases and disorders. It also targets improving the quality of life of the population through more systematic efforts in terms of counselling, support, rehabilitation and other patient-oriented measures. A key aspect of the new programme is to provide individuals with the necessary knowledge and tools to be able to promote their own health status and health care. The programme focuses on eight preventable diseases and disorders, namely: type 2 diabetes; cancer; heart disease; osteoporosis; musculoskeletal diseases; allergy diseases; psychological diseases; and chronic obstructive pulmonary disease (COPD). The aim is to rehabilitate people who are already sick, so that further loss of function is reduced. Important elements of the programme are prevention and health promotion, the individuals’ own contribution, and patient guidance, support and rehabilitation. The health care programme has set goals for each of the eight public diseases, and briefly runs through the causes, the opportunities for prevention and the actual status. The Danish programme differs from other Scandinavian programmes in that it focuses strongly on health-related behaviour and less on social and structural factors that influence health. Political responsibility for the health of the population is also less pronounced in the new programme, as compared to previous Danish programmes and to those of Norway and Sweden (Vallgårda 2006; Vallgårda 2001; Vallgårda 2007). A list of indicators has been developed in connection with the “Healthy throughout life” programme. The purpose of this list is to ensure regular monitoring and documentation of trends in the population’s health status and health behaviour, and efforts to promote health and prevent disease. The programme is based on the following key indicators: 96
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• • • • • • • •
life expectancy; the number of healthy life years lost; infant mortality; self-rated health; social differences in mortality; social differences in the quality of life; the prevalence of heavy smoking among children, adolescents and adults; the proportion of the population exceeding the recommended alcohol consumption (based on weekly standards) among children, adolescents and adults; • the prevalence of fat intake, which exceeds 40% of total energy intake; • the level of physical activity at leisure and at work among children, adolescents and adults; • the prevalence of BMI exceeding 30 among children, adolescents and adults; • road, home and leisure accidents among children, adolescents and adults; • serious occupational accidents, including fatal ones; • the prevalence of the use of controlled substances (among young people). The indicator programme was created on the basis of existing data sources. It is to be developed as the data improve, as the strategy comes into effect for the eight major preventable diseases and disorders progresses and as new or alternative targets are given a higher priority in the efforts to improve public health (Ministry of the Interior and Health 2002b). The 2007 reform gave rise to a large number of health prevention and promotion tasks and the responsibility for these belongs to the municipalities. The municipalities are responsible for the aspects of prevention, care and rehabilitation that do not fall under hospital admission, and they are supposed to establish new service solutions for the aspects of prevention and rehabilitation, such as community health centres. The municipalities and the regions are obliged by law to cooperate with each other regarding treatment, training, prevention and care. Obligatory health agreements should also contain accords on prevention and rehabilitation methods as well as on the appropriate hospital discharge for elderly patients.
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6.2
Denmark
Patient pathways
The pathways for Group 1 patients in the Danish health system are illustrated in Fig. 6.1. Depending on the type of examination or treatment needed, the patient has the following five options available: (1) GPs; (2) open specialties (ophthalmologists, and ear, nose and throat specialists); (3) dentists; (4) emergency wards; and (5) pharmacies. The pathway does not differ across the country. In the Danish health care system, GPs act as gatekeepers with regard to hospital and specialist treatment for Group 1 coverage (see Subsection 2.5.2 on Patient rights and empowerment). This means that patients usually start the process of seeking health care by consulting their GP, whose job it is to ensure that they are offered the treatment they need and that they will not be treated at a higher specialization level than necessary. It is usually necessary to be referred to a hospital by a GP, for medical examination and treatment, unless the patient has suffered an accident or has an acute illness. Referral to a specialist for treatment is also necessary by a GP. GPs and specialists are the ones who prescribe medication in the health system. The prescribed medication can subsequently be bought at pharmacies. If referral is necessary, patients are free to choose among any public hospital in Denmark, provided that it offers the necessary services and is at the same Fig. 6.1
Group 1 patient pathway in the statutory health care system
General practitioners P a t i e n t s
Hospitals Practising specialists
Ophthalmologists Ear, nose and throat specialists
Dentists Source: Author’s compilation. 98
Emergency wards
Pharmacies
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level of specialization considered relevant by the referring physician. This is according to the Act on free choice of hospital (Law on Health of 2005) (see Subsection 2.5.2 on Patient rights and empowerment). The GP may advise the patient on which hospital to attend based on information such as waiting time, quality and special needs. The patient can also choose to be treated at a private hospital on a fee-for-service basis; however, he/she will not be publicly reimbursed for these fees. Some people have VHI, which may cover part or all of these fees (see Subsection 4.1.4 on Voluntary health insurance). If the waiting time for either examination or treatment exceeds one month, the patient is entitled to choose to receive these services at private hospitals or clinics and hospitals abroad. As a precondition for the use of the extended free choice, the chosen hospital or clinic must have an agreement with the regions regarding the necessary treatment. The regions also pay for the expenses involved. If the patient needs surgery, rehabilitation is established and it is assessed whether there is a need for additional home care. If rehabilitation or home care are prescribed by the GP or the hospital, they will be provided free of charge by the municipality. GPs are to receive a discharge summary for each patient from the hospital and are responsible for further follow-up, such as referral to physiotherapist. Finally, the patient often has a follow-up hospital visit to check on the outcome of the treatment. Besides referring patients to a hospital or a specialist, GPs refer patients to other health professionals, working within a health care service agreement, and arrange for home nursing to be provided. Patients are called in once or twice a year for regular dental examinations and check-ups, or they may choose to make an appointment when necessary. Dentists who provide services that are reimbursed by the regions are paid a fee-for-service payment to cover part of the expenses. Necessary medicines are prescribed by the dentist and obtained at the pharmacy by the patient. Patients that have had an accident or an acute illness can attend, without referral, open emergency wards, which are often situated at hospitals. Depending on the severity of the injury or illness, patients are examined, treated and medicated or admitted for further examination and treatment and/or operation. If an accident occurs, the patient must attend an emergency ward within 24 hours; otherwise, a referral is needed from a GP. Emergency wards are open 24 hours a day and are free of charge. The necessity of open emergency wards without referral is often debated; and, in recent years, several wards have been closed or changed, so that referral is necessary. Patients may go to pharmacies if they need non-prescription medicines or guidance regarding minor health problems such as coughing, tenderness or 99
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pain in muscles, and so on. Otherwise, they must have a prescription from a GP or specialist. The patient pathways in the Danish health care system are not always free from problems. Lack of coordination regarding the primary/secondary care interface can harm the delivery of integrated care, with unnecessary delays and complications possibly leading to a suboptimal clinical outcome for vulnerable groups, such as the elderly and the chronically ill. Some problems have been identified, such as an unsettled responsibility and lack of mutual understanding between providers, and inadequate communication systems. Seen from the patient’s point of view, this reflects a fragmented health system that is inefficient in terms of continuity, coordination and information exchange (StrandbergLarsen & Krasnik 2006). The Danish Health Care Quality Assessment Programme was established to strengthen the patient pathway. The Programme intends to support a higher level of transparency regarding quality and to promote continuous quality improvement in the patient pathways within the Danish health care service. Its overall aims are to promote good patient pathways, ensuring that patients experience improved quality, and to improve the continuous clinical, professional and organizational quality of the patient pathways. Quality assessment through the programme is mandatory and covers, in principle, all providers of publicly financed health care services in Denmark (National Board of Health 2005a). Private profit-making organizations are also examining the market for providing patient guidance for the strengthening of patient pathways. Such initiatives aim to guide, inform and lead the patient through the health care system via the optimal pathway and health services. The current initiative is especially targeted towards patient groups with severe and chronic illnesses (Dagens Medicin 2005).
6.3
Primary/ambulatory care
The Danish health system can be described as a tripartite health care delivery system consisting of: • private (self-employed) practitioners – GPs, specialists, physiotherapists, dentists, chiropractors and pharmacists, who are financed by the regions through capitation and/or fee-for-service payment, including various levels of patient co-payments for dentists, physiotherapists and GPs, and for specialists who treat Group 2 patients; 100
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• hospitals – primarily managed and financed by the regions (with the exception of a few private hospitals); • municipal health services – nursing homes, home nurses, health visitors and municipal dentists are mainly managed and financed by 98 municipalities (Vallgårda & Krasnik 2007). Primary health care in Denmark is provided by private practitioners and municipal services (Vallgårda & Krasnik 2007). General practitioners GPs play a key role in the Danish health system as the first point of contact for patients and as the gatekeepers to hospitals, specialists, physiotherapists and others. It is up to GPs to decide whether their own competence or practice, given the necessary technology, is sufficient to diagnose and treat the patient. Since 1993, referred patients are entitled to undergo treatment at any hospital (at the same level of specialization) in the country. GPs, therefore, serve an important function in advising patients on which hospital they should choose (Vrangbæk 1999). After referral, GPs have no further influence on the treatment and care of the patient, although hospitals or specialists are required to inform them of patient discharges. The number of patients registered with each GP is limited and fixed through negotiations between the Organisation of General Practitioners, which is part of the Danish Medical Association, and the Danish Regions. For further information on the patient’s choice of GP, see Subsection 2.5.2 on Patient rights and empowerment. In principle, GPs run private practices, either on their own as solo practitioners (approximately a third of all GPs) or in collaboration with other GPs. The trend at the time of writing shows a decreasing number of solo practitioners and an increasing number of group practices. The Ministry of Health is generally encouraging this trend in order to strengthen the potential for teamwork, learning and quality improvement in primary health care. However, in some rural areas, this trend has resulted in patients having to travel greater distances to see a GP. Due to this collaboration between GPs, services are usually available 24 hours a day, as required by the health authorities. Many hospitals also provide open 24-hour emergency services, although some regions have restricted access to these services to only those cases, which have been referred by a GP or brought in by special emergency services. GPs derive their income from the regions, according to a fee scale that is agreed on by the Organisation of General Practitioners and the Danish Regions. They are responsible for the costs of their practice, including building (rented or owned) and staff. These costs are generally covered by their fee structure. 101
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Remuneration for GPs is a mixture of capitation (without risk adjustment), which makes up between a third and half of their income, and fees for services rendered (per consultation, examination, operation, etc.). The fee-for-service payments include special fees for after-hours consultations, telephone consultations and home visits. For more detailed information on the remuneration of GPs and on the way in which remuneration influences their activities (see Subsection 4.4.1 on Paying health care personnel). GPs must have an agreement with the region in order to receive fees from them. The regions may limit the number of practising GPs as a means of cost-containment. The number of practising GPs per region is negotiated by the regions and the Organisation of General Practitioners. There is an even distribution of doctors across the country, with very little variation in the number of inhabitants per GP across regions. In 2003 there were between 1480 and 1651 inhabitants per GP (excluding the island of Bornholm, which formed a so-called regional municipality with only 1332 inhabitants per GP). In this way, the Danish health system has succeeded in achieving relatively short travel distances to GPs and reasonable equity in access to GP services. However, recently, the recruitment of doctors into general practice has again started to become more problematic and some regions are facing difficulties when having to replace retiring GPs, especially in rural areas. Specialists Privately practising specialists that have an agreement with the region are also remunerated by the regions according to specific fees paid for services provided. In 2004, a total of 1387 privately practising specialists – mainly those specializing in dermatology, eye, and ear, nose and throat diseases – were working full-time, primarily in Copenhagen and other urbanized areas (Danish Medical Association 2005). Another 262 specialists were working part-time, privately; of these, most were also employed full-time by a public hospital. A small group of consultants employed by public hospitals are allowed to provide three hours of care per week at the hospital and are paid additional fees for their services from the regions. Previously, these consultants were much more common, but the counties have tried to reduce these types of agreements in order to maximize hospital-based specialist services and to contain costs. A few specialists work on a fully private basis, without a regional licence, and are, therefore, wholly dependent on direct payments from patients. There are no restrictions as to how much private work specialists employed by public hospitals are permitted to undertake. This is probably because only a very small number of specialists choose to engage in such activity. 102
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The regions also reimburse parts of certain services provided by physiotherapists, privately practising dentists, psychologists and chiropractors, for which there are varying levels of patient co-payment. Outpatient visits According to WHO data, the number of outpatient visits in Danish hospitals is relatively close to the EU average (WHO Regional Office for Europe 2005). National figures show that visits to outpatient clinics amount to 0.9 per inhabitant per year; visits to GPs 6.5 per inhabitant per year; and visits to specialists 0.5 per inhabitant per year (Danish Medical Association 2005; Dagens Medicine 2005). Outpatient activity has increased substantially during recent decades as a result of initiatives to increase the efficiency of patient hospital stays. The average length of stay is now shorter than in past decades, and more diagnosis and treatment takes place in outpatient clinics. Visits to GPs and specialists have also increased. Municipal services The municipalities are responsible for nursing homes, home nurses, health visitors, municipal dentists (children’s dentists and home dental services for the physically and/or mentally disabled), school health services, people carrying out home help services, and the treatment of alcohol and drug users. Professionals involved in delivering these services are paid a fixed salary. Nursing homes are actually categorized as a social service. The number of nursing homes has decreased dramatically in recent years. Nursing homes provide both day care and residential services. It is possible for many chronically and terminally ill patients to stay in their homes and to avoid or delay institutionalization because of the combination of day care services, an increased number of home nurses, extensive home help and GP support. Home help is an offer for citizens who, due to health-related conditions, are not capable of performing daily living activities (e.g. personal care and hygiene, cleaning, and nutritional guidance). Visiting public health nurses call on children several times during their first year, according to individual needs. Public health nurses and school physicians or municipal physicians with special preventive responsibilities provide health examinations for all children when they start school. Public health nurses also offer health examinations once a year or every other year to schoolchildren. Municipal dentists provide free preventive and curative dental care for children and young people under the age of 18 as well as for people with special disabilities. 103
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6.4
Denmark
Secondary/inpatient care
Most secondary and tertiary care takes place in general hospitals owned and operated by the regions. Doctors and other health professionals are employed at hospitals on a salaried basis. Hospitals have both inpatient and outpatient clinics as well as 24-hour emergency wards. Outpatient clinics are often used for pre- or post-hospitalization diagnosis and treatments. Many of the open emergency wards, however, have been closed in recent years and patients with minor emergency problems are encouraged to seek after-hours services with the GP instead. Patients without a referral from a GP or a private specialist are generally only accepted at hospitals in emergency situations. Specialist doctors, like the GPs, work on a private basis and are reimbursed by the regions. They must have an agreement with the region, however, to receive reimbursement. Free access to private specialists, except for eye, and ear, nose and throat specialists, requires a referral from a GP. Like GPs, practising specialists can refer patients to public hospitals. Approximately 1% of the population has chosen Group 2 access under other conditions (see Subsection 2.5.2 on Patient rights and empowerment). There are a few, private profit-making clinics and hospitals where patients may go without referral and pay for the care themselves or with the help of private health insurance. In some cases, the regions have made agreements with private hospitals; generally, so that they may fulfil the waiting time guarantee or have some treatments performed by the private hospital. In such cases, care is free for the patients. In 2003, the number of beds in privately owned hospitals was 281, and there were 155 beds in other hospitals – also privately owned – treating patients with rheumatic or sclerotic diseases. Most public hospitals are general hospitals with different specialization levels. There is no official classification of hospitals according to the level of specialization, technological equipment or performance. There are 14 psychiatric hospitals and a few other “single specialty” hospitals. Contracting is used to a limited extent by the regions. Contracts are entered into either with public hospitals, in the region or in another region, or with private hospitals. There are usually contracts for a number of specific interventions, such as elective surgery. Since Denmark is a small country with good transportation facilities, the location of very specialized services in just a few hospitals does not present a problem. One of the purposes of the 2007 reform is to encourage municipalities to take on more responsibility for disease prevention and rehabilitation. A means to do so, suggested by nurses and allied professions, is to establish health centres in the municipalities to take care of minor health problems. The proposal has 104
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been contested, not least by medical doctors. However, it does form a part of the 2007 reform as a possible way of reorganizing health care. Funds from the Ministry of Health have been allocated to the municipalities for pilot projects based around health centres. A general trend since the 1940s has been to reduce the length of stay at hospitals by making care more efficient, changing routines, improving home nursing, and increasing outpatient activities pre- and post-hospitalizations. On some occasions, the regions have billed the municipalities for patients who were ready to be discharged from hospital but could not be discharged because the municipalities were not ready to provide them with the necessary outpatient care services; this thereby forced the hospital to prolong the patient’s stay more than should have been necessary. Since the mid-1980s, municipalities have increased the number of home nurses and decreased the number of nursing homes. Efforts are being made to improve cooperation between GPs and hospitals by appointing coordinators to work closely with hospital departments and report back to the local GPs. The free choice of hospital also seems to have encouraged hospitals to better inform GPs about discharges and about services in general.
6.5
Pharmaceutical care
Distribution of pharmaceuticals Any pharmaceutical product that has marketing approval from the Danish Medicines Agency can be distributed by community and hospital pharmacies. See Fig. 6.2 for the organization of the distribution system for pharmaceuticals. Denmark has three wholesalers distributing drugs to private pharmacies, in addition to some wholesalers that only distribute drugs for veterinary use. Wholesale profits are fixed through individual negotiations between the manufacturers or importers and the wholesalers; the profit level generally is determined through competition. Community pharmacies are organized as a liberal profession but subject to comprehensive state regulation on price and location. Pharmacies are organized in such a way as to ensure that everybody has reasonable access to a pharmacy, even in rural areas where pharmacies may not be profitable. A collective financial equalization system is in place, with which pharmacies with above-average turnovers contribute to pharmacies with below-average turnovers. Pharmacy services are provided by the pharmacy owner and the staff. The staff are composed of pharmacists and pharmaconomists. Their competence includes 105
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Fig. 6.2
Denmark
Organization of the distribution system for pharmaceuticals, 2006
Danish and foreign manufacturers Parallel importers
Gross regional sales
Gross private sales
Hospital production
Pharmacy production
Hospital pharmacies
Pharmacies
Hospital departments
General practitioners Dentists Individuals
Source: Personal communication from Ellen Westh Sørensen (Department of Social Pharmacy, University of Copenhagen), 2006.
handling and checking prescriptions, dispensing medicines and the provision of information regarding the pharmaceuticals. Pharmacy owners must ensure that their staff have the basic education and continuing training to enable them to properly carry out their tasks. The average number of full-time employees (including the owner) per pharmacy was 14.2; in total this is 578 pharmacists, 2597 pharmaconomists (pharmacy assistants), 456 trainees and 667 others. The number of prescriptions handled per pharmacy (or branch of a pharmacy) was 167Â 000 in 2005, corresponding to 630 prescriptions per pharmacy per day. The number of pharmacies and employed pharmacists is decreasing, while the number of pharmacy assistants is increasing. The number of pharmacies in Denmark has also decreased since the mid-1970s (Danish Pharmaceutical Association 2006). Community pharmacies are comparatively large; in 2006 there were 322 pharmacies in Denmark, of which 55 were branch pharmacies. Pharmaceuticals may also be sold in other types of outlet without pharmacists. Pharmacy outlets 106
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(138) are served only by pharmaconomists. In rural or scarcely populated areas, shops under the supervision of a pharmacy are allowed to act as OTC outlets or delivery facilities (Danish Pharmaceutical Association 2006). The total gross profits of community pharmacies are fixed by the Ministry of Health and the Danish Association of Pharmacists every two years on the basis of current figures and forecasts. In 2005, the total gross profit of the pharmacies was DKK 11.4 billion, exclusive of VAT. The average total gross profit per pharmacy was DKK 43.0 million (Danish Pharmaceutical Association 2006). All community pharmacies provide advice about medicine use, dose dispensing, generic substitution and the administration of individual reimbursement registers. Except for very simple processes, compounding of pharmaceutical materials is centralized at three pharmacies (Herborg, Sørensen & Frøkjær 2007). Many pharmacies offer BMI, blood sugar, blood pressure and cholesterol measurements, and 60% offer inhalation counselling; however, only inhalation services are reimbursed. Extending services in clinical pharmacy is a priority for all Danish pharmacy organizations. The professional strategy is to use the competence of the pharmacy to take co-responsibility for the pharmaceutical treatment of the patient and for patient safety. The 2007 structural reform shifted the responsibility of a major part of primary health care from the regional authorities to the local authorities. This change might result in new services being provided by community pharmacies. In 2006, a few local authorities had made preliminary contracts with pharmacies regarding nursing home services. Research in pharmacy practice and pharmaceutical care is well established. Research trends tend to focus on collaborative health care, on developing and documenting the value of community pharmacy services, and on optimizing services and strengthening implementation (Herborg, Sørensen & Frøkjær 2007). Hospitals can choose to buy drugs from the private pharmacies or through hospital pharmacies. Hospitals buy approximately 90% of their drugs from hospital pharmacies. Where hospitals buy drugs from private pharmacies, the retail price is based on the hospital’s drug purchases in the preceding year. Some hospital pharmacies have established AMGROS, a wholesaler that invites tenders for pharmaceutical contracts. Most hospital pharmacies buy drugs through AMGROS and thereby make use of the opportunity to benefit from lower prices on the basis of large, joint contracts. Since October 2001, other outlets, such as supermarkets and kiosks, have been permitted to sell a selection of non-prescription drugs. The total consumption of OTC drugs has not changed despite this increased number of 107
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outlets. The pharmacies’ share of OTC pharmaceuticals was approximately 90% in 2005 (Herborg, Sørensen & Frøkjær 2007). The issue of price liberalization has been subject to conflicting political interests and lobbying by strong interest groups in the pharmaceutical sector. With the exception of a minor liberalization of the sale of non-prescription drugs in October 2001, there are no further plans to liberalize this sector.
6.6
Rehabilitation/intermediate care
Many actors across different sectors in Denmark are involved in rehabilitation work. Rehabilitation occurs within the health care sector, the social sector, the occupational sector and the educational sector; however, each sector carries out a different aspect of rehabilitation, for example, training or the development of competences, and so on. Rehabilitation is partly provided by public hospitals, which are the responsibility of the regions. Municipalities have the responsibility of providing training and rehabilitation that are not offered in connection with hospital treatment. A few private clinics provide rehabilitation in the form of physiotherapy, occupational therapy and chiropractice therapy. An act passed in January 2004 states that hospitals must appoint a regular contact person to ensure better cooperation between the hospitals and municipalities (Law on Health of 2005) (National Association of Local Authorities 2005). Rehabilitation is provided free of charge at hospitals and in the municipalities. Increasingly, geriatric departments for rehabilitation of elderly people are being set up in regional hospitals. If patients cannot be placed in municipal care as soon as they are discharged because of waiting lists, then the municipalities are liable for any extra hospital expenses incurred. It is hoped that this liability will encourage municipalities to provide care as quickly as possible. Municipalities offer different kinds of rehabilitation settings, such as training in the patient’s home, in a care centre or in the municipality rehabilitation centres. Some municipalities have, in addition to their own rehabilitation centres, an agreement with the regions to provide rehabilitation services as a partnership with joint financing. Training can therefore be conducted at a regional rehabilitation centre, a rehabilitation hospital or within a hospital department. This type of partnership enables service provision in a professional environment with a group of competent professionals, such as doctors and physiotherapists (National Association of Local Authorities 2005). 108
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6.7
Denmark
Long-term care
Long-term care facilities are varied and numerous in Denmark. For example, in addition to conventional nursing homes, there are psychiatric nursing homes, small apartments (providing basic medical care and located adjacent to nursing homes), group homes and foster homes. To initiate long-term placement, the caregiver or community nurse contacts the GP, who in turn visits the patient at home or at the social services office. Upon completion of the assessment, the physician refers the case to a social worker, whose job it is to ensure that the appropriate forms are completed (including a section completed by the family) and then to forward the forms to the social services authorities. In addition to facilitating the application process, the social worker provides information regarding fees for long-term care. If the patient is in the hospital at the time of application, the family contacts the GP, who in turn contacts the appropriate professionals within the hospital. Between 80% and 90% of total placements costs are covered by the Government, with a small contribution made by the individuals concerned. The total cost of care depends on the types of service that a patient decides to use. It takes an average of two weeks to complete an assessment of a patient’s placement needs, and the waiting period ranges from a few weeks to six months (Payne, Wilson, Caro & O’Brien 1999). Municipal level The municipalities deliver social services including social welfare allowances (sickness allowances and disability pensions), care for elderly people, and care for disabled people and people with chronic diseases, including those with mental disorders. They deliver care both outside of hospitals and in community mental health centres. Municipalities are also responsible for providing housing for mentally disabled and homeless people. Such municipal services are financed through taxes and run primarily by salaried professionals employed by the municipal health authorities. Contracting with private non-profit-making agencies, however, is becoming increasingly common, in an attempt to provide services that are more efficient. Privately contracted services include long-term inpatient care in nursing homes, care in day care centres and social services for chronically ill and/or elderly people. Some additional services, such as catering and cleaning, have been contracted out to private profit-making firms. Cooperation between municipalities and regions The distribution of authority and operational health-related tasks between the regions and municipalities is based on the principle that the municipalities 109
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have the responsibility for care and rehabilitation outside of hospitals, disease prevention and health promotion. Since 1994, joint health planning has been a tool for coordination and cooperation between the regions and municipalities. Under the provisions of joint health planning, the regions are obliged to produce health plans covering a 4-year period (see Section 3.2 on Planning and health information management). From 2007, the health plan procedures have been replaced by the so-called health agreements, which define the specific collaboration between the municipalities and the regions (Strandberg-Larsen, Nielsen & Krasnik 2007). Nursing homes Since 1987, nursing homes have been considered as ordinary housing. The rights and duties of nursing home inhabitants, therefore, closely resemble those of the rest of the population. However, following this legislation, no new nursing homes have been set up, and protected housing now provides services according to individual needs. Consequently, the number of people in nursing homes has fallen dramatically, from approximately 51 000 in 1987 to 40 000 in 1996 and then again to 31 500 in 2003 (Statistics Denmark 2005). This has been accompanied by a large increase in the number of home nurses and people carrying out home help services employed by municipalities. Many municipalities provide home care around the clock. Nursing home inhabitants are now individually registered with a GP, whereas in the past each nursing home was assigned its own doctor. Nursing homes and protected housing are financed by their inhabitants, according to complex computations of their financial situation. The expenses of low-income inhabitants are paid using a proportion of their old-age pension allowance. Elderly people The demographic development of a proportionally increasing number of elderly people over the total population in Denmark is expected to pose a serious challenge for municipalities. In order to reduce the financial cost of care for elderly people, health and social authorities are attempting to place more and more emphasis on self-care, increased support for people to remain in their homes for as long as possible, and effective preventive and health promoting activities. However, it seems likely that patient co-payments and contracting services to private non-profit-making agencies will become increasingly popular tools for reducing costs and raising revenue in the future. Municipalities have developed a wide range of services to accommodate the preference of senior citizens to remain independent for as long as possible in their own homes. These services include care and assistance with cleaning, 110
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shopping, washing, the preparation of meals, and personal hygiene. Home care can be used to assist or relieve family members, who are caring for a sick or disabled person. Two forms of home care are available: long-term and temporary help. Long-term care is provided free of charge, whereas temporary home care visits may warrant individual payment, depending on the income of the recipient (Jarden & Jarden 2002). Public health nurses offer day and night services such as patient education, care and treatment, and help in filling out applications for various needs. These services include a change of residence, aid, emergency help, senior centres and senior day care facilities, and they are provided free of charge. All disabled or ill individuals can have an emergency or safety phone system installed in their home, which provides them with direct 24-hour contact to their public health nurse. When elderly people are in need of another living arrangement due to health reasons, a more suitable residence is offered. There is an array of possibilities available for this, based on the individual’s needs and desires. Senior citizen residences, gated communities, assisted living units and nursing homes are all designed specially for the elderly and the disabled, offering a one- or tworoom apartment, elevator services, emergency and contact systems, and social activities. These residences often differ in their management and administration, and some are associated with nursing homes that supply health aides as well. Resident councils provide representation of the residents’ needs in these senior citizen units. A day care centre is offered as an option for those who do not wish to move permanently but who still require extra care. Transportation to and from the day care centre is arranged. There is also the option of using a nursing home for a shorter period as a respite for the family (Jarden & Jarden 2002).
6.8
Services for informal carers
A number of services are available for the informal care of a person with reduced functional capability due to a severe physical or mental condition or a radically chronic or long-term illness. Someone who wishes to be an informal carer for a close relative may be employed by the municipality. However, the following preconditions must be fulfilled to do so: (1) the alternative to home care is day and night care outside the home or the quantity of care needed corresponds to a full-time position; (2) there is an agreement between the parties concerning the care arrangement; and (3) the municipality has approved the suitability of the person in question as an informal carer. The informal carer can be employed 111
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for up to six months with a monthly salary of DKK 14 875 (Danish National Centre for Employment Initiatives 2005), which is approximately three quarters of the average Danish monthly income of DKK 20 072 in 2005 (Statistics Denmark 2005). A person who takes care of a close relative with terminal illness can apply for a compensation of lost earnings. The application should be sent to the municipality. The preconditions of the compensation are: (1) that a doctor assesses the close relative and deems further hospital treatment to be hopeless; and (2) that the condition of the patient does not demand hospital admission. This compensation amounts to 1.5 times the amount the informal carer would have been given as sickness benefit. However, exceeding the informal carer’s normal salary is not allowed (Danish National Centre for Employment Initiatives 2005).
6.9
Palliative care
Palliative care is organized at two levels, basic and specialist care. Basic palliative care is directly integrated into the mainstream health system, and it includes GPs, municipality home care and hospital departments. Specialist palliative care includes palliative teams, hospices and palliative units. This care is mainly contracted out to independent hospice institutions but a few units have been set up in hospitals and are thus integrated into the health care system. The National Cancer Plan, published in 2000, concluded that the development of palliative care in Denmark is behind that of other countries and that resources should be allocated to the improvement of, and education in the field of, palliative care (Cancer Steering Committee 2000). The development of palliative care has historically varied across the country. According to the Association of County Councils’ 2001 report, very few counties had developed palliative care according to the national recommendations (National Board of Health 1999; Association of County Councils, Ministry of Health & National Association of Local Authorities 2001). Only four counties had beds dedicated to palliative care, and there were only 10 hospices in the whole country. The report concluded that more resources and efforts were needed for the education and training of health care professionals to develop palliative care according to the national recommendations. According to English calculations, there should be 12 palliative/hospice beds per 250 000 inhabitants is an appropriate measure. This would correspond to a total of 257 palliative/hospice beds in Denmark (Danish Cancer Society 2005). In 2001, the number of palliative/hospice beds in Denmark was 73: 22 palliative 112
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beds and 51 hospice beds (Association of County Councils, Ministry of Health & National Association of Local Authorities 2001). Thus, according to English standards, Denmark had a deficit of 184 palliative/hospice beds in 2001. Legislation determines the general municipal and regional obligations regarding the care and treatment of terminally ill patients in hospitals, nursing homes and their own homes. Legislation specifically states that access to care compensation, medicine, physiotherapy, psychological assistance, health care commodities and cleaning, among other things, should be provided. According to legislation, the regions are obliged to offer treatment in hospitals including the treatment of terminally ill patients. It is up to the individual region to determine whether it will establish a hospice as a means of complying with its hospital obligations. Hospices are permitted to be built and run in cooperation with another region or with a private promoter; however, its services should always be free of charge for the patients (Association of County Councils, Ministry of Health & National Association of Local Authorities 2001). Patients with great palliative needs fall under the same rules as other patients in the health care system when it comes to access to secondary care facilities. They have to be referred by a GP who is the first point of contact and who functions as a gatekeeper to hospitals, specialists and physiotherapists. It is up to the GP to decide when his/her own field of competence is no longer sufficient or if his/her practice does not have the necessary technology to treat the patient. In principle, however, patients are able to contact some Danish hospices on their own, and to be admitted without referral. Some specialist care services have a broad range of health care professionals (social workers, psychologists, physiotherapists, occupational therapists, complementary therapists, speech therapists, etc.) involved in the delivery of palliative care. Bispebjerg Hospital is one of the hospitals in Denmark that has many different kinds of health care professionals involved in the palliative care unit. Palliative care services do not rely on volunteers to help provide services because this kind of voluntary involvement is not common in Denmark. However, in Bispebjerg Hospital, a development project is experimenting with volunteers to help provide services. Patients and their relatives are explicitly involved in determining palliative care management plans and are dependent on the local availability of palliative care specialists. In 1996, the National Board of Health published guidelines, containing organizational instructions for palliative care, on how to care for seriously ill and terminally ill patients. The guidelines were expanded in 1999 to target professional health personnel and their respective responsibilities. WHO’s recommendations for palliative care, which address the health care personnel 113
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performing palliative care, were the point of origin of these guidelines (National Board of Health 2005a). Palliative care, as such, is not mentioned; however, many objectives are set related to understanding and managing serious illness, death and dying from different perspectives. In 1999 and 2001, the National Board of Health, the Danish Regions, the Ministry of Health and the National Association of Local Authorities proposed a strategic plan for a palliative programme, which has since been used to some extent to determine the level of services required for palliative care in the country (Association of County Councils, Ministry of Health, National Association of Local Authorities 2001; National Board of Health 2005a). Overall, palliative care has not developed as intended in the national recommendations from 1999 and, as a result, a national steering group was appointed in December 2003 to investigate the reasons for this slow development and to ensure implementation of the national recommendations in both the regions and communities. Following from recent political pressures, DKK 35 million has been made available for the establishment of 5–10 new hospices. Preconditions for this are that the economic resources should be given only to independent institutions that have a working agreement with the region, and that the hospices should be included under the Act on free choice of hospital. The establishment of these new hospices is an attempt to change the care delivery setting from hospitals to community-based locations. These grants, however, do not fully cover the need for new hospice places. For the coming years, a new reform is being developed that will further change responsibilities in the palliative care area (see Section 7.2 on Recent developments). Information surveys, patient/family surveys or performance indicators containing data on the quality of palliative care services are not widely published in Denmark. However, some surveys do exist that contain information which could be used indirectly as a measure of the quality of palliative care services (Goldschmidt et al. 2005; StrÜmgren et al. 2005). The palliative care effort in Denmark is still developing and there is thus a need to test different models of organization and cooperation combined with systematic evaluations and research.
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6.10 Mental health care In 1977, responsibility for psychiatric hospitals was transferred from the State to the counties. This led to a major decrease in hospital beds, which took place simultaneously with increased local and district psychiatric outpatient treatment. The development of decentralized psychiatric care emphasizing outpatient treatment and the adjustment of sick individuals to the local environment were facilitated as a result of the appearance of modern psychoactive drugs and a change in the psychological and social treatment of the mentally ill. This organizational change has, as planned, resulted in many mentally ill people living in their homes. However, their integration into wider society has not always been successful, especially in the big cities, where some of these people have ended up homeless or living in shelters (Mental Institute 2005). Full implementation of the organizational change in psychiatric care did not take place until the 1990s, and it was followed by problems relating to coordination and service coherence. Because the provision of services was divided between counties and municipalities, there were many problems embedded in organizational fragmentation. The counties made a number of subsequent organizational changes in order to secure coordination and coherence of services within and between clinical psychiatry and social psychiatry care. Psychiatry has developed from long-term admission to psychiatric departments to shorter admissions and more outpatient and district psychiatric treatments combined with social psychiatric day services. The aim of this change was to integrate the mentally ill better into society. Because it is particularly difficult to integrate the severely mentally ill into society, special admission conditions have been established for this group, based on 24-hour stays. Public services for patients with mental disorders are provided in crosssectoral collaboration between the health and the social care sectors. The regions are responsible for health care services, and the municipalities are responsible for the social psychiatric services. The main responsibility of the regions is a specialized effort towards caring for the long-term mentally ill. The municipalities take care of all other psychiatric tasks. There is, however, partial overlap of some of the social psychiatric services that are provided by the regions and municipalities. This can further complicate efforts to run an effective, coherent system linking decision competence and financing responsibility. Private practising psychiatrists There were 108 full-time private practising psychiatrists in 2000. Patient admission to these private practising psychiatrists tends to be from two sources: a direct approach from the patient without referral (to be fully paid for by the 115
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patient), or referral from a GP (financed by the region). All patients have the right to confidentiality. Information about admission and treatment can only be passed on to a GP with the patient’s approval. Hospital psychiatry In 2002, a total of 3894 beds were available in hospital psychiatric departments. GPs are entitled to admit immediately a patient to a psychiatric hospital. If this requires the use of force, the police may be involved. District psychiatry A district psychiatric unit is established locally, providing outpatient care and interdisciplinary psychiatric treatment. Most treatment is conducted at the mentally ill patient’s residence. The treatment is conducted by district psychiatric teams, which comprise interdisciplinary doctors, nurses, social workers, occupational therapists, psychologists, physiotherapists, and so on. In some regions, these teams are located locally in district psychiatric centres, which are sometimes connected with a day care centre. Other regions have placed the teams in hospitals’ psychiatric departments. The regions also have different district psychiatric services; some strictly provide services only for people with long-term and socially disabling diseases, while others also include services for people with short-term mental illness. A referral is needed for a mentally ill person to seek treatment from district psychiatry care providers. The referral can be obtained from a GP, the hospital or, in some cases, the caseworker. District psychiatry has been criticized for providing insufficient treatment, which is primarily explained by a lack of economic resources and a reduction in the number of beds without simultaneously increasing outpatient care resources. The planned extension of resident institutions outside of hospitals has not yet been executed, despite the fact that a third of the available psychiatric beds have been removed from service. Almost all of Denmark is served by district psychiatric services, with approximately 120 units across the country (Association of County Councils 2005). The current focus is still on the development of the level of care and education of personnel. Social psychiatry The municipalities have the primary responsibility for social psychiatry, and the regional authorities are responsible for those services requiring special competencies. In 2002 the counties had 2061 occupied day centre 116
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accommodation places (versus 3256 day and night accommodation places). The municipalities are also responsible for the mentally ill at local nursing homes, as well as providing temporary residence and home care arrangements. In 2001 a total of 4979 individuals were included in the municipalities’ support and contact person arrangements (Ministry of the Interior and Health 2004b). Legislation and strategic programmes From the early 1990s, mental health care has continuously been on the agendas of the Danish Parliament and Government, regions and municipalities. According to legislation, the regions and municipalities have a considerable degree of freedom in the organization and management of mental health care services. Treatment in psychiatric departments is regulated by the law, which includes details on the patient’s loss of freedom and the use of force in psychiatric care (Ministry of the Interior and Health 2004b). The current legislation amended the legislation from 1938, and places more focus on the rights of patients. According to the current Act, the health authorities are obligated to offer hospital stay, treatment and care, corresponding to accepted psychiatric hospital standards; bed and personnel nomination; possibilities for stays outside of the hospital; and occupational, educational and other activity services. However, the State has had a greater influence on the county and municipality management of psychiatry through economic and psychiatry agreements. In 2003, a plan for the treatment of the mentally ill was agreed on for the period 2003–2006, which provided DKK 250 million a year for four years. The plan focused to a large extent on increasing the quality of services to the mentally ill (Association of County Councils 2005). The latest development within the psychiatric field has been the establishment of new organizational forms with outgoing and interdisciplinary teams for treatment of the mentally ill in their homes or within their living arrangements. Fieldwork teams for psychotic patients and for young schizophrenic patients are some examples of these new organizational forms, which are targeted towards the most challenging group of mentally ill patients in order to create a uniform and coherent service. This service can include treatment, various social psychiatric services, educational services, and so on (Ministry of the Interior and Health 2004b). There is a well-established system of appeals and advocacy in place for mental health care. The Mental Health Act states that treatment must be a collaborative effort between the patient and professionals. A plan must be prepared and implemented within seven days of admission for all patients. The patient, if capable, must be consulted on, and accept, the plan. Patients 117
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are also given access to a list of approved advocates from outside of the hospital. Advocates support the patient if a complaint is raised or if the patient is to be subjected to physical restraint. Although the use of physical restraints is still widespread, it is more common in Denmark than many other countries, but measures to minimize this are being taken at the time of writing. Discrimination and social stigma The regional authorities have established different programmes to tackle discrimination and social stigma from which individuals with mental health disorders often suffer (Association of County Councils 2005). The Danish Mental Health Fund, the primary aim of which is to disseminate knowledge about mental disorders and to minimize prejudice existing within the field, has established a nationwide programme against depression (Danish Mental Health Fund 2005). One of the many goals of this programme is to focus on discrimination and social stigma in order to minimize the burden of the mentally ill. The programme is coordinated by the Danish Mental Health Fund and based in the regions. A great deal of the nationwide effort against depression has been undertaken through regional and local projects. The projects depend on the needs and situation of the local area, but they generally offer courses, themes, public meetings, and activities in the workplace, schools, educational institutions, and so on. As an integrated part of the nationwide effort, the Danish Mental Health Fund runs a project aimed at children and adolescents, primarily those aged 14–19 years (Danish Mental Health Fund 2005). The fund has a bus, which is driven around the country with free information and education about psychiatry, mental disorders and problems with a special focus on children with mentally ill parents. The Ministry of Health and the former Ministry of Social Affairs created a proposal regarding a common set of fundamental values within the field of mental health. The aim was to establish positive interplay between the services provided in both the health and social care sectors for people with long-term mental disorders. Special efforts are made to provide services that are meaningful and coherent for the users and their families as well as for professional personnel (Ministry of the Interior and Health & Ministry of Social Affairs 2004). Refugees and asylum seekers No specific public services are provided to deal with the particular problems that are faced by refugees and asylum seekers. Red Cross Denmark, however, offers three hours of psychological consultation per individual. If that individual needs further consultation, they have to apply to the Danish Immigration Service to 118
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obtain it. The Danish Immigration Service is unfortunately quite restrictive in this area, and can put the involved individual in a difficult position (see Section 6.14 on Health care for specific populations). Families and care Families are not legally obligated to provide care for fellow family members with mental health problems. Each region assesses the individual situation and decides which arrangements are best for the patient. However, in recent years, the focus has been on creating a set of common values, to be applied nationwide (Association of County Councils 2005). Availability of specialist professionals The number of specialist professionals in the delivery of mental care is illustrated in Table 6.1. Psychiatric beds The number of beds in hospital and district psychiatry services was 3799 in 2002. This is approximately one fifth of the beds available in Danish somatic hospitals (see Subsection 5.1.1 on Infrastructure and capital investment). This relative reduction is most significant in psychiatry, largely due to a policy of deinstitutionalization. The general decline in the number of beds in psychiatric hospitals has been associated with a large increase in the number of outpatient visits. Many diagnostic and therapeutic procedures now take place without inpatient admission or before and after inpatient stay. The rate of deinstitutionalization and the insufficient development of community mental Table 6.1 Number of full-time specialist professionals involved in the delivery of mental health care, 2001–2003 Profession Doctors Psychologists Nurses Psychiatric nursing aids Social and health care assistants Social workers Social workers helping to advise the mentally ill Physiotherapists and occupational therapists Other health care personnel
2001 1 069 366 2 918 991 2 079 328 230 463 363
2002 1 165 394 3 172 923 2 296 284 297 440 296
2003 1 179 444 3 260 1 020 2 223 287 289 442 123
Source: Association of County Councils, 2005.
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health care systems are partly responsible for what is known as “revolving door psychiatry” in Denmark. The increased risk of suicide, compulsory hospitalization and abuse among psychotic patients in Denmark can, to a certain extent, be explained by the rate of deinstitutionalization and patient dropouts in community psychiatry, despite the fact that one of the basic principles in outpatient treatment is continuity (Aagaard & Nielsen 2004). Priorities for mental health care The main priority in Danish mental health care is to provide treatment for the mentally ill according to severity, with first priority given to individuals suffering from, for example, schizophrenia and severe depression. However, the regions have established a pilot project, which examined whether milder illnesses, such as anxiety and abuse, should also be included as priority areas (Association of County Councils 2005). Over the coming years, the distribution of responsibility in mental health care is to be reformed, along with the organizational structure of mental health services (see Section 7.2 on Recent developments).
6.11 Dental health care In Denmark, oral health care for children and adolescents is provided by the Municipal Dental Service. According to the 1986 Act on dental care, the system also provides health promotion, systematic prevention and curative care free of charge (Danish Parliament 1986). Dental health for children and adolescents is essentially school based and, as a result of outreach activities, the participation rate is nearly 100%. The 1972 Act on children’s dental care created the first concrete framework for preventive and health promoting activities for children and adolescents (Danish Parliament 1971; Ministry of the Interior 1974). These Acts have ensured the continued expansion of a public health programme within the framework of primary health care. An important element of the Danish Act on children’s dental care was that municipalities were mandated to take on the responsibility to report oral health data to a national recording system (the SCOR-system), which is developed and implemented by the National Board of Health. The system was established to evaluate the evolution of oral health status nationally, regionally and locally (Hansen, Foldspang & Poulsen 2001). Information derived from the register shows that an improvement in dental health among children and adolescents occurred primarily from the late 1970s and throughout the 1980s, concurrent with the introduction of populationoriented preventive programmes (Petersen & Torres 1999). 120
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The aim of the dental health service is to develop good oral health habits through oral self-care at home and a coherent prevention and care system within the population so that teeth, mouth and jaws can be maintained and function for life. The objectives, therefore, include aspects of behaviour, care and health. The means used to reach the goals of the Municipal Dental Health Service include health promotion, prevention, regular check-ups and dental treatment of oral disease (Danish Parliament 1971). Great importance is also attached to individual needs and contact with key people associated with the care of children. Dental care is free for children and young people below the age of 18 under the Municipal Dental Health Service or with a private practising dentist, who is reimbursed based on fees paid by the municipalities. This latter option, however, is only used by a small minority. The municipal children and youth dental care includes periodic check-ups and treatments (e.g. in connection with caries). Municipal children and youth dental care services also refer children to orthodontists if necessary. Dental health care for adults is offered by private dental practitioners. The adults are responsible for a substantial part of the payments; however, some of the payments, in particular the curative services, are covered by the regions. If a person is covered by private health insurance, for instance Health Insurance “denmark”, dental care is further subsidized. Prices are regulated through negotiations between the Association of Dentists and the Danish Regions every third year, and through negotiated changes in the salaries of public sector employees (Health Care Reimbursement Negotiating Committee & Danish Dental Association 2004). There is no direct monitoring of the quality of dental health services in Denmark. However, the dentist has to negotiate with the regions, which look at the services provided and assess the overall composition of services. Complaints about the quality of a dental service are to be sent to the National Board of Health. The Board does not generally monitor dental health services, but it does take action against the dentist concerned if there has been a substantiated complaint (Danish Dental Association 2005). Denmark has had a tradition for several decades of community-oriented preventive oral health care programmes, in particular in relation to children. The Danish Municipal Dental Health Service is a school-based programme, which includes comprehensive clinical oral care, prevention and oral health education for children and parents. School-based activities encompass oral health education in the classroom, diet control, supervised oral hygiene instructions, fissure sealing of permanent molars and the effective use of fluorides. In Denmark, only fluoridated toothpaste is available on the market. Increased 121
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control of dental caries has been observed among children and adolescents of varying social and economic backgrounds and across regional and geographical boundaries. From an overall perspective, considerable improvements have been registered. The prevalence rate of dental caries, the average incidence of caries and the number of children with particularly severe caries have all decreased substantially (Petersen & Torres 1999).
6.12 Alternative/complementary medicine In Denmark, a wide choice of alternative treatment exists such as zone therapy, osteopathy, homoeopathy, acupuncture, herbal medicine, and so on. Chiropractice is no longer considered an alternative treatment. The provision of complementary and alternative medicine is regulated by a medical law regarding quackery, but it can be practised freely as long as the law is respected. The law states that authorization is required, and that if the individual without professional qualification calls him/herself a doctor or performs surgery, then a penalty will be executed. Acupuncture is considered a surgical operation and, therefore, can only be conducted by an authorized doctor. Alternative medical products are also governed by regulations. As a response to EU directives regarding the production and sale of homoeopathic medicine, these regulations have been revised in Denmark. All alternative medicines sold in Denmark have to be approved by the Danish Medicines Agency, which sets out regulations on production standards, safety and product efficacy (Johannessen 2001). Complementary and alternative medicine is partly accepted by the mainstream medical profession. The biggest problem lies in the interaction between different preparations and conventional treatments. These interactions have not been fully explored, can be potentially dangerous for the patient and can result in complaints for doctors who have not guided the patient properly. It can be difficult for the doctor to guide a patient if he/she is not aware that patient is using alternative treatments and herbal medicines. Approximately half of the GPs in Denmark use some kind of alternative treatment in their practices (Johannessen 2001). Physiotherapists, psychologists and chiropractors also use alternative treatments to some extent, but they are only used in a few hospitals and often in the form of acupuncture as pain treatment. There are no authorized clinics or hospitals specializing in alternative treatments, but a number of centres for integrated medicine do exist. At these centres, therapists with government-approved therapist education cooperate with alternative therapists of varying education and therapeutic specialties. 122
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Approximately 10% of the adult Danish population attended zone therapy during 2003; it is the most used alternative treatment. A total of 21% of the adult population received an alternative treatment during 2003, which is almost double compared to 1987. As illustrated in Fig. 6.3, zone therapy, massage/ manipulation, homoeopathy and acupuncture are the forms of alternative treatment sought most in Denmark. The age groups 25–44 and 45–66 years mostly attend zone therapy and, within these groups, there are three times as many women as men. The general patterns in the use of alternative treatments indicate that there are relatively few users among people with less education and nonprofessional workers, but there are a much larger number of users among the self-employed (National Institute of Public Health 2003). The only alternative therapy that is reimbursable within the Danish health care system by third-party payers is acupuncture practised by a doctor. The regions and Health Insurance “denmark” provide contributions to this alternative treatment. Alternative therapists are, otherwise, reliant on out-of-pocket payments, details of which are not available. The Knowledge and Research Centre for Alternative Medicine was established in 2000. In the future, it is expected that the Centre will continue to explore complementary and alternative therapies and herbal medicines, to raise knowledge of such therapies and their effects and to engage in dialogue with health care providers, complementary and alternative therapists and health care consumers. In 2004, legislation was introduced on a voluntary self-administrated registration arrangement for alternative therapists.
Fig. 6.3
Percentage of the population having received different forms of alternative treatment in 2003
Zone therapy Massage/manipulation Homoeopathy Acupuncture Relaxation Dietary guidance Healing Magnetic stroking Laying-on of hands Hypnosis Other 0
2
4
6
8
10
12
Source: National Institute of Public Health, 2003. 123
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6.13 Maternal and child health Since the 1930s and 1940s, maternal and child health care has been free of charge and regulated by laws. Pregnant women are offered antenatal care and the number of such visits is regulated by need, which is decided by the health professionals. Care may be administered at separate clinics or at outpatient clinics within hospitals. Health examinations are performed by GPs, midwives and sometimes obstetricians. Antenatal care is organized and financed by the regions, as is delivery-related care, whether the woman chooses to deliver at hospital or at home. Less than 1% of women opt for home deliveries. The municipalities are responsible for providing and financing health checks for infants, which take place in the child’s home, carried out by a health visitor. Preschool children are offered seven free health examinations by a GP, financed by the regions. Health checks for schoolchildren usually take place at school clinics, carried out by a school nurse and a medical doctor. Extra examinations are offered for children with special needs. The acceptance rate for these services is very high, reaching almost 100% for antenatal and infant care, but somewhat lower for preschool health checks. They are also generally considered to be adequate and of high quality. The only major change that has occurred in the services since their inception is that needs assessment has played a role in establishing the type of care and number of consultations to be offered since the 1970s. Adolescent pregnancies are few and their number is not considered a problem. Perinatal death rates continue to decline but are also continuously higher than those in the other Nordic countries (NOMESCO 2005). Maternal deaths are very rare, and syphilis is not particularly prevalent in the population. Table 6.2 Reproductive health, 1991–2004 (selected years) 1991 1993 1995 1997 1999 2000 2001 2002 2003 2004 Adolescent pregnancy rates below 18 years, % Perinatal deaths per 1000 births Maternal deaths per 100 000 Sexually transmitted infections (syphilis, gonorrhoea, HIV)
0.40
0.40
0.30
0.30
0.30
0.30
0.30
0.20
0.20
0.30
7.90
7.50
7.40
8.50
7.20
7.30
7.10
6.20
6.40
4.80a
3.13
7.50 10.16 7.47
6.12
–
3.10
–
–
–
447
427
472
553
539
830
Source: NOMESCO, 2005. Note: a preliminary data. 124
–
–
456
368
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The number of people that are registered as HIV positive has increased recently, causing some concern, but in general, reproductive health in Denmark is considered to be very good (see Table 6.2).
6.14 Health care for specific populations Special population groups have different kinds of access to the statutory health care system. Recognized refugees are included in regional health care coverage and have the same rights as Danish citizens, although they have to undergo a 6-week period of quarantine before entitlement commences. There are no national plans to offer services for preventive examinations and vaccination programmes for refugees and family reunion refugees. It is up to each municipality to decide whether to implement screening services or preventive initiatives. Asylum seekers are all offered a volunteer screening examination by Red Cross Denmark. This examination is a general health check-up as well as an offer to perform an HIV test and an X-ray for thorax for risk groups. Children are examined for their vaccination status. Asylum seekers are not covered by regional health care and are only directly entitled to: (1) basic primary health care provided by the Red Cross or selected municipalities; and (2) hospital care in case of emergency. If an asylum seeker has a chronic disease, Red Cross Denmark can apply to the Danish Immigration Service for economic support. According to the Danish Immigration Service, this support can only be provided if the treatment is necessary, to relieve pain or to deal with a life-threatening situation. The application is assessed by a medical consultant and case officers from the Danish Immigration Service. Illegal immigrants are only entitled to acute treatment and are not covered by the regions. They are, however, often afraid of being reported to the authorities if they attend the health services for acute care. In Denmark, a network of doctors exists that treats illegal immigrants despite the act being unlawful. Commercial sex workers living illegally in Denmark are also helped by nongovernmental organizations, which treat them for sexually transmitted infections and other problems. Psychological diseases are a major problem among asylum seekers and refugees. They have often been traumatized by war, have been tortured or experienced other events that have had a profound impact on their lives. Red Cross Denmark offers three hours of psychological consultation free of charge. For further consultation, the asylum seeker has to apply to the Danish Immigration Service. However, the Service is quite restrictive in this area, which can put the involved individual in a difficult position. 125
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Access to health care services is generally affected by various barriers, such as lack of knowledge regarding the health system’s functions, language problems, and cultural and structural barriers.
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7
7.1
T
Denmark
Principal health care reforms
Analysis of recent reforms
able 7.1 provides an overview of the major reforms and policy initiatives that had a substantial impact on health care from 1970 to 2007. For information regarding earlier and more recent reforms, see Section 2.1 on Historical background. Free choice of hospitals and waiting time guarantee An Act on free choice of hospital for patients was introduced in 1993. Once referred by a GP, patients may choose among all public hospitals in Denmark and some private non-profit-making hospitals with the same level of specialization. An “extended free choice” was introduced in 2002. With this, choice was extended to a number of private facilities and facilities abroad for patients with expected waiting times of more than two months. This is a waiting time guarantee and patients’ choice is limited to the hospitals that have an agreement with the region. There has been a slight increase in the utilization of the “free choice” of hospitals, but current official data sources do not represent accurate trends. An official study, based on data from the National Patient Register, shows a growth in the share of non-acute patients treated outside their home county, from 8.0% of all patients in 1997 to 11.3% in 2003 (percentage of non-acute basic-level patients treated in other counties as a percentage of the total number of non-acute basic-level patients) (Ministry of the Interior and Health 2004b). This study includes patients treated at higher levels of specialization outside the county, 127
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Table 7.1 Overview of major reforms and policy initiatives with a substantial impact on health care, 1970–2007 Year
Description
1970
Political and administrative structural reform: the responsibility of a large part of the health care sector is placed with 14 new counties and the cities of Copenhagen and Frederiksberg. The National Board of Health has the responsibility of approving county hospital plans.
1970–1980 The responsibility of state hospitals and those financed by the State is assigned to the counties (with the exception of Rigshospitalet). 1972
The municipalities are obligated to offer free dental care for children. This is extended in 1994 to include the elderly and the disabled.
1973
Counties and municipalities are given the responsibility of managing practising health professionals.
1980
Annual budget negotiations between the State and the counties, and between the State and the municipalities, are introduced.
1985
Hospital plans that are developed by the counties no longer need approval by the National Board of Health but only need to be presented to the Board.
1989
The first coherent, national prevention programme for health is developed in cooperation with all relevant sectors.
1990
Budget agreements between the State and the counties increasingly include specific objectives and demands.
1993
Free choice of hospital is mandated by law, including all counties and the cities of Copenhagen and Frederiksberg.
1994
Counties and municipalities are obligated to coordinate plans for health care services.
1995
The Copenhagen Hospital Cooperation (H:S) is formed. All hospital-related tasks in the cities of Copenhagen, Frederiksberg and Rigshospitalet are transferred to H:S.
1999
As part of the 1998 budget agreement, full diagnostic-related group (DRG) payments for patients treated are introduced at hospitals outside their home county (under the 1993 free choice scheme). 10% of hospital budgets are allocated according to activities by DRG.
2002
A waiting time guarantee, named the “extended free choice”, is introduced. Patients with waiting times of more than two months can choose between a number of private facilities and facilities abroad, provided the patient’s county has an agreement with them.
2003
The 1999 reform is extended to include activity-based financing (20% of budget) in hospitals from 2004.
2005
A major structural reform of the Danish administrative system is passed in Parliament. The reform was implemented in 2007 with 2006 being a transition year.
2007
The waiting time guarantee is reduced from two months to one month.
Sources: Ankjær-Jensen & Rath, 2004; Ministry of the Interior and Health, 2005c.
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but excludes choices made within counties. Thus, there are no exact figures on the extent to which the right to choose a hospital has been utilized. A study group organized by the Ministry of Health in 2004 concluded that there had been a slight increase in the number of “extended free choice patients” from approximately 2000 in the third quarter of 2002 to approximately 6000 in the final quarter of 2004. The extended choice scheme is mostly used for eye surgery, orthopaedic surgery, ear, nose and throat treatment and plastic surgery (Association of County Councils, Copenhagen Hospital Co-operation, Ministry of Finance & Ministry of Health 2004). Although variations in waiting times persist, the limited utilization of this opportunity reflects the generally short waiting times in Denmark. Travel costs, limited information on quality matters, traditions, and patient preferences for treatment close to home may be other explanatory factors for this utilization pattern (Vrangbæk 1999; Birk, Vrangbaek, Winblad & Østergren 2007). The waiting time guarantee has been further reduced to one month as of 1 October 2007. DRG and activity-based financing A Danish DRG system and diagnosis-related prices have been developed from the late 1990s. This has formed the administrative backbone of a number of experiments with activity-based financing as a supplement to the standard block grants and global budgets. “Free choice” patients across regional lines are paid on a full DRG price basis. In most cases this has created incentives for counties to try to retain “free choice” patients by reducing waiting lists. The Government as of autumn 2006 has actively sought to use activity-based financing to create incentives for increased activity when redistributing funds. This seems to have led to increases in activity levels, but possibly also to a bias against some of the areas where the activity level is harder to measure and influence (e.g. geriatrics, internal medicine, etc). The current objective is to gradually increase the level of activity-based financing from 20% to 50% (Ankjær-Jensen & Rath 2004; Ministry of Health 2005c). Danish model for quality development In 2002, the national and regional authorities agreed to implement a national model for quality assurance in health care. The idea was to integrate a number of previously national and regional projects – including clinical databases, clinical guidelines, accreditation schemes and national patient satisfaction surveys – into a comprehensive scheme covering all areas of the health sector. The main components of the model were the development of standards (e.g. general, process-related; specific, diagnosis-related; and organizational) and 129
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measurement indicators. Standards and indicators are supposed to support internal quality assurance, benchmarking and external accreditation. Quality data are published on the Internet to facilitate comparison and choice. So far, it is possible to compare quality for seven diagnosis areas (diabetes, lung cancer, schizophrenia, heart failure, hip fracture, stroke and acute surgery for gastrointestinal bleeding) as well as patient satisfaction ratings for all hospital departments (Danish eHealth Portal 2007; Danish National Indicator Project 2007). The accreditation of hospitals takes place every third year based on previous internal assessments. External accreditation is carried out by independent accreditation experts. So far, the Government has entered into a contract with the American Joint Commission for Accreditation of Health Organizations. The structure of the data builds on the integration of existing and new electronic patient records.
7.2
Recent developments
Structural reform A major structural reform of the administrative system was passed by the Danish Parliament in 2005. The reform was implemented in 2007, with 2006 as a transition year. The reform reduced the number of regional authorities from 14 counties to 5 regions (0.6–1.6 million inhabitants per region) and the number of municipalities from 275 to 98 (37% of the new municipalities have more than 50 000 inhabitants; 38% have 30 000–50 000; 18% have 20 000–30 000; and 7% have fewer than 20 000 inhabitants). Both levels are governed directly by elected politicians. The main responsibility of the regions is to provide health care services, but some environmental and regional development tasks have also been maintained at this level. Most other tasks have been moved to either the State or the municipalities. The new municipalities have assumed full responsibility for prevention, health promotion and rehabilitation outside of hospitals. From an economic point of view, several important changes have been implemented. First, the regions’ right to tax was removed. Health care is now financed by a combination of national earmarked “health taxes” (the new state health contribution), which are redistributed in terms of block grants to regions and municipalities. A total of 80% of the regional health care activities are financed by the State via block grants and some activity-based payments (approximately 5%). The remaining public financing for regional health care activities comes from municipal contributions, which are paid as a combination of per capita contributions and activity-based payments related to the use of 130
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services by the citizens of the municipality. The idea behind the municipal co-financing is to create incentives for municipalities to increase preventative services in order to reduce hospitalization. The impetus behind the new state health contribution is to create greater transparency for taxpayers with regards to their health contributions and priorities. The size of the block grants from the State are calculated according to a formula, which includes the expected health care needs of the population as a central component. The expected need is assessed by combining the number of inhabitants in different age groups and across certain socioeconomic status levels (Strandberg-Larsen, Nielsen, Krasnik & Vrangbaek 2006). The reform passed through the Parliament with a small majority. This is unusual in Denmark, as the norm has previously been that major structural reforms have needed a broad consensus between the Government and the Opposition. Two of the parties behind the reform, including the Conservative coalition government party, had been in favour of dismantling the counties for a number of years. The main arguments for the reform were related to bureaucratic costs and taxation levels. It is not clear, however, whether the reform will lead to major reductions in administrative costs. Significant implementation costs are currently being incurred. Another main driver of the reform was the perception that larger catchment areas were needed to support future specialization and to secure structural adjustments. Many observers have pointed to the ambiguous evidence on the benefits of scale and specialization in health care (Christensen, Nielsen, Holm-Petersen & Lassen 2005). Other observers have pointed out that the counties were performing well in terms of controlling expenditure levels, increasing productivity and making gradual structural adjustments (Søgürd 2004), and that the evidence behind benefits of scale in hospital treatment is unfounded. Most observers agree that the strengthening of the municipal level is beneficial; however, there is some fear that the municipalities will not have sufficient competences to plan and carry out their new tasks and that they will prioritize activities that directly reduce hospital admissions over general, longterm preventive programmes. No independent experts have argued in favour of the changes in financing scheme (Pedersen, Christiansen & Bech 2005).
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8
8.1
Denmark
Assessment of the health system
A
Objectives of the health system
8.2
Distribution of the health system’s costs and benefits across the population
n official government report from 2003 outlines the objectives of the Danish health system as follows (Advisory Committee to the Minister for the Interior and Health 2003): • free and equal access to treatment • choice • high quality • coherent patient pathways • consideration for diversity in patient needs and preferences • efficient use of resources • efficient macroeconomic control of expenditure • democratic control. In this chapter, we investigate recent policies and the status regarding these objectives, where evidence is available.
Financing health services Until 2007, the Danish health system was financed through progressive general income taxation at the national level and proportional income and property taxes at the regional level (see Chapter 4 on Financial resources). The national-level 133
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tax revenue was redistributed to the counties via block grants based on objective criteria and some activity-based financing for hospitals. The system was designed to support solidarity in financing and equity in coverage (Gundgaard 2006; Wagstaff et al. 1999). Since 2007, financing has taken place through earmarked proportional taxation at the national level (see Section 7.2 on Recent developments). Most of this revenue (80%) is redistributed to the regions via block grants based on objective criteria (social and demographic indicators). The remaining 20% is redistributed to the new municipalities, which in turn co-finance regional hospital services for their population. The system continues to be based on principles of solidarity and redistribution across the population. The earmarking of health taxes is a new feature in Denmark and is intended to create greater transparency for taxpayers with regard to the health sector. However, this mechanism also reduces the potential for redistribution across sector areas. There is an increasing level of user charges in Danish health care. These are mostly related to payments for pharmaceuticals, dental care and physiotherapy, and also to a fast growing private health insurance market, which is partly established by labour market agreements for groups of employees. Some argue in favour of introducing more co-payments, such as patient fees for GP consultations, as this may reduce the unnecessary utilization of services. Increases in private financing of health services may lead to major changes in the patterns of health care financing in Denmark over time, which could threaten the general principles of solidarity and equity in the tax-based financing of health care services. Provision of benefits At the time of writing, the system is based on the principles of universal, free and equal access to health care. Although utilization patterns vary somewhat across the regions, these objectives have largely been met. In practice, some groups (such as the homeless, the mentally disabled, immigrants, and drug and alcohol abusers) appear to have a more unstable utilization pattern than other groups. The high individual costs of dental care for adults seem to result in social inequity in the utilization of this kind of service, which has also led to social differences in dental health status. The use of private practising specialists reveals a geographic and social bias, as services are mostly established in affluent urban areas. The utilization of patient choice appears to favour patients with higher education and stable employment. There is some speculation that the increasing use of activity-based financing will divert investments and activities away from areas such as internal medicine and geriatrics and towards areas 134
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where increases in activity are easier to demonstrate. However, the evidence base for this claim is limited. Equal access and utilization of services according to need will probably remain a strong focus in the Danish health sector in the near future. However, ever increasing demands as a result of new technology and expected changes in age distribution and disease patterns of the population might foster political initiatives to reduce access through new financial and structural reforms.
8.3
Efficiency of resource allocation in health care
Allocative efficiency In general, current resource allocation for health care meets the needs of the population. The reduction in waiting times, along with the waiting time guarantee and “extended free choice� of hospital, ensure access to health services within relatively short periods. The waiting time guarantee ensures access to treatment in the public system or at private facilities in Denmark or abroad, if expected waiting times exceed one month. Patient satisfaction surveys continue to demonstrate remarkably high levels of satisfaction with both GPs and hospital services. However, international comparisons of survival rates among some patient groups (i.e. patients with lung cancer and ovarian tumours) seem to indicate that the efficiency of some diagnostic and curative services is not optimal. This may be due to a lack of staff, equipment or skills, or to structural problems in the Danish health care system related to service coordination and specialization. There are also some issues of personnel coverage in peripheral areas; however, regional authorities are actively seeking to remedy such difficulties by employing non-native doctors and nurses. Recent years have seen special emphases placed on psychiatric care and common life-threatening diseases, such as cancer and heart problems. Psychiatric diseases and treatments for musculoskeletal ailments are given low priority despite general statements to the contrary in national health policy. There is no evidence of significant shifts in the balance between primary, secondary and tertiary care. However, a stated objective of the current structural reform is to create incentives for the municipalities to place more emphasis on prevention, health promotion and rehabilitation outside of hospitals.
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Denmark
Technical efficiency in the production of health care
The health system is in general considered to provide good “value for money”. Consecutive government reports have indicated that the relationship between overall expenditure levels and service levels, including available indicators on waiting times and quality, is acceptable in comparison with other European countries (Advisory Committee to the Minister for the Interior and Health 2003; Ministry of the Interior and Health 2004b). Efficiency in this area is a result of many different initiatives, which aimed at controlling expenditure, raising productivity and improving quality, over the decades. The use of global budgeting and hard budget constraints is a pervasive feature of the system. In recent years, this has also been combined with internal contracts and some activity-based payments in order to encourage higher activity and stronger productivity. A recent government report highlights the gradually improving productivity in the sector, with a 2.4% increase from 2003 to 2004 (Ministry of the Interior and Health 2005d). Productivity is measured at the system level and for the individual units on an annual basis. It is measured as the relationship between DRG production values (output) and expenditure (input). Hospital productivity is compared to average productivity at national, regional and county levels (Ministry of the Interior and Health 2005a). There is limited information on the efficiency of the primary care sector; however, it is generally assumed that the combined per capita and fee-for-service payment mechanisms provide incentives to optimize both activity levels and composition. Fees are negotiated with the public authorities on a regular basis and activity profiles are monitored regularly. GP “gatekeeping” has been a significant feature of the Danish system for many years, along with the general principle of treating patients at the lowest effective care level, as opposed to providing free access to units that are more specialized. There is a general policy to promote the generic substitution of pharmaceuticals, and all regional authorities have implemented policies that monitor and influence the use of drugs in their health facilities. Efforts to reduce the general costs of drugs have not been particularly successful, in spite of some positive results in terms of drug pricing. Any potential savings have been more than counterbalanced by wider use of new and more expensive drugs and by changes in the treatment indications of hypertension, high cholesterol, and so on. There has been some experimentation with substitution of doctors with nurses, but the most important efficiency drive has been a massive, and largely successful, effort to convert inpatient treatment to outpatient or ambulatory treatment. 136
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Denmark
Accountability of payers and providers
Accountability of payers and providers is largely ensured by hierarchical control within political-bureaucratic structures at national, regional and municipal levels. The budgeting and economic management processes include accountability assessments at all levels. Annual negotiations between the State and the regional and municipal authorities involve a detailed evaluation of needs, results and new activity areas. Regional and municipal public management is based on contracting, incentives and surveillance measures, to control the performance of hospitals and other public organizations. The activities of practising primary and secondary care doctors are monitored and funded with the nationally negotiated fee schedules, by the regional authorities. Quality is monitored by state-employed medical health officers via internal bureaucratic procedures, national measures of patient satisfaction and various national and regional initiatives to develop standards, clinical guidelines, clinical databases, and so on. All hospitals have been included in the general Danish model for quality assurance since 2007, and external accreditation takes place at regular intervals (see Section 7.2 on Recent developments). A national system for reporting inadvertent events has been established as well. HTA has become an integrated part of the system, along with other types of evaluation at local or regional levels. HTAs are performed at national, regional and local levels. The HTA practice has become institutionalized via a national institute and several regional resource centres. HTA is recommended for major decisions, but has not yet been implemented comprehensively. Evaluations may be performed by local or regional initiatives, in addition to the nationally mandated quality assurance programme. Patients rights have been extended and formalized during recent years (see Subsection 2.5.2 on Patient rights and empowerment). These rights are generally respected and there are mechanisms in place for sanctioning professional misconduct and abuse.
8.6
The contribution of the health system to health improvement
The contribution the health system has made to the health of the population is difficult to assess. It depends on the measure of health utilized and the time span under consideration. For instance, the decline in mortality stagnated in Denmark during the 1950s and at the same time health care costs started to 137
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increase substantially. However, in recent decades, mortality caused by heart disease has declined remarkably, partly due to better survival among heart patients. In addition, survival rates for some types of cancer have increased due to better interventions. That said, Denmark is still lagging behind other Nordic countries regarding general mortality and some cause-specific mortality figures; this is probably due to a combination of health care, environmental and health behaviour factors. There is also reason to believe that people’s functional abilities and quality of life have improved because of enhanced surgical and pharmaceutical treatments; however, there is little quantitative evidence to support this assumption. A recent study on amenable deaths in 19 industrialized countries indicates that the Danish system is performing at an average level. It is not performing as well as other Scandinavian countries (namely, Norway and Sweden) but it is performing better than countries such as the United Kingdom, Portugal, Ireland, the United States, Austria, New Zealand and Greece (Nolte & McKee 2003). Although the method used in the WHO World Health Report 2000 for evaluating the performance of health systems is far from perfect and widely debated, it indicated a rather poor ranking of Denmark (Nolte & McKee 2003). In spite of the rather weak public health interventions regarding tobacco consumption, there have been some changes in the population’s behaviour, showing a gradual decrease in the Danish population’s high tobacco consumption. However, a new, stricter legislation largely banning smoking in places of work was implemented as of 15 August 2007. Alcohol consumption is also high in Denmark. The public health effort continues to focus on general campaigns in this area, which have been counteracted by a reduction in alcohol taxes. The increase in obesity and related diseases such as diabetes has become a public health issue in recent years, but major interventions are yet to be put into practice. Health inequalities are increasing between educational and occupational groups, as is the trend in many other western European countries (Mackenbach et al. 2003). There is, however, no evidence indicating that this is due to unequal access to or utilization of health care services; that is, with the exception of specific instances such as the high co-payment for adult dental care. It is rather caused by unfavourable social and environmental conditions and health behaviours in some population groups, which cannot be modified by the ongoing types of public health interventions in effect at the time of writing.
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Denmark
Conclusions
T
he general picture that emerges from the bulk of the evidence presented here is of an integrated, yet decentralized public health system, which appears to have delivered sustainable good value for money. A predominantly political and administrative governance system has found a dynamic balance between the objectives of equity, efficiency, cost-containment and relatively high levels of service and quality. Various policy tools have been implemented to achieve this balance. However, the country’s continued ability to strike an acceptable balance in this respect has been drawn into question. As in all Western health systems, there are increasing demands for individualized services at a high level of quality, an ageing population, rapid development of technological possibilities and the resulting pressures on health expenditures. At the same time, health care has become more politicized and is subject to increasing attention by both the voting population and political parties. It is generally understood that elections can be lost or won on health sector issues. The media-fuelled public perception of waiting time problems, the relatively poor life expectancy in Denmark compared to other Scandinavian countries and the identification of substandard results in some critical treatment areas such as heart disease and cancer have contributed to greater scepticism than was previously evident in the population towards both health professionals and health administration. Signs of this can be found in the media coverage of health issues, while the national patient satisfaction surveys show remarkably high, albeit slowly declining, rates of satisfaction with the system. Various pressures and the changing political dynamics have led to the introduction of many new reform initiatives in the sector. The reforms have strengthened the position of patients and are gradually changing the managerial dynamics to combine professional and decentralized political governance with various national monitoring, control and incentive schemes. Several aspects 139
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of these developments are worth considering: first, a gradual change in the dominant medical thinking from a local clinical focus to global, evidence-based approaches; second, the evidence-based transparency systems are introduced in a more or less uneasy alliance with the managerial demands for accountability and control through auditing; and third, economic incentives are used more consciously as an instrument to affect behaviour at department, hospital, and regional and municipal levels. This is gradually changing the “rules of the game” and the mix of values and cost–benefit assessment within the system. Furthermore, the free choice of hospitals was introduced in 1993 as a goal in its own right, and as an instrument intended to put pressure on the public hospital system. That element of choice has been combined with a waiting time guarantee, which extends the principle of choice to a set of private providers both in Denmark and abroad, if expected waiting times exceed one month from referral to treatment. The Danish health system has thus gradually moved from a predominantly hierarchically managed and supply-driven system to one based on a combination of supply and demand governance and mixed with a stronger role for economic incentives and emerging openings for more entrepreneurial behaviour, both within the public sector and by private actors. Some of the specific policies to strengthen the position of users/patients include the general waiting time guarantee of one month from referral to treatment, free choice of hospitals, and improved general patient rights to information and dialogue. Added to this is an ongoing focus on better coordination of patient pathways from initial diagnosis to treatment and rehabilitative followup. Incentive-based policies include the partial introduction of activity-based financing for hospitals and the introduction of municipal co-financing of regional health services. Other performance-oriented policies aim to develop detailed monitoring and control systems for service and quality. A combination of user assessments, self-evaluation and external accreditation is the chosen approach in the Danish national programme for quality assessment, which is to be implemented in all parts of the health system in the years to come. A structural reform took effect on 1 January 2007. This reform reconfigures the administrative landscape within which health governance takes place. The previously existing 14 counties have been replaced by 5 regions, with largely the same responsibilities for primary care and hospital services but, importantly, without the independent right to raise taxes. Both the introduction of larger regions and the shift to predominantly state-funded health care can be regarded as a recentralization of powers. This is further underlined by the strengthening of the National Board of Health with regard to planning of specialty treatment capacity. However, the general tendency towards more centralized power in 140
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health governance is combined with a new role for the municipalities as cofinancers of health services and as the main responsible administrative level for rehabilitation, prevention and health promotion. The municipal co-financing is a unique feature in Denmark, which is intended to create incentives for the municipalities to focus their attention on prevention and substitution of hospital services with various forms of outpatient care. The municipal capacity to do this has been questioned, but it seems that most municipalities are actively working on the development of new health functions. A main argument for embarking on the structural reform was to improve coordination and create patient pathways that function more smoothly. This may be the outcome within the larger regions, while the coordination across regions and municipalities may become problematic as a result of the new financial relationships and potential conflicts of interest. Special coordination councils are supposed to take care of this, but results will only gradually emerge over the years to come. Structural changes are not limited to the administrative level. The new regions as well as the new municipalities are now actively seeking to develop a new delivery infrastructure. In all regions this means political backing for a series of mergers and closures of hospitals and departments in an effort to reap benefits of scale and scope. Some of these aspirations are likely to be successful, while there is less evidence that anything useful can be gained from other mergers and structural changes. The overall effects of the reform will become apparent in the coming years, although it will be difficult to evaluate effects in a clear causal pattern. It is considered likely that a “blame game� will emerge between the regions and the State, as the regions have incentives to increase demands for funding, and are more likely to be backed by their population, than in the previous situation where higher service levels were immediately linked to higher regional taxation. Equity remains a core value in the Danish health sector, but it coexists with long-standing elements of private ownership in general and specialist practices, as well as supplementary health insurance, particularly to reimburse co-payments. Several developments may lead to a slow de facto erosion of the equity principle. First, the rapid spread of voluntary supplementary health insurance will allow some segments of the population more direct access to private health providers. This is likely to lead to a greater role for both private and public entrepreneurship as new actors enter the market and public health organizations attempt to respond to challenges by creating more differentiated service concepts. Second, the demands for more individualized services in the public health sector, combined with increasing focus on lifestyle and self141
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inflicted conditions, may be part of a broader cultural change in the perception of health services. Another factor that is gradually changing the political landscape is the internationalization of health care, and particularly the development of internal EU markets for people, services and goods. Mobility of health professionals and cross-border patient mobility are gradually making an impact in the Danish health system. Cross-border patient mobility challenges national planning capacity and changes the conditions of the national health policy situation. Attracting health professionals from abroad may be a solution to the shortages of skilled staff in the Danish system, but it also creates new challenges in terms of communication, cultural barriers and quality control.
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10 Appendices
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Association of County Councils, Copenhagen Hospital Co-operation (H:S), Ministry of Finance, Ministry of the Interior and Health [Amtsrådsforeningen, Hovedstadens Sygehusfællesskab, Finansministeriet, & Indenrigs- og Sundhedsministeriet] (2004). Rapport fra arbejdsgruppen om evaluering af det udvidede frie sygehusvalg [An evaluation of the extended free choice of hospital - a working group report]. Copenhagen, Amtsrådsforeningen, Hovedstadens Sygehusfællesskab, Finansministeriet, & Indenrigs- og Sundhedsministeriet (http://www.im.dk/publikationer/Rapport_evalu_frit_svalg/rapport_evalu_frit_ svalg.pdf, accessed 11 June 2007). Association of County Councils, Ministry of Health, National Association of Local Authorities [Amtsrådsforeningen, Sundhedsministeriet, Kommunernes Landsforening] (2001). Hjælp til at leve til man dør. Rapport fra arbejdsgruppe om palliativ indsats i amter og kommuner [Assistance to live until one dies. Palliative efforts in counties and municipalities. A working group report]. Copenhagen, Amtsrådsforeningen, Sundhedsministeriet, Kommunernes Landsforening (http://www.sum.dk/publikationer/palliativ/index.htm, accessed 4 November 2005). Association of Danish Physiotherapists [Danske Fysioteraoeuter] (2005) [web site]. Medlemstal [Number of members]. Copenhagen, Danske Fyioterapeuter (http://www.fysio.dk, accessed 4 November 2005). Birk HO, Henriksen LO (2003). Brugen af det frie sygehusvalg inden for tre amter, 1991–1999 [The use of the free choice of hospital rights in three different counties, 1991–1999]. Ugeskr Laeger, 165(38):3613–3616. Birk HO, Vrangbæk K, Winblad U, Østergren K (2007). Patients reactions to hospital choice in Norway, Denmark, and Sweden. Health Economics, Policy and Law, 2(2):125–152. Brunn-Rasmussen M, Bernstein K, Vingtoft S, Andersen SK, Nøhr C (2003). EPJ Observatoriet statusrapport 2003 [EHR Observatory status report 2003]. Ålborg, EPJ Observatoriet. Cancer Steering Committee [Kræft Styregruppen] (2000). Den nationale kræftplan, status og forslag til initiativer i relation til kræftbehandlingen februar 2000 [The national cancer strategy, status and proposals for initiatives related to cancer care - February 2000]. Copenhagen, Sundhedsministeriet [Ministry of Health] (http://im.dk/publikationer/kraeftplan/index.htm, accessed 11 June 2007). Christensen M, Nielsen ML, Holm-Petersen C, Lassen A (2005). Sygehusstruktur i Danmark - en antologi om konsekvenserne af centralisering i sygehusvæsenet [The structure of the hospital sector in Denmark - the consequences of centralisation in the hospital sector. An anthology]. Copenhagen, DSI - Institut for Sundhedsvæsen [DSI – Danish Institute of Health Services Research]. 144
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CIA (2005). The World Factbook. Washington, DC, Central Intelligence Agency. CIA (2007) The World Factbook. Washington, DC, Central Intelligence Agency (https://www.cia.gov/library/publications/the-world-factbook/index.html, accessed 12 July 2007). Dagens Medicin (2005) [web site]. Copenhagen, Dagens Medicin (http://www. dagensmedicin.dk, accessed 4 November 2005). Danish Association of Psychologists [Dansk Psykolog Forening] (2005) [web site]. Om foreningen [About the association]. Copenhagen, Dansk Psykolog Forening (http://www.dp.dk, accessed 4 November 2005). Danish Association of the Pharmaceutical Industry [Lægemiddel industriforeningen] (2005) [web site]. Sundhed er en del af moderne personaleordninger [Health as a part of modern human resource programme]. Copenhagen, Lægemiddelindustriforeningen (http://www.lifdk.dk/sw10476. asp, accessed 14 June 2007). Danish Cancer Society [Kræftens bekæmpelse] (2005) [web site]. Kræftens bekæmpelses politik vedrørende palliation - lindrende behandling [The policy of the Danish Cancer Society regarding palliative care]. Copenhagen, Kræftens bekæmpelse (http://www.cancer.dk/Cancer/Nyheder/Vi+mener/politik+vedroe rende+palliation+lindrende+behandling.htm, accessed 12 June 2007). Danish Centre for Health Technology Assessment [Center for Evaluering og Medicinsk Teknologivurdering] (2005) [web site]. Purpose, Vision & Strategic Plan. Copenhagen, Sundhedsstyrelsen [National Board of Health] (http:// www.sst.dk/Planlaegning_og_behandling/Medicinsk_teknologivurdering/ Om_CEMTV/Formaal_visioner_strategi.aspx?lang=enwww.mtv-instituttet. dk, accessed 4 November 2005). Danish Chiropractors’ Association [Dansk Kiropraktor Forening] (2005) [web site]. Generelle oplysninger [General information]. Copenhagen, Dansk Kiropraktor Forening (http://www.kiropraktor-foreningen.dk, accessed 4 November 2005). Danish Council for Research Policy [Danmarks Forskningspolitiske Råd] (2005). Årsrapport 2004 for Forskningsstyrelsen [Annual Report 2004, Danish Research Agency]. Copenhagen, Ministeriet for Videnskab, Teknologi og Udvikling [Ministry of Science, Technology and Innovation] [http://fist. dk/site/forside/publikationer/2005/aarsrapport-2004-for-forskningsstyrelsen/ aarsrapport-forskningsstyrelsen-2004.pdf, accessed 14 August 2007). Danish Dental Association [Dansk Tandlæge Forening] (2005) [web site]. EU manual of dental practice 2004. Copenhagen, Dansk Tandlæge Forening (http:// www.dtfnet.dk/dtf/pics/doksys/o100/k203/EU_Manual_of_Dental_Practice_ Denmark.pdf, accessed 14 June 2007).
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Vallgårda S (1989). Hospitals and the poor in Denmark, 1750–1880. Scandinavian Journal of History, 13:95–105. Vallgårda S (1992). Sygehuse og sygehuspolitik i Danmark. Et bidrag til det specialiserede sygehusvæsens historie 1930–1987 [Hospitals and policy in Denmark. A contribution to the history of specialised hospitals 1930–1987]. Copenhagen, DJØF’s forlag. Vallgårda S (1999a). Who went to a general hospital during 18th and 19th centuries in Copenhagen? European Journal of Public Health, 9(97):102. Vallgårda S (1999b). Rise, heyday and incipient decline of specialisation. Hospitals in Denmark 1930–1990. International Journal of Health Services, 29:431–457. Vallgårda S (2001). Governing people’s lives. Strategies for improving the health of the nations in England, Denmark, Norway and Sweden. European Journal of Public Health, 11(4): 386–392. Vallgårda S (2007). Public health policies: a Scandinavian model? Scandinavian Journal of Public Health, 35(2):205–211. Vallgårda S, Krasnik A (2004). Sundhedstjeneste og sundhedspolitik – en introduktion, 3. udgave [Health services and health policy – an introduction, 3rd edition]. Copenhagen, Munksgaards Forlag. Vallgårda S, Krasnik A (eds) (2007). Sundhedsvæsen og sundhedspolitik [Health care services and health policy]. Copenhagen, Munksgaard Danmark. Vallgårda S, Krasnik A, Vrangbæk K (2001). Health care systems in transition: Denmark. Copenhagen, WHO Regional Office for Europe, on behalf of the European Observatory on Health Systems and Policies. von der Fehr FR (1994). Caries prevalence in the Nordic countries. International Dental Journal, 44(4 Suppl. 1):371–378. Vrangbæk K (1999). Markedsorientering i sygehussektoren [A marketoriented hospital sector]. Copenhagen, Institut for Statskundskab, Københavns Universitet [Department of Political Science, University of Copenhagen]. Licentiatserien 1999/4. KOMMISSION Statskundskab. Wagstaff A et al. (1999). Redistributive effect, progressivity and differential tax treatment: personal income taxes in twelve OECD countries. Journal of Public Economics, 72(1):73–98. WHO (2005) [web site]. WHO Statistical Information System (WHOSIS). Geneva, World Health Organization (http://www.who.int/whosis/en/, accessed 4 November 2005).
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WHO Regional Office for Europe (2005). European Health for All database (HFA-DB) [online database]. Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/hfadb, accessed 4 November 2005). WHO Regional Office for Europe (2007). European Health for All database (HFA-DB) [online database]. Copenhagen, WHO Regional Office for Europe (http://www.euro.who.int/hfadb, accessed 9 August 2007). World Bank (2005). World Development Indicators 2005. Washington DC, World Bank (http://devdata.worldbank.org/wdi2005/Cover.htm, accessed 12 June 2007).
10.2 Principal legislation Law of health [Sundhedsloven]. Law no. 546, 24-6-2005. Law of authorization of health professionals and of health care activities [Lov om autorisation af sundhedspersponer of om sundhedsfaglig virksomhed]. Law no 451, 22-5-2006. Ministerial order of Law of the central administration of health services [Bekendtgoerelse af lov om sundhedsvæsenets centralstyrelse]. LBK no. 790, 10-9-2002. Law on pharmaceuticals [Lov om lægemidler]. Law no. 1180. 12-12-2005. Law of access to complaint and compensation within the health services [Lov om klage- og erstatningsadgang inden for sundhedsvæsenet]. Law no. 547, 24-6-2005. Ministerial order of Law on infectious diseases [Bekendtgoerelse af lov om foranstaltninger mod smitsomme og andre overfoerbare sygdomme]. LBK no. 640, 14-6-2007. Law of a scientific ethical committee system and biomedical research projects [Lov om et videnskabetisk komitesystem og behandling af biomedicinske forskningsprojekter]. Law no. 402, 28-5-2003. Ministerial order of Law on use of force in psychiatric treatment [Bekendtgoerelse af lov om anvendelse af tvang i psykiatrien]. LBK no. 1111, 1-11-2006. Law on psychiatric treatment according to a legal proceeding [Lov om retspsykiatrisk behandling]. Law no. 1396, 21-12-2005.
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10.3 Useful web sites www.cancer.dk
Danish Cancer Society
www.cvuoeresund.dk
Centre for Higher Education, University College Øresund
www.dagensmedicin.dk
Dagens Medicin
www.dp.dk
Danish Association of Psychologists
www.dsi.dk
Danish Institute of Health Services Research
www.dst.dk
Statistics Denmark
www.dtfnet.dk
Danish Dental Association
www.europa.eu
Europa – Gateway to the European Union
www.fleksjob.dk
CABI – Danish National Centre for Employment Initiatives
www.fysio.dk
Association of Danish Physiotherapists
www.sum.dk
Ministry of Health
www.kiropraktor-foreningen. dk
Danish Association of Chiropractors
www.kl.dk
National Association of Local Authorities in Denmark
www.laegemiddelstyrelsen.dk
Danish Medicines Agency
www.dkma.dk
Danish Medicines Agency
www.lifdk.dk
Danish Association of the Pharmaceutical Industry
www.mm.dk
Mandag Morgen
www.oecd.org
Organisation for Economic Co-operation and Development
www.pkn.dk
Patients’ Complaints Board
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www.plo.dk
Organisation of General Practitioners in Denmark
www.psykiatrifonden.dk
Danish Mental Health Fund
www.psykisk-institut.dk
Mental Institute
www.regioner.dk
Danish Regions
www.retsinfo.dk
Legal Information of the Danish State
www.sfi.dk
Danish National Centre for Social Research
www.niph.dk
National Institute of Public Health
www.ssi.dk
National Serum Institute
www.sst.dk
National Board of Health
www.sygeforsikring.dk
Health Insurance “denmark“
www.uvm.dk
Ministry of Education
www.optagelse.dk
Ministry of Education
www.videnskabsministeriet.dk
Ministry of Science, Technology and Innovation
www.who.int
World Health Organization
10.4 HiT methodology and production process The Health Systems in Transition (HiT) profiles are produced by country experts in collaboration with the Observatory’s research directors and staff. The profiles are based on a template that, revised periodically, provides detailed guidelines and specific questions, definitions, suggestions for data sources, and examples needed to compile HiTs. While the template offers a comprehensive set of questions, it is intended to be used in a flexible way to allow authors and editors to adapt it to their particular national context. The most recent template is available online at: http://www.euro.who.int/observatory/Hits/20020525_1. Authors draw on multiple data sources for the compilation of HiT profiles, ranging from national statistics, national and regional policy documents, 160
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and published literature. Furthermore, international data sources may be incorporated, such as those of the Organisation for Economic Co-operation and Development (OECD) and the World Bank. OECD Health Data contain over 1200 indicators for the 30 OECD countries. Data are drawn from information collected by national statistical bureaux and health ministries. The World Bank provides World Development Indicators, which also rely on official sources. In addition to the information and data provided by the country experts, the Observatory supplies quantitative data in the form of a set of standard comparative figures for each country, drawing on the European Health for All (HFA) database. The HFA database contains more than 600 indicators defined by the WHO Regional Office for Europe for the purpose of monitoring Health for All policies in Europe. It is updated for distribution twice a year from various sources, relying largely upon official figures provided by governments, as well as health statistics collected by the technical units of the WHO Regional Office for Europe. The standard HFA data have been officially approved by national governments. With its January 2007 edition, the HFA database started to take account of the enlarged European Union (EU) of 27 Member States. HiT authors are encouraged to discuss the data in the text in detail, especially if there are concerns about discrepancies between the data available from different sources. A typical HiT profile consists of 10 chapters: 1. 2.
3.
4.
Introduction: outlines the broader context of the health system, including geography and sociodemography, economic and political context, and population health. Organizational structure: provides an overview of how the health system in a country is organized and outlines the main actors and their decision-making powers; discusses the historical background for the system; and describes the level of patient empowerment in the areas of information, rights, choice, complaints procedures, safety and involvement. Financing: provides information on the level of expenditure, who is covered, what benefits are covered, the sources of health care finance, how resources are pooled and allocated, the main areas of expenditure, and how providers are paid. Regulation and planning: addresses the process of policy development, establishing goals and priorities; deals with questions about relationships between institutional actors, with specific emphasis on their role in regulation and what aspects are subject to regulation; and describes 161
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5.
6.
7. 8.
9. 10.
• • • • •
162
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the process of health technology assessment (HTA) and research and development. Physical and human resources: deals with the planning and distribution of infrastructure and capital stock; the context in which information technology (IT) systems operate; and human resource input into the health system, including information on registration, training, trends and career paths. Provision of services: concentrates on patient flows, organization and delivery of services, addressing public health, primary and secondary health care, emergency and day care, rehabilitation, pharmaceutical care, long-term care, services for informal carers, palliative care, mental health care, dental care, complementary and alternative medicine, and health care for specific populations. Principal health care reforms: reviews reforms, policies and organizational changes that have had a substantial impact on health care. Assessment of the health system: provides an assessment based on the stated objectives of the health system, the distribution of costs and benefits across the population, efficiency of resource allocation, technical efficiency in health care production, quality of care, and contribution of health care to health improvement Conclusions: highlights the lessons learned from health system changes; summarizes remaining challenges and future prospects. Appendices: includes references, useful web sites, legislation.
Producing a HiT is a complex process. It involves: writing and editing the report, often in multiple iterations; external review by (inter)national experts and the country’s Ministry of Health – the authors are supposed to consider comments provided by the Ministry of Health, but not necessarily include them in the final version; external review by the editors and international multidisciplinary editorial board; finalizing the profile, including the stages of copy-editing and typesetting; dissemination (hard copies, electronic publication, translations and launches). The editor supports the authors throughout the production process and in close consultation with the authors ensures that all stages of the process are taken forward as effectively as possible.
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The Health Systems in Transition profiles A series of the European Observatory on Health Systems and Policies
T
he Health Systems in Transition (HiT) country profiles provide an analytical description of each health care system and of reform initiatives in progress or under development. They aim to provide relevant comparative information to support policy-makers and analysts in the develop ment of health systems and reforms in the countries of the European Region and beyond. The HiT profiles are building blocks that can be used: • to learn in detail about different approaches to the financing, organization and delivery of health care services; • to describe accurately the process, content and implementation of health care reform programmes; • to highlight common challenges and areas that require more in-depth analysis; and • to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in countries of the WHO European Region.
How to obtain a HiT
All HiT profiles are available in PDF format on www.euro.who.int/observatory, where you can also join our listserve for monthly updates of the activities of the European Observatory on Health Systems and Policies, including new HiTs, books in our co-published series with Open University Press, policy briefs, the EuroObserver newsletter and the Eurohealth journal. If you would like to order a paper copy of a HiT, please write to: info@obs.euro.who.int
The publications of the European Observatory on Health Systems and Policies are available at www.euro.who.int/observatory
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HiT country profiles published to date: Albania (1999, 2002a,g) Andorra (2004) Armenia (2001g, 2006) Australia (2002, 2006) Austria (2001e, 2006e) Azerbaijan (2004g) Belgium (2000, 2007) Bosnia and Herzegovina (2002g) Bulgaria (1999, 2003b, 2007) Canada (2005) Croatia (1999, 2007) Cyprus (2004) Czech Republic (2000, 2005g) Denmark (2001, 2007) Estonia (2000, 2004g,j) Key Finland (2002) France (2004c,g) All HiTs are available in English. Georgia (2002d,g) When noted, they are also Germany (2000e, 2004e,g) available in other languages: Hungary (1999, 2004) a Albanian Iceland (2003) b Bulgarian Israel (2003) c French Italy (2001) d Georgian Kazakhstan (1999g) e German Kyrgyzstan (2000g, 2005g) f Romanian Latvia (2001) g Russian Lithuania (2000) h Spanish Luxembourg (1999) i Turkish Malta (1999) j Estonian Mongolia (2007) g Netherlands (2004 ) New Zealand (2001) Norway (2000, 2006) Poland (1999, 2005) Portugal (1999, 2004, 2007) Republic of Moldova (2002g) Romania (2000f) Russian Federation (2003g) Slovakia (2000, 2004) Slovenia (2002) Spain (2000h) Sweden (2001, 2005) Switzerland (2000) Tajikistan (2000) The former Yugoslav Republic of Macedonia (2000) Turkey (2002g,i) Turkmenistan (2000) Ukraine (2004g) United Kingdom of Great Britain and Northern Ireland (1999g) Uzbekistan (2001g, 2007)
ISSN 1817-6127
HiTs are in-depth profiles of health systems and policies, produced using a standardized approach that allows comparison across countries. They provide facts, figures and analysis and highlight reform initiatives in progress.
The European Observatory on Health Systems and Policies is a partnership between the WHO Regional Office for Europe, the Governments of Belgium, Finland, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science and the London School of Hygiene & Tropical Medicine.
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Health Systems in Transition Vol. 10 No. 4 2008
Finland Health system review
Lauri Vuorenkoski
Editors: Philipa Mladovsky
Elias Mossialos
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Editorial Board Editor in chief Elias Mossialos, London School of Economics and Political Science, United Kingdom and European Observatory on Health Systems and Policies Editors Reinhard Busse, Berlin Technical University, Germany Josep Figueras, European Observatory on Health Systems and Policies Martin McKee, London School of Hygiene and Tropical Medicine, United Kingdom and European Observatory on Health Systems and Policies Richard Saltman, Emory University, United States Editorial team Sara Allin, European Observatory on Health Systems and Policies Cristina Hernandez Quevedo, European Observatory on Health Systems and Policies Anna Maresso, European Observatory on Health Systems and Policies David McDaid, European Observatory on Health Systems and Policies Sherry Merkur, European Observatory on Health Systems and Policies Philipa Mladovsky, European Observatory on Health Systems and Policies Bernd Rechel, European Observatory on Health Systems and Policies Erica Richardson, European Observatory on Health Systems and Policies Sarah Thomson, European Observatory on Health Systems and Policies International advisory board Tit Albreht, Institute of Public Health, Slovenia Carlos Alvarez-Dardet Díaz, University of Alicante, Spain Rifat Atun, Imperial College London, United Kingdom Johan Calltorp, Swedish Association of Local Authorities and Regions, Sweden Armin Fidler, The World Bank Colleen Flood, University of Toronto, Canada Péter Gaál, Semmelweis University, Hungary Unto Häkkinen, Centre for Health Economics at Stakes, Finland William Hsiao, Harvard University, United States Alan Krasnik, University of Copenhagen, Denmark Joseph Kutzin, World Health Organization Regional Office for Europe Soonman Kwon, Seoul National University, Korea John Lavis, McMaster University, Canada Vivien Lin, La Trobe University, Australia Greg Marchildon, University of Regina, Canada Alan Maynard, University of York, United Kingdom Nata Menabde, World Health Organization Regional Office for Europe Ellen Nolte, London School of Hygiene and Tropical Medicine, United Kingdom Charles Normand, University of Dublin, Ireland Robin Osborn, The Commonwealth Fund, United States Dominique Polton, National Health Insurance Fund for Salaried Staff (CNAMTS), France Sophia Schlette, Health Policy Monitor, Germany Igor Sheiman, Higher School of Economics, Russia Peter C. Smith, University of York, United Kingdom Wynand P.M.M. van de Ven, Erasmus University, The Netherlands Witold Zatonski, Marie Sklodowska-Curie Memorial Cancer Centre, Poland
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Health Systems in Transition Written by Lauri Vuorenkoski, Senior Researcher, STAKES, Finland
Edited by Philipa Mladovsky and Elias Mossialos, European Observatory on Health
Systems and Policies
Finland:
Health System Review
2008
The European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine.
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Keywords: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTHCARE REFORM HEALTH SYSTEM PLANS – organization and administration FINLAND © World Health Organization 2008, on behalf of the European Observatory on Health Systems and Policies All rights reserved The European Observatory on Health Systems and Policies welcomes requests for permission to reproduce or translate its publications, in part or in full Please address requests about this to:
Publications WHO Regional Office for Europe Scherfigsvej 8 DK-2100 Copenhagen Ø, Denmark
Alternatively, complete an online request form for documentation, health information, or for permission to quote or translate, on the WHO/Europe web site at http://www euro who int/PubRequest
The views expressed by authors or editors do not necessarily represent the decisions or the stated policies of the European Observatory on Health Systems and Policies or any of its partners
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the European Observatory on Health Systems and Policies or any of its partners concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries Where the designation “country or area” appears in the headings of tables, it covers countries, territories, cities, or areas Dotted lines on maps represent approximate border lines for which there may not yet be full agreement
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the European Observatory on Health Systems and Policies in preference to others of a similar nature that are not mentioned Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters The European Observatory on Health Systems and Policies does not warrant that the information contained in this publication is complete and correct and shall not be liable for any damages incurred as a result of its use
Printed and bound in the United Kingdom
Suggested citation: Vuorenkoski L, Mladovsky P and Mossialos E. Finland: Health system review. Health Systems in Transition. 2008; 10(4): 1–168.
ISSN 1817-6119 Vol. 10 No. 4
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Contents
Preface.............................................................................................................v Acknowledgements........................................................................................vi List of abbreviations......................................................................................ix List of tables and figures................................................................................xi Abstract....................................................................................................... xiii Executive Summary......................................................................................xv 1. Introduction...........................................................................................1 1.1 Overview of the health system.......................................................1 1.2 Geography and sociodemography..................................................4 1.3 Economic context...........................................................................6 1.4 Political context..............................................................................8 1.5 Health status..................................................................................10 2. Organizational structure......................................................................21 2.1 Historical background...................................................................21 2.2 Organizational overview...............................................................27 2.3 Decentralization and centralization..............................................36 2.4 Patient empowerment...................................................................38 3. Financing............................................................................................43 3.1 Health expenditure........................................................................45 3.2 Population coverage and basis of entitlement..............................50 3.3 Revenue collection/sources of funds............................................58 3.4 Allocation of resources and purchaser–provider relations............65 3.5. Payment mechanisms...................................................................67 4. Planning and regulation......................................................................73 4.1 Regulation.....................................................................................73 4.2 Planning and health information management.............................76 5. Physical and human resources............................................................85 iii
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6. 7. 8. 9. 10.
iv
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5.1 Physical resources.........................................................................85 5.2 Human resources..........................................................................90 Provision of services...........................................................................97 6.1 Public health.................................................................................97 6.2 Patient pathways.........................................................................104 6.3 Primary care................................................................................105 6.4 Secondary care............................................................................109 6.5 Emergency care...........................................................................112 6.6 Pharmaceutical care....................................................................113 6.7 Rehabilitation..............................................................................117 6.8 Long-term care............................................................................117 6.9 Mental health care.......................................................................118 6.10 Dental care................................................................................120 6.11 Health care for specific populations..........................................121 Principal health care reforms............................................................123 7.1 Analysis of recent reforms..........................................................124 7.2 Future developments...................................................................137 Assessment of the health system......................................................143 8.1 Stated objectives of the health system........................................143 8.2 Distribution of the health system’s costs and benefits across the population..................................................................144 8.3 Efficiency of resource allocation in health care..........................147 8.4 Technical efficiency in the production of health care.................148 8.5 Accountability of the health care system....................................149 8.6 Contribution of the health system to health improvement...............................................................................150 Conclusions.......................................................................................153 Appendices.......................................................................................157 10.1 References.................................................................................157 10.2 Principal legislation..................................................................166 10.3 Useful web sites........................................................................167 10.4 HiT methodology and production process................................168 10.5 About the author.......................................................................170
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Preface
T
he Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of reform and policy initiatives in progress or under development in a specific country. Each profile is produced by country experts in collaboration with the Observatory’s research directors and staff. In order to facilitate comparisons between countries, the profiles are based on a template, which is revised periodically. The template provides detailed guidelines and specific questions, definitions and examples needed to compile a profile. HiT profiles seek to provide relevant information to support policy-makers and analysts in the development of health systems in Europe. They are building blocks that can be used: • to learn in detail about different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; • to describe the institutional framework, the process, content and implementation of health care reform programmes; • to highlight challenges and areas that require more in-depth analysis; • to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in different countries. Compiling the profiles poses a number of methodological problems. In many countries, there is relatively little information available on the health system and the impact of reforms. Due to the lack of a uniform data source, quantitative data on health services are based on a number of different sources, including the
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World Health Organization (WHO) Regional Office for Europe Health for All database, national statistical offices, Eurostat, the Organisation for Economic Co-operation and Development (OECD) Health Data, the International Monetary Fund (IMF), the World Bank, and any other relevant sources considered useful by the authors. Data collection methods and definitions sometimes vary, but typically are consistent within each separate series. A standardized profile has certain disadvantages because the financing and delivery of health care differ across countries. However, it also offers advantages, because it raises similar issues and questions. The HiT profiles can be used to inform policy-makers about experiences in other countries that may be relevant to their own national situation. They can also be used to inform comparative analysis of health systems. This series is an ongoing initiative and material is updated at regular intervals. Comments and suggestions for the further development and improvement of the HiT series are most welcome and can be sent to: info@obs.euro.who.int. HiT profiles and HiT summaries are available on the Observatory’s web site at www.euro.who.int/observatory. A glossary of terms used in the profiles can be found at the following web page: www.euro.who.int/observatory/glossary/ toppage.
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Acknowledgements
T
he Health Systems in Transition (HiT) profile on Finland was written by Lauri Vuorenkoski (National Research and Development Centre for Welfare and Health, STAKES). It was edited by Philipa Mladovsky and Elias Mossialos (European Observatory on Health Systems and Policies, London hub). This HiT draws upon an earlier edition (2002) prepared by Jutta Järvelin (STAKES). The author would like to thank the following people who have helped in preparation of the manuscript: Pertti Asplund, Jutta Järvelin, Unto Häkkinen, Ilmo Keskimäki, Jan Klavus, Heikki Laapio, Kristian Lampe, Miika Linna, Kristiina Manderbacka, Matti Rimpelä, Marja-Leena Sandelin, Marita Sihto, Juha Teperi, Hanna Toiviainen, Kristian Wahlbeck and Eeva Widström. Additionally, Vaida Bankauskaite, Simo Kokko, Mauno Konttinen, Juhani Lehto and Kimmo Leppo have reviewed the report in different stages and have significantly contributed to it. Sara Allin contributed to the editing. The current series of HiT profiles has been prepared by the research directors and staff of the European Observatory on Health Systems and Policies. The European Observatory on Health Systems and Policies is a partnership between the World Health Organization (WHO) Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. The Observatory team working on the HiT profiles is led by Josep Figueras, Director, and Elias Mossialos, Co-director, and by Reinhard Busse, Martin vii
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McKee, Richard Saltman, heads of the research hubs. Jonathan North and Caroline White managed the production, Kathy Pond undertook the copyediting, Peter Powell typeset the material and Aki Hedigan proofread the volume. Special thanks are also due to national statistical offices that have provided data. Special thanks are extended to the WHO European Health for All database, from which data on health services were extracted; to the Organisation for Economic Co-operation and Development (OECD) for the data on health services in western Europe; and to the World Bank for the data on health expenditure in central and eastern European countries. The data used in this report are based on information available in February 2008.
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List of abbreviations
AIDS BMI CIS CT DEHKO DMFT DRG EBM EEA EPR ESPAD EU EU15 EUnetHTA FCHP Finohta FIOH GDP GP HiT HIV HTA HUS ICD KELA KTL MRI MSAH NAM NAMLA NGO NHI OECD OTC PPB PPP PYLL
Acquired immunodeficiency syndrome Body mass index Commonwealth of Independent States Computed tomography National Programme for the Prevention of Type 2 Diabetes Decayed, missing or filled teeth Diagnosis-related group Evidence-based medicine European Economic Area Electronic patient record European School Survey Project on Alcohol and Other Drugs European Union EU Member States before May 2004 European network for Health Technology Assessment Finnish Centre for Health Promotion Finnish Office for Health Technology Assessment Finnish Institute of Occupational Health Gross domestic product General practitioner Health Systems in Transition Human immunodeficiency virus Health Technology Assessment Hospital district of Helsinki and Uusimaa International Classification of Diseases Social Insurance Institution, SII National Public Health Institute Magnetic resonance imaging Ministry of Social Affairs and Health National Agency of Medicines National Authority for Medico-legal Affairs Nongovernmental organization National Health Insurance Organisation for Economic Co-operation and Development Over the counter Pharmaceutical Pricing Board Purchasing power parity Potential years of life lost ix
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Rohto SII Sitra SOTKA STAKES STD TEKES TRIPS VAT WHO
Centre for Pharmacotherapy Development Social Insurance Institution (KELA) Finnish National Fund for Research and Development Municipal Database for Social and Health Statistics National Research and Development Centre for Welfare and Health Sexually transmitted disease National Technology Agency of Finland Trade-related Aspects of Intellectual Property Rights Value-added tax World Health Organization
Finland
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List of tables and figures Tables
Table 1.1 Table 1.2 Table 1.3 Table 1.4 Table 1.5 Table 1.6 Table 1.7 Table 1.8 Table 2.1 Table 3.1 Table 3.2 Table 5.1 Table 5.2 Table 5.3 Table 5.4 Table 7.1
Services funded by public sources (municipalities and NHI) in 2005 Population/demographic indicators, 1970–2005 (selected years) Macroeconomic indicators, 1996–2005 (selected years) Mortality and health indicators, 1970–2005 (selected years) Healthy life expectancy, 2002 Main causes of death (underlying cause of death, deaths per 100 000) Factors affecting health status (working age population) Dental health Milestones in the history of the Finnish health care system Trends in health care expenditure Health care expenditure by service category, (%) of total expenditure on health care, 2005 Patients in inpatient care Inpatient utilization and performance in acute hospitals in the European Union, 2006 or latest available year Items of functioning diagnostic imaging technologies Health care personnel (man years) Major health care reforms and policy measures, 1995–2007
3 6 7 11 12 13 16 17 27 44 50 86 89 90 91 124
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Figures
Fig. 1.1 Fig. 1.2 Fig. 1.3 Fig. 2.1 Fig. 3.1 Fig. 3.2 Fig. 3.3 Fig. 3.4 Fig. 3.5 Fig. 3.6 Fig. 5.1 Fig. 5.2 Fig. 5.3 Fig. 5.4 Fig. 5.5 Fig. 6.1
xii
Overview chart on health system Map of Finland Levels of immunization for measles in the WHO European Region, 2005 or latest available year (in parentheses) Organizational chart of the statutory health system Financial flow chart Total expenditure on health as a percentage of GDP in the WHO European Region, 2003 Trends in health care expenditure as a share of GDP (%) in Finland and selected other countries Health care expenditure in US$ PPP per capita in the WHO European Region, 2003 Health care expenditure from public sources as a percentage of total health care expenditure in countries in the WHO European Region, 2003 Total expenditure on health according to source of revenue, 2005 Hospital beds in acute hospitals per 1000 population in the European Union, 1990 and 2003 or latest available year (in parentheses) Beds in acute hospitals per 1000 population in Finland and selected other countries Number of physicians and nurses per 1000 population in Finland and selected other countries Number of physicians per 1000 population in Finland and selected other countries New students accepted in universities (related to health care) Outpatient contacts per person in the European Union, 2003 or latest available year (in parentheses)
2 5 19 28 44 46 47 48 49 59 87 88 93 94 95 110
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Abstract
T
he Health Systems in Transition (HiT) profiles are country-based reports that provide a detailed description of a health system and of policy initiatives in progress or under development. HiTs examine different approaches to the organization, financing and delivery of health services and the role of the main actors in health systems; describe the institutional framework, process, content and implementation of health and health care policies; and highlight challenges and areas that require more in-depth analysis. According to various indicators, the health of the Finnish population has considerably improved over the last few decades. Average life expectancy has improved throughout the 20th century, especially during the last three decades, reaching 76 years for men and 83 years for women in 2005. Although overall mortality has fallen, the socioeconomic inequality in mortality seems to be increasing. The most significant public health problems are circulatory diseases, malignant tumours, musculoskeletal diseases, diabetes and mental health problems. In practice in Finland there are three different health care systems which receive public funding: municipal health care, private health care and occupational health care systems. The largest share of health care services is provided by the municipal health care. There are also different public financing mechanisms for health care services in Finland: municipal financing based on taxes and National Health Insurance (NHI) financing based on compulsory insurance fees. The Finnish health care system offers relatively good quality health services for reasonable cost with quite high public satisfaction. The most visible problems are long waiting times and personnel shortages in some municipalities. xiii
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The most important state level reforms from the beginning of the 1990s are: the deregulation of state steering of municipal health services and related changes in state administration; the introduction of the ‘National Project to Ensure the Future of Health Care’; the extension of public dental health care to all age groups; the introduction of the waiting time guarantee; a project to restructure municipalities and services; and the development of the national electronic patient record system. Future challenges for the decentralized Finnish health care system are: strengthening steering capacity for strategic priorities and resources; revitalizing the gradually weakening primary care system; improving cooperation between municipal primary and secondary care; improving cooperation between health care and personal social services; and addressing dual financing in publicly subsidized health care.
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Executive summary
F
inland is located to the north-east of the Baltic Sea. Finland became an independent republic with its own constitution in 1917, having first been under Swedish rule for 600 years and then under Russian rule for 100 years. At the start of 2007 the population of Finland was 5.3 million. The Finnish public administration system consists of three levels: state, province and municipality. The provinces are regional representatives of the central state administration. Finland is divided into five administrative provinces and the Åland Islands, the latter having autonomous status. Finland has a constitution (latest major review in 2000). Power in Finland is vested in the people, who are represented by deputies assembled in a single chamber parliament which is elected every four years. The head of state is the President of the Republic, who is elected for a period of six years by direct popular vote. In practice, the President’s power in political areas other than foreign policy is limited. The highest level of Government of the state is the Council of State (the Government) which consists of a Prime Minister and a requisite number of ministers. Judicial power is vested in independent courts of law, at the highest level in the Supreme Court and the Supreme Administrative Court. Finland is divided into 415 self-governing municipalities (in 2008) with a median number of inhabitants of 5000. Municipalities are autonomous and they are responsible for providing basic services for their residents, including primary education and social and health services. The highest decision-making body in the municipality is the municipal council which is elected by general election every four years. Municipalities levy a municipal income tax, the rate being decided independently by each municipality. Municipalities also receive xv
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some other tax revenues (real estate tax and part of the corporate tax), subsidies paid by the state and other revenues (such as user-fees). The objectives of Finnish health policy are to reduce premature deaths, to extend people’s active and healthy life, to ensure the best possible quality of life for all and to reduce differences in health. The foundation of the health services is laid down in the constitution of Finland (section 19). According to the constitution: Everyone shall be guaranteed by an act the right to basic subsistence in the event of unemployment, illness, and disability and during old age as well as at the birth of a child or the loss of a provider. The public authorities shall guarantee for everyone, as provided in more detail by an act, adequate social, health and medical services and promote the health of the population.
According to various indicators, the health of the Finns has considerably improved over the last few decades. Average life expectancy among the Finnish population has improved throughout the 20th century, and especially during the last three decades, reaching 76 years for men and 83 years for women in 2005. The most significant public health problems are currently circulatory diseases, malignant tumours, musculoskeletal diseases and mental health problems. Emerging problems are obesity, chronic lung diseases and diabetes, particularly type 2 diabetes. Total expenditure on health as a percentage of gross domestic product (GDP) in Finland was 7.5% in 2005. Health care expenditure expressed in US$ purchasing power parity (PPP) per capita was 2331, which was one of the lowest among the Organisation for Economic Co-operation and Development (OECD) countries. The Finnish health system is primarily funded through taxation (61%) and National Health Insurance (NHI). Total public sector funding as a percentage of total expenditure on health is 78%. In practice in Finland there are three different health care systems which receive public funding: municipal health care, private health care and occupational health care. There are significant differences between the systems, for example in the scope of the services provided, user-fees and waiting times. There are also different public financing mechanisms for health care services in Finland: municipal financing based on taxes and NHI financing based on compulsory insurance fees. Municipalities fund municipal health care services (except outpatient drugs and transport costs) and NHI funds for example private health care, occupational health care, outpatient drugs, transport costs, sickness allowances and maternity leave allowances. This dual public financing creates challenges for the overall efficiency of service production, particularly in pharmaceutical care where dual financing incurs cost-shifting problems. xvi
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The largest share of publicly financed health care is provided by the municipal health care system (71% of outpatient physician visits, 59% of outpatient dentists visits and 95% of inpatient care periods). According to legislation, more than 400 municipalities are responsible for providing all necessary health services for their residents. Municipalities have a significant degree of freedom to plan and steer the services as they see best, and state level steering is rather weak. Currently there are many ongoing local development projects and experiments concerning municipal services (for example increasing cooperation between municipalities, between primary and secondary care services and between municipalities and the private sector). However, they are not well coordinated from the national level, probably leading to increasing regional variance in structures. Public responsibility for health care has arguably been decentralized in Finland more than in any other European country, and in recent years, concerns have increasingly been raised that the problems of extreme decentralization outweigh the advantages. However, there are signs that the decentralization trend has slightly reversed and national level steering will increase. For example, the governmental programme for the restructuring of municipalities and services has a goal to decrease the number of municipalities and increase cooperation between municipalities. According to legislation, every municipality must have a health centre which provides primary health services. Additionally, legislation divides the country into 20 hospital districts (excluding Åland islands) which are responsible for the provision of municipal secondary care services. Each municipality must be a member of one hospital district. Hospital districts are financed and managed by the member municipalities. Often municipalities experience a lack of influence on the volume and costs of the hospital districts, despite the fact that they directly own them, and find that primary health care is in too weak a position relative to secondary health care. Legislation sets maximum user-fees and an annual ceiling for health care charges for municipal services. These user-fees cover on average 7% of municipal health care expenditure. Outpatient drugs are not covered by the municipal health care system, but by NHI instead. On average, 67% of outpatient drug costs are reimbursed to the patient. There is a (separate) ceiling for out-of-pocket payments for outpatient drugs. Both the municipal health care and outpatient drugs ceilings are high compared with other Nordic countries. In extreme situations social assistance is available (when an individual’s or a family’s income is not enough to cover the user-fees of municipal health care services or outpatient drugs). The statutory NHI scheme finances 17% of the total costs of health care. The scheme is run by the Social Insurance Institution (SII), with about 260 local offices all over the country. SII falls under the authority of the Parliament and
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covers all Finnish residents. NHI is funded by the insured (38%), employers (33%) and the state (28%). The insured pay income-based insurance fees which are collected alongside taxation. The use of private health care is partly reimbursed by NHI. It mainly comprises ambulatory care available in the larger cities. The private sector provides about 16% of outpatient visits to physicians, 41% of outpatient visits to dentists and 5% of inpatient care periods. NHI covers about one third of the actual costs of the private health services. Additional voluntary health insurance has a very marginal role in the Finnish health care system and is mainly used to supplement the reimbursement rate of NHI. Legislation on occupational health care obliges all employers to provide preventive occupational health care services for their employees. As part of compulsory preventive occupational health services, many large- or mediumsized employers also provide curative outpatient services (13% of outpatient physician visits are provided by the occupational health care system). The NHI scheme reimburses about 40% of the occupational health care expenses for the employer. Occupational health care services are free of charge for employees. The majority of physicians work for municipalities and hospital districts. Physicians in health centres and hospital districts are usually salaried employees of the municipalities. However, during the last 10 years a new trend has emerged to lease the physician workforce to health centres from private firms. Eleven per cent of physicians have a private practice as a full-time job and 30% work full-time in the public sector but hold a private practice outside their regular working hours. Since the late 1990s there has been a significant shortage of physicians in Finland, which has had a significant impact on the developments of the health care system. In order to rectify this situation the yearly intake of medical students has been increased considerably. The most important state level reforms from the beginning of the 1990s have been: • the deregulation of state steering of municipal health services and related changes in state administration (1993); • the National Project to Ensure the Future of Health Care (2002–2007); • the extension of public dental health care to all age groups (2002); • introduction of the waiting time guarantee (2005); • the project to restructure municipalities and services (ongoing since 2005); and
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• the development of the national electronic patient record system (ongoing since 2006). In addition, there have been several reforms concerning pharmaceuticals, with one important goal being to further promote cost containment. In terms of the distribution of benefits, there are two major challenges in the Finnish health care system: geographical inequities and inequities between socioeconomic groups. There are significant differences between municipalities in service provision (for example in physician visits, dental care, mental health care, elective surgery) and waiting times. There are also significant differences between municipalities in resources invested in municipal health care leading to differences in the quality and scope of municipal services. However, these inequalities can also partly be explained by other differences between municipalities such as age structure, morbidity rates and use of private and occupational health care services. There are also significant socioeconomic inequalities in the use of health care services. Among OECD countries pro-rich inequity in physician visits was found to be one of the highest in Finland (along with the United States and Portugal) in 2000. Significant pro-rich differences are also evident in screening, dental care, coronary revascularizations and in some elective specialized care operations (hysterectomy, prostatectomy and lumbar disc operations). Although overall mortality has fallen, the socioeconomic inequality in mortality seems to be increasing. The Finnish health care system offers relatively good quality health services for reasonable cost with quite high public satisfaction. The most visible problems are long waiting times and personnel shortage in some municipalities. An ageing population, new medical technology, drug innovations and increasing population expectations will create challenges for the Finnish health care system in the near future. There are also some structures in the Finnish health care system which are perceived as problematic: the level of decentralization, poor steering capacity in the system, relatively weak position of primary care, a lack of cooperation between primary and secondary care and dual financing.
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1. Introduction
1.1 Overview of the health system
I
n practice in Finland there are three different health care systems which receive public funding: municipal health care, private health care and occupational health care (Fig. 1.1 and Table 1.1.). Usually, employed persons have the possibility to choose between these. According to a population survey, about 45% of physician visits of employed people were in occupational health care, 35% in municipal health care and 15% in private health care (PerkiöMäkelä et al. 2006). For low-income unemployed people the municipal health care system is, in practice, the only choice. There are significant differences between the systems, for example in the scope of services, user-fees and waiting times. There are also different public financing mechanisms for health care services in Finland: municipal financing based on taxes and National Health Insurance (NHI) financing based on compulsory insurance fees (this is henceforth referred to as “dual financing”). Municipalities fund municipal health care services (except outpatient drugs and transport costs) and NHI funds, for example, private health care, occupational health care, outpatient drugs, transport costs and sickness allowance. The largest share of health care services is provided by the municipal health care system (71% of outpatient physician visits, 59% of outpatient dentist visits and 95% of inpatient care periods). In 2008 there were 415 municipalities in Finland, with a median number of inhabitants of 5000. Municipal health care services are financed by municipal taxes, state subsidies and user-fees. All municipalities are, by law (Primary Health Care Act), obliged to maintain health centres for the provision of primary health care services, either on their own or jointly through a local federation of municipalities. There were 237 health centres in Finland in 2007 (excluding Åland Islands). Practically all health
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Overview chart on health system Health insurance fee
Tax funding Parliament
Social Insurance Institution
Government
STAKES
Ministry of Social Affairs and Health Provinicial State Offices (5)
State owned hospitals (2)
The National Agency for Medicines
The National Authority for Medico-legal Affairs
Municipalities (415) Private companies for leasing professionals
Pharmacies (804)
Reimbursement for patient
Fig. 1.1
Finland
Private providers - for-profit hospitals - outpatient clinics - third sector, not-forprofit hospitals - call centres
Hospital districts (20) Health centres (237)
Specialist level hospitals
Municipal hospitals or inpatient wards
Employers (occupational health care)
Primary care/ health stations
Hierarchical relationship Contractual relationship
Funding Regulation
Note: STAKES: National Research and Development Centre for Welfare and Health.
centres have general practitioner (GP)-run inpatient units or an arrangement for using such beds in a nearby health centre. Municipalities with their own health centres usually use prospective budgets. In federation-owned health centres the budgets are built in a similar way but the sharing of costs between member municipalities is usually determined by the volume of services given. Physicians in health centres are usually salaried employees of the municipalities. The payment system of GPs in municipal health centres varies. Specialist level care in the municipal health care system is provided by 20 hospital districts. Each municipality must belong as a member to one of the hospital districts (Act on Specialized Medical Care). Each hospital district has one or several hospitals, of which one is a central hospital. The hospital district organizes and provides specialist medical services for the population of their member municipalities. Hospital districts are managed and funded by the member municipalities. Hospital districts have varied methods for collecting funding. The majority of funding collected is based on actual clinical services used. The population base of hospital districts varies from 65Â 000 to 1.4 million.
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Table 1.1
Finland
Services funded by public sources (municipalities and NHI) in 2005
Municipal health care Private health care Occupational health care1
Outpatient physician visits2 71% 16% 13%
Outpatient dentist visits 59% 41%
Inpatient care periods3 95% 5%
Occupational curative medical care Includes primary and secondary care 3 Inpatient care periods reported by the hospitals 1 2
Sources: SII 2007b, SII 2007a, STAKES 2006b, STAKES 2007b. Note: NHI: National Health Insurance.
Municipalities can also purchase health care services (primary health care services or specialized health care services) from other municipalities, other hospital districts, private providers or from the third sector. The Åland Islands are an autonomous Swedish-speaking region with 16 municipalities and 26 000 inhabitants. The Åland Government is responsible for providing health care services in the region. Services which are not provided in the region are purchased from Finland or Sweden. Seventeen per cent of the total cost of health care in Finland is financed by the statutory NHI scheme. The scheme is run by the Social Insurance Institution (SII, Finnish acronym KELA), with about 260 local offices throughout the country. SII falls under the authority of Parliament. The main funding to NHI comes from the state budget (28% in 2006), the insured (33%) and employees (38%). NHI covers part of outpatient drug costs, part of medical costs in the private sector, part of the costs of occupational health care, compensation of travel costs to health care units, sickness allowance and maternity leave allowance. Of services funded by public sources (municipalities and NHI), about 16% of outpatient visits to physicians, 41% of outpatient visits to dentists and 5% of inpatient care periods are provided by the private sector (Table 1.1). Employers are obliged to provide preventive occupational health care for their employees (under the Occupational Health Care Act). As part of occupational health care, many large- or medium-sized employers also provide curative outpatient services (13% of outpatient physician visits are provided by the occupational health care system). Occupational health services can be provided by the employer itself or the employer can purchase them from another employer (42% of expenses in 2004), or from the municipal health centres (16% of expenses), from private health care providers (29% of expenses) or from other sources (12% of expenses). The NHI scheme covers about 40% of the expenses (SII 2007b).
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Pharmacies are mainly privately owned by pharmacists. There were 804 pharmacies in Finland in 2006 (NAM 2007). They are regulated in several ways: their margins and prices are fixed by the Government, they cannot be owned by companies, and the National Agency of Medicines (NAM) decides in which locations pharmacies are placed and who runs them. Outpatient drugs are partly reimbursed by NHI. These reimbursements are paid mainly directly to pharmacies. The Ministry of Social Affairs and Health (MSAH) directs and guides social and health services at the national level. It defines general social and health policy, prepares major reforms and proposals for legislation, monitors their implementation and assists the Government in decision-making. The Government decides on general national priorities and proposes bills to be discussed by the Parliament. The lower level of state administration comprises five provinces plus the autonomous Ă…land Islands. The provincial state offices promote national and regional objectives of the central administration, and keep contacts with municipalities in their area. Their social and health departments are responsible for, among other things, guiding and supervising both municipal and private health care providers.
1.2 Geography and sociodemography Finland is an independent republic located to the north-east of the Baltic Sea. It is bordered by Norway to the north, the Gulf of Finland to the south, Sweden and the Gulf of Botnia to the west and the Russian Federation to the east (Fig. 1.2). Estonia is situated close to the south, across the Gulf of Finland. The Finnish language is closely related to the Estonian language and belongs to the Finno-Ugric language family. The land area is 338Â 145 km2. Some 68% of it is covered by forests, 10% by water, and 6% is under cultivation. The climate is marked by cold winters and warm summers where the Gulf Stream has some influence. Much of the country is sparsely populated, with an average population density of 16/km2. The bulk of the population is concentrated in the urban areas of the southern and western parts of the country, while roughly a third lives in rural areas. In 2005 the population of Finland was 5.26 million (Table 1.2). The majority of the population is Finnish speaking (92% in 2005) and Evangelic Lutheran (83%). Swedish is another official language in Finland (besides Finnish) and 5.5% of the population speaks Swedish as their first language. The Finnish population grew by about a quarter of a million per decade
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Fig. 1.2
Finland
Map of Finland
Source: CIA 2007.
during the 20th century, growth being rapid in the first half of the century and slowing down towards the end. People under 15 years of age constitute about 17% of the total population and those over 65 years some 16% (in 2005). The number of people aged 65 years or over is expected to grow by about 600Â 000 (i.e. by over 50%) in the next 15 years. Because of the ageing population, the economic dependency ratio (the number of non-employed relative to the number of employed) will become less favourable, particularly after the year 2015.
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Table 1.2
Finland
Population/demographic indicators, 1970–2005 (selected years)
Population (million) Population, female (%) Dependency ratio1 (%) Swedish speaking population (%) Population aged 0–14 (% of total) Population aged 65 and above (% of total) Population density (people per sq km) Single person households (%) Urban population (% of total population)2 Fertility rate, total (births per woman) Live births per 1000 population Death rate, crude (per 1000 people)
1970 1980 4.60 4.79 52 52 50.7 47.5 6.6 6.3
1990 1995 5.00 5.12 52 51 48.7 – 5.9 5.8
2000 2002 2004 2005 5.18 5.21 5.24 5.26 51 51 51 51 49.4 49.6 50.0 49.8 5.6 5.6 5.5 5.5
24.0
20.3
19.3
19.0
18.1
17.9
17.5
17.3
9.2
12.0
13.4
14.2
14.9
15.3
15.7
16.0
15.1
15.8
16.4
16.8
17.0
17.1
17.2
17.3
– 50
27.1 60
– 60
35.2 63
37.3 59
38.4 61
39.3 61
39.7 –
1.8
1.6
1.8
1.8
1.7
1.7
1.8
1.8
14.0 9.6
13.2 9.3
13.1 10.0
12.3 9.6
10.9 9.5
10.7 9.5
11.0 9.1
11.0 9.1
Sources: Statistics Finland, 2005; 2WHO Regional Office for Europe, January 2007. Note: 1proportion of the under 15 year-olds and over 64 year-olds from other population.
1.3 Economic context The Finnish economy is based on industry and services. Finland’s industry has traditionally been built on harnessing forest resources. Forests are still an important raw material but engineering and high technology, led by information technology, have now become other leading industries. Finland is relatively dependent on foreign trade. The main export products are electro-technological products, pulp and paper and machinery and equipment. The main import products are raw materials and other production necessities, investment goods and consumer goods. Between 1990 and 1993 Finland suffered a major economic recession. The economy shrank by almost 15% and massive unemployment emerged, the unemployment rate rising from 3.5% to 19% in the same period. The state had to finance many public sector activities by taking up a growing amount of debt. The economies of the municipalities also suffered from the crisis to various degrees. The recession was caused by a number of factors such as the global economic slowdown, the collapse of trade with the former Soviet Union, and sudden liberation of capital flows.
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Table 1.3
Finland
Macroeconomic indicators, 1996–2005 (selected years)
GDP (milion euro) GDP per capita (euro) GDP growth (annual %) Unemployment (% of labour force) Labour force (total, million) Poverty rate (less than 60% of median income %) Income inequality (GINI %)
1996 1998 2000 2002 2004 2005 99 258 117 111 132 272 143 974 151 935 157 377 19 367 22 727 25 555 27 682 29 066 30 005 3.7 5.2 5.0 1.6 3.5 2.9 14.6 11.4 9.8 9.1 8.8 8.4 2.49 2.51 2.59 2.61 2.59 2.62 8.3 9.7 10.4 11.0 11.9 12.3 22.1
24.6
26.5
25.5
26.5
26.5
Source: Statistics Finland, 2006b.
Since 1994, Finland has been recovering from the crisis (Table 1.3). By 2003, real GDP per capita (purchasing power adjusted) was close to the European Union (EU) average (members before May 2004, EU15). The state debt has decreased from the worst figures in the mid-1990s: in May 2007 it was 57 billion euros, about 10 800 euros per inhabitant and about 35% of GDP (before the recession in 1991 the state debt was less than 20% of GDP and peak of the debt was in 1998 when it was about 70 billion euros). The overall economic situation in the municipalities also improved after the mid-1990s but it has recently worsened again. In 2007 municipalities’ total debt was almost 9 billion euros, about 5% of GDP (about 4 billion euros in 2000). About 20% of the municipalities ran deficits in 2006. During the last 10 years unemployment has been reduced following the rapid growth in the national economy and the employment policy of the Government. In January 2008, the unemployment rate fell to 6.8%. Unemployment has become more polarized, however: those who have recently become unemployed usually find a new job rapidly, but the situation of those who have prolonged difficulty in finding work is becoming even worse. Also, the structural features of unemployment have become more obvious: the older long-term unemployed find it more and more difficult to become employed, and regional differences in unemployment have grown. The growing regional differences in unemployment can be observed in the continuing population drift from rural areas to the large cities in the south and west of Finland. This internal migration is the largest since the 1970s, when the previous large wave of internal migration was seen. There are between five and seven “growth centres” at present. Although there has generally been an increase in the number of available jobs almost everywhere in the country, the majority of new jobs are located in southern Finland. This, together with the changes in working life, such as the dwindling of traditional industries and
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unstable employment, are forcing working age people to move to the large cities in the south and west. At the same time, the proportion of old people is growing in the regions that are being abandoned. The financial basis for arranging basic services is likely to weaken as the number of working age people diminishes in these regions. Internal migration is also likely to lead to significant changes in social networks and possibly in the service structure in all regions.
1.4 Political context Having been under Swedish rule for 600 years and then under Russian rule for 100 years, Finland became an independent republic with its own constitution in 1917. After that, the country’s development was influenced by two wars: the civil war and later the Second World War. The Finnish public administration system consists of three levels: state, province and municipality. The provinces are actually regional representatives of the central state administration. Their administrators are appointed by the state; they do not have any democratically elected organs. Finland is divided into five administrative provinces and the Åland Islands, the latter having autonomous status. Finland has a Constitution (latest major review in 2000). Power in Finland is vested in the people, who are represented by deputies assembled in Parliament. Legislative power is exercised by Parliament, the President of the Republic having a minor role. The Council of State (the Government) consists of a Prime Minister and a requisite number of ministers. Judicial power is vested in independent courts of law, at the highest level in the Supreme Court and the Supreme Administrative Court. The head of state is the President of the Republic, who is elected for a period of six years by direct popular vote. In practice, the President’s power in political areas other than foreign policy is limited; but the power to accept laws and to appoint senior civil servants does incorporate the potential for acts of political significance. For the first time in Finnish history, a female president, Mrs Tarja Halonen, was elected in March 2000 and re-elected in March 2006. The Parliament has a single chamber of 200 representatives, elected for a fouryear term by direct popular vote. Parliament has three main functions through which it represents the people and makes basic decisions on Finnish policy. It passes laws, it debates and approves the national budget and it supervises the way the country is governed. Passing laws is a complicated process that usually begins with the Government placing a bill before Parliament. To be passed, a bill must have the support of a majority in Parliament and it must
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be signed by the President of the Republic. Finland’s presidents have refused to sign a law once a year on average. Moreover, Parliament may approve the same law again after it has been rejected by the President. If this happens, the President must then sign it. After the parliamentary elections in March 2007, the seats were divided among the political parties as follows: the Finnish Centre Party, 51 seats (23% of votes); the National Coalition Party, 50 (22%); the Finnish Social Democratic Party, 45 (21%); the Left Wing Alliance, 17 (9%); the Green Party, 15 (9%); the Swedish People’s Party, 9 (5%); the Finnish Christian Union, 7 (5%) and the True Finns Party, 5 (4%). The Government must enjoy the support of a majority in Parliament. The Parliament elects the Prime Minister (who is then formally appointed by the President). Other ministers are appointed by the President under the proposal of the Prime Minister. The Government is the executive body that produces material for Parliament to consider, for example the bills placed before Parliament. The Government (and different ministries) can enact lower level decrees in certain cases. Since the voting system is proportional, no single party can form a majority to govern, which leads to coalitions, and relative stability of the political system. The present Government, formed in April 2007, is a coalition of the Finnish Centre Party (eight ministers), the National Coalition Party (eight ministers), the Green Party (two ministers) and Swedish People’s Party (two ministers). The Prime Minister is Mr Matti Vanhanen (the Finnish Centre Party). Mr Matti Vanhanen was also the Prime Minister of the previous Government, which was a coalition consisting of the Finnish Centre Party, the Social Democratic Party and the Swedish People’s Party. Closest to the people are the 415 self-governing municipalities, which are all governed according to uniform national legislation. Many responsibilities, including primary education and the social and health services, are devolved to the level of municipalities. The tradition of devolving responsibility to municipalities has a long history in Finland, evolving over several centuries. In the municipalities the municipal councils are the main decision-making bodies. They are elected for a four-year term. Municipalities levy a municipal income tax, the rate being decided independently by each municipality (it varies from 16% to 21% of taxable income, and between 17.5% and 19% in the 10 largest municipalities). Municipalities also receive other tax revenues (real estate tax and part of the corporate tax), subsidies paid by the state and other revenues (such as user-fees). Municipalities and joint municipal organizations account for almost two thirds of all public expenditure in Finland. Most of the
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municipalities’ expenditure arises from arranging basic services such as social and health services, primary education, cultural services and infrastructure. Cooperation with the other Nordic countries – Denmark, Iceland, Norway and Sweden – has long existed and covers a large number of issues, ranging from social and cultural to technical matters. Finland became a member of the EU in 1995. This membership gave new duties and roles to the political institutions, and in many instances national legislation has had to be amended to correspond with EU legislation. The impact of EU membership on the Finnish economy is difficult to evaluate, as many other factors such as the preceding economic recession also had an influence. Finland was one of the first countries to enter the third stage of the Economic and Monetary Union in 1999. Finland is also a member of the United Nations, the Council of Europe and the World Trade Organization. Finland is not a member of the North Atlantic Treaty Organization. The human rights situation in Finland is relatively good. Corruption is rare in Finland and Finland is the least corrupted country in the Corruption Perception Index held by Transparency International (TIN 2007). Although the human rights situation is considered to be good in Finland, some problems have been identified. Human Rights Watch has been worried about Finland’s stockpile of landmines which are intended to be used during war. Amnesty International has focused on the problem that Finnish men who refuse to take part in the system of compulsory military service or replacement civilian service because of ethical reasons are sentenced to imprisonment (Amnesty International 2007). Amnesty International has also drawn attention to the practice where in some cases of problematic deportation of refugees, officials in Finland have administered sedating and neuroleptic medication without proper examination by a medical doctor (Amnesty International 2004).
1.5 Health status According to various indicators, the health of the Finns has considerably improved over the last few decades. Average life expectancy among the Finnish population has improved throughout the 20th century, especially during the last three decades. In the 1950s and 1960s, mortality among Finnish men was notably high when compared to international standards, mainly due to the high prevalence of coronary heart disease. Life expectancy has grown considerably since then, to 76 years for men and 83 years for women in 2005 (Table 1.4). During the 1980s and 1990s the improvements in life expectancy in Finland were mainly due to 10
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Table 1.4
Finland
Mortality and health indicators, 1970–2005 (selected years)
Life expectancy at birth, total (years) Life expectancy at birth, male (years) Life expectancy at birth, female (years) Crude death rate per 1000 population, female Crude death rate per 1000 population, male Infant deaths per 1000 live births
1970 1980 70.4 73.7 66.2 69.2 74.5 78.0 8.5 8.4
1990 75.1 71.0 79.1 9.8
1995 76.8 72.9 80.4 9.6
10.7 10.3 10.4
9.8
9.5
13.2
4.0
3.6
7.6
5.6
2000 2003 77.9 78.7 74.3 75.2 81.3 82.1 9.5 9.4
2004 79.0 75.4 82.5 8.9
2005 79.4 75.8 82.7 8.9
9.4
9.3
9.3
3.2
3.3
3.1
Source: WHO Regional office for Europe, January 2007.
the decline in mortality amenable to health care (avoidable mortality), especially in mortality from ischaemic heart disease, although in the 1990s the contribution of avoidable mortality was somewhat smaller (Nolte and McKee 2004). The potential years of life lost (PYLL) rate has lowered in Finland between 1992 and 2004 by approximately 25% (Vohlonen, Bäckmand, Korhonen 2007). In 2002 healthy life expectancy in Finland was 71.1 years (Table 1.5). In a comparative study by Nolte and McKee (2003) using an aggregate measure of avoidable mortality (not including deaths from ischaemic heart disease) from the year 1998, Finland ranked middle among 19 countries of the OECD, performing worse than for example Sweden and Norway. Infant mortality has also decreased rapidly over the last 30 to 40 years. At the beginning of the 1970s, almost 15 out of every 1000 newborn infants died; since the mid-1990s the rate has been less than 5 per 1000 newborns, one of the lowest in the world. There are still significant differences in mortality and health between groups with different socioeconomic status, education, marital status, gender and geographical regions. Differences between socioeconomic groups and marital status groups are increasing while differences between genders are decreasing (Martelin, Koskinen, Lahelma 2006). The average life expectancy of a white collar worker male aged 35 years is six years longer than that of a manual worker of the same age; for women the corresponding difference is smaller (three years). The largest minority in Finland are Swedish speaking people, who comprise 5.5% of the Finnish population. It has been found that Swedish speaking people living on the west coast are healthier than Finnish speaking population living in the same area (Hyyppä and Mäki 1997). The most significant public health problems are circulatory diseases, malignant tumours, musculoskeletal diseases and mental health problems (Table 1.6). Emerging problems are obesity, chronic lung diseases and diabetes, particularly type 2 diabetes. 11
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Table 1.5 Healthy life expectancy, 2002 Total population At birth 71.1 Males At birth 68.7 At age of 60 15.7 Females At birth 73.5 At age of 60 18.9 Source: World Health Report, 2004.
According to the national health survey (Helakorpi et al. 2008) in 2007 68% of the 15–64 year old population reported having good or reasonably good health status. In the Health 2000 Study 43% of all working age people and 80% of people aged over 64 reported at least one long-term illness in 2000 (Aromaa and Koskinen 2002). According to the survey for school aged children in 2003, about 9% of 12 to 18 year-olds had a long-term illness which had an influence on everyday activities (Rimpelä et al. 2004). In 2006 about 7% of the working age population had a disability pension (ETK and KELA 2007b) and in 2007 19% of the working age population in Finland reported themselves as having restricted capacity to work because of illness or disability (Helakorpi et al. 2008). Cardiovascular diseases made up 41% of all causes of death in 2005 (compared to 52% in 1983) (Statistics Finland 2006a). The incidence and mortality from coronary heart disease increased at the end of the 1960s, but has significantly dropped since then. Among working age people age-standardized mortality from coronary heart disease dropped more than 50% between 1984 and 2005 (Statistics Finland 2006a). The annual number of myocardial infarctions has decreased during the last 10 years, especially among the working age population. According to the national health survey 16% of 15 to 64 year-olds reported having high blood pressure and 14% having a high blood cholesterol level in 2007 (Helakorpi et al. 2008). This positive development is due, inter alia, to changes in lifestyle (e.g. reduced smoking rates and nutritional habits) and improved medical treatment. Regional and social group differences in mortality from coronary heart disease still persist. For example, age-standardized coronary heart disease mortality is significantly greater among men in eastern Finland than in western and southwestern Finland. Mortality from ischaemic heart disease among working age men was more than six times greater than among working age women in 2005 (Statistics Finland 2006a). 12
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Table 1.6
Finland
Main causes of death (underlying cause of death, deaths per 100 000)
1985 1990 1995 2000 2004 2005 I. Communicable diseases: Infectious and parasitic diseases (A00-B99, J65) 7.6 8.6 7.5 7.6 6.5 7.0 Tuberculosis (A15-A19, B90, J65) 3.6 3.6 2.6 2.5 1.3 0.0 II.
Noncommunicable conditions: Circulatory diseases (I00-I425, I427-I99) Malignant neoplasms (C00-C97) Trachea/bronchus/lung cancers (C32-C34) Respiratory diseases (J00-J64, J65-J99) Dementia, Alzheimer’s disease (F01, F03, G30, R54) Digestive diseases, excluding alcohol-related diseases Alcohol-related diseases
III. External causes (V01-X44, X46-Y89)
515.3 480.2 443.0 411.2 373.7 373.8 193.6 196.4 196.6 197.5 199.7 201.5 43.3 39.9 37.4 36.3 36.3 37.6 77.9 75.0 73.5 82.9 56.5 46.9 20.4 44.8 56.2 67.2 75.4 78.8 23.2
26.4 27.6
26.8
25.8
26.2
15.7
23.2 23.3
28.5
35.4
38.2
72.1
87.1 77.3
72.1
73.7
71.4
Source: Statistics Finland, 2004.
Cancer is the second most common cause of death after circulatory diseases. More than one in four Finns suffer from cancer at some stage in life. Ageadjusted incidence rates of cancer increased by 10% among males and 21% among females during the last 20 years (Cancer Society of Finland 2005), while age-standardized cancer mortality somewhat decreased during the same period (Statistics Finland 2006a). Stomach and cervical cancer mortality particularly have experienced significant decreases, while mortality due to melanoma and liver cancers has increased. Mortality from prostate cancer has remained constant and mortality from breast cancer has increased only moderately. The most common types of cancer among men are prostate cancer (34% of new cancer cases in 2003) (Cancer Society of Finland 2005), lung cancer and colorectal cancer. The most common types of cancer among women are breast cancer (32% of new cancer cases in 2003), colorectal cancer and uterine cancer. The prognosis of cancer patients has continuously improved. During the last 20 years, five-year relative survival rates have improved among males from 34% to 56% and among females from 49% to 65% (Cancer Society of Finland 2005). The most common reason for claiming sickness allowance – 33% of sickness periods in 2006 – is musculoskeletal diseases (SII 2007c). Almost half of sickness periods were due to back disorders and one fourth due to osteoarthritis. According to the national health survey, 11% of the population aged 15 to 64 years had back problems in 2007 (Helakorpi et al. 2008). According to another study conducted in 2000, about 6% of the population over the age of 13
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30 suffered from osteoarthritis of the knee (35% of women and 46% of men over 85 years) (Aromaa and Koskinen 2002). The number of people suffering from musculoskeletal diseases is expected to increase because of the ageing of the population, diminishing physical exercise and increasing overweight. Improved diagnostic and therapeutic methods also reveal an increasing range of musculoskeletal diseases. According to Helakorpi et al. (2008), 6% of the working age population suffered from depression diagnosed by a physician in 2007. This was more common among women. Mental health disorders as a reason for sickness day allowance and disability pension have increased during the last 10 years. In 1992, 32% of all persons claiming disability pensions did so because of a mental health disorder compared to 43% in 2005 (ETK and KELA 2007a). Mental health disorders were the second most common reason for sickness day allowance, comprising 16% of sickness day allowances (SII 2007c). Allergies and asthma are rapidly growing health problems in Finland. About 5% of the working age population suffered from asthma diagnosed by a physician in 2007 (Helakorpi et al. 2008). Eczema is also a common problem (prevalence is about 17% of the working age population in 2007). According to the Health 2000 survey, 0.7% of men over the age of 30 and 0.3% of women had type 1 diabetes in 2000 (Aromaa and Koskinen 2002). In 2001, the incidence among under 15 year-olds was 56/100 000 (Karvonen 2004). Type 1 diabetes is more common in Finland than in any other country in the world. During the last decades the incidence has increased steadily (from 18/100 000 in 1965 at a rate of 3.5% per year). The reasons for this increase are mainly unknown, but currently under intensive study. The prevalence of type 2 diabetes is also fairly high compared to other western countries. In the Health 2000 survey, 4.4% of males and 3.0% of females over the age of 30 had type 2 diabetes in 2000 (Aromaa and Koskinen 2002). It is estimated that during the years 1969 to 2003 the number of type 2 diabetes patients increased from 50 000 to 190 000 (Reunanen 2004). If people that are unaware of their condition are included, the current figure is estimated to rise to 400 000 which is 12% of the population aged 30 years or older. With the ageing of the population, dementia will gain more importance as a public health problem. It is estimated that there are about 110 000 patients with some form of dementia (Soininen 2005). Mortality from dementia increased from 20.4/100 000 in 1985 to 78.8/100 000 in 2005 (Table 1.6). However, part of this is due to changed practices of classifying dementia as the underlying cause of death. Suicide mortality in Finland has generally been one of the highest in Europe. Suicide rates were highest towards the end of the 1980s, when the Finnish 14
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economy was booming, being almost 30 per 100 000 population in 1990. The trend has been decreasing since then, being 18 per 100 000 population in 2005 (Statistics Finland 2006a). One reason for this may be the large national suicide prevention project which was carried out between 1986 and 1996. The number of abortions fell from a peak of over 23 000 in 1973 to 10 900 in 2005 (9.3 per 1000 women of childbearing age and 190 per 1000 life births) (STAKES 2006b). The number of abortions among females in the age group 15–19 years was 14.9 per 1000. The abortion rate in Finland is the lowest among Nordic countries. Keeping abortion rates low by employing a variety of measures through school and maternity health services and general arrangements of family planning has been a high priority for decades. One of the major changes in the lifestyle of Finnish people during the last decades is the change in dietary habits. One example of this change is the more frequent use of margarine instead of butter on bread. Twenty years ago more than 60% of people used mainly butter on bread while in 2007 this figure fell to only 4% of men and 3% of women (Helakorpi et al. 2008). Also, use of low fat milk, vegetables and vegetable oil in cooking has significantly increased (Table 1.7). Nevertheless, being overweight remains an increasing problem in Finland. In 2006, 55% of men and 41% of women were overweight (compared to 42% and 31% between 1978 and 1982). The prevalence of smoking among men has fallen since the 1960s, but among women the prevalence has been rather stable. 18% of working age women and 23% of working age men were daily smokers in 2006 (Table 1.7). During last the 20 years alcohol consumption has risen from 7.6 litres (in 1985) to 10.5 litres, 100% alcohol equivalent per capita in 2005 (the figure includes both recorded and estimated unrecorded consumption) (STAKES 2006d). This is an average level for western industrialized countries. Anticipating the EU membership of neighbouring Estonia in 2004, under the EU free market regulations, Finland decided to lower the alcohol tax in 2003, in order to smooth over great price differences and to counteract expected large imports and ensuing loss of alcohol taxes. It seems that partly because of this, alcohol consumption rose by 10% between 2003 and 2004 (STAKES 2006d). According to a survey conducted in 2007, 28% of men and 9% of females consumed six or more doses of alcohol (one dose is equivalent of 4cl of 40% spirit) on one occasion at least once a week (2.9% and 0.6% almost daily) (Helakorpi et al. 2008). The number of heavy drinkers is estimated to be between 250 000 and 500 000 (STAKES 2006d). In 2005, about 2000 people died from alcohol intoxication or due to an illness related to alcohol consumption (29% increase from 2003). Alcohol-related death is the second most common cause of death among working age men and women. Alcohol use among young people 15
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Table 1.7
Factors affecting health status (working age population)
Males Overweight (BMI>25) Leisure-time physical excercise (at least twice a week) Daily smokers Use of skimmed or semi-skimmed milk Use of mostly vegetable oil in cooking Daily consumption of fresh vegetables Females Overweight (BMI>25)
Finland
Leisure-time physical excercise (at least twice a week) Daily smokers Use of skimmed or semi-skimmed milk Use of mostly vegetable oil in cooking Daily consumption of fresh vegetables
1978– 1983– 1988– 1993– 1998– 2002– 2006 2007 1982 1987 1992 1997 2001 2005 42% 44%
43% 48%
46% 50%
50% 58%
52% 60%
55% 60%
55% 63%
57% 67%
35% 4%
33% 6%
33% 18%
29% 30%
28% 36%
27% 39%
24% 43%
26% 46%
7%
7%
26%
32%
41%
45%
46%
46%
16%
20%
24%
27%
28%
28%
29%
30%
31% 42%
31% 45%
31% 52%
35% 60%
36% 63%
38% 66%
41% 68%
43% 73%
17% 6%
18% 11%
20% 27%
19% 37%
20% 42%
19% 47%
19% 53%
17% 52%
8%
10%
29%
35%
44%
49%
53%
53%
23%
28%
35%
39%
45%
44%
48%
47%
Source: Helakorpi et al. 2008. Note: BMI: Body mass index.
is also common. According to the school survey conducted in 2005 among 14 year-olds, 4% of boys and 6% of girls drank at least once a week (among 16 year-olds, 19% of boys and 15% of girls drank at least once a week) (STAKES 2006d). According to statistics, alcohol consumption per capita is highest in the northern part of Finland (Lapland). Oral health has improved markedly during the last 30 years, especially among children and adolescents. Since the early 1970s when the Primary Health Care Act came into force, children and adolescents have attended oral health check-ups regularly. This policy seems to have been effective. In 1976, only 1% of 12 year-olds had healthy teeth, whereas in 2000 the corresponding figure was 38% (Nordblad et al. 2004). Among the same population the number of decayed, missing or filled teeth decreased from 5.2 to 1.3 between the years 1979 and 2003 (Table 1.8). The number of annual dental fillings halved between the years 1985 and 2000 among children and adolescents under 18 (Nordblad et al. 2004). 16
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Table 1.8
Finland
Dental health
1978– 1983– 1988– 1993– 1998– 2002– 2006 2007 1982 1987 1992 1997 2001 2005 No missing teeth (working age population)1 22% 29% 36% 41% 46% 48% 50% 50% DMFT at age 12 years (mean value)2 5.2 2.8 1.2 1.2 1.2 1.2 Source: 1Helakorpi et al 2008; 2OECD, 2007. Note: DMFT: Decayed, missing or filled teeth (years 1979, 1985, 1991, 1994, 1997, 2000, 2003).
Until the early 1990s, drug abuse was not a major problem in Finland, but there has been a rapid rise in the use of drugs since then. However, the increase has slowed during last few years. Also crimes related to illegal drugs have increased during the last 10 years. In 2004, 12% of 15–69 year-olds had used or tried cannabis and 3% of them had used it during the last year (STAKES 2006d). About one fifth of 15–34 year-olds has tried cannabis at least once. The use of other illegal drugs in Finland is less common. Amphetamine is the second most commonly used illegal drug in Finland. In 2004, about 1–2% of the adult population had tried amphetamine or ecstasy, and 0.5% during the last year (STAKES 2006d). Based on data from several registers (the Hospital Discharge register; a register of the Finnish Police; the National Communicable Disease Register; and the register of people driving a motor vehicle when intoxicated), it is estimated that in 2005 between 0.5% and 0.7% of 15–54 year-olds had a problem with opiate or amphetamine use (Partanen et al. 2007). This figure increased between 1999 and 2005, the problem being most common among men, among 15–34 year-olds and in the metropolitan Helsinki area. According to the ESPAD survey (The European School Survey Project on Alcohol and Other Drugs), 11% of 15–16 year-olds had tried some illicit drugs in Finland in 2003 (STAKES 2006d). Vaccination coverage is good in Finland (see Fig. 1.3 for measles). Ninetythree per cent of children born in 1999 had all the vaccinations included in the national vaccination programme in 2005 (Joensuu et al. 2005). The national vaccination programme was last revised in 2006, when vaccination against tuberculosis was removed, now being given only to children at risk. In the current national vaccination programme all children are vaccinated against diphtheria, tetanus, pertussis, measles, mumps, rubella, polio and Hib. The measles, mumps and rubella vaccination was included in the programme in 1982 and 12 years later Finland was the first country in the world to have eliminated these diseases. In the late 1990s, only sporadic cases of these diseases were seen in Finland (the infections were acquired from foreign countries). Hib vaccination is a similar success story. 17
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Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) has not been a major problem in Finland. In late 1990s, HIV incidence among intravenous drug users increased dramatically, but after that incidence has been rather stable (130–140 new infections a year). However, in 2006 incidence increased again by 39% (191 new cases of HIV were diagnosed in 2007), this time due to infections from sexual relationships. In February 2008, the total number of HIV positive cases identified in Finland was 2279 (National Public Health Institute). Road traffic deaths and injuries have significantly decreased in the last 15 years. In 2004, there were 6.5 deaths due to land traffic accidents per 100 000 population, compared to 14.1 in 1990 (Statistics Finland 2006a). Finland has actively, and rather successfully, tried to reduce deaths and injuries from road traffic accidents. For example in the late 1980s, it became law for back seat passengers to wear a seatbealt and in the early 1990s winter time speed limits were expanded to apply to the whole country.
18
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Fig. 1.3
Finland
Levels of immunization for measles in the WHO European Region, 2005 or latest available year (in parentheses) Western Europe
Monaco (2004) Andorra (2004) Finland Spain Netherlands Israel Sweden Luxembourg Denmark San Marino Germany Portugal Turkey Austria Norway Iceland Greece (2004) Belgium Italy Cyprus Malta France (2004) Ireland United Kingdom Switzerland Central and south-eastern Europe Hungary (2004) Poland Slovakia Lithuania Albania Czech Republic (2004) Romania The former Yugoslav Republic of Macedonia Bulgaria Estonia Serbia Croatia Latvia Slovenia (2004) Bosnia and Herzegovina CIS Kazakhstan Uzbekistan Belarus Turkmenistan Kyrgyzstan Russian Federation Azerbaijan Republic of Moldova Ukraine Armenia Tajikistan Georgia Averages CIS average EU average EU Member States before May 2004
99.0 97.6 97.0 96.8 96.3 96.0 95.4 95.4 95.0 94.1 93.3 92.6 91.0 91.0 90.0 90.0 88.0 88.0 87.2 86.3 86.0 86.0 84.2 82.1 82.0 99.9 98.2 98.0 97.2 97.2 96.9 96.7 96.4 96.2 95.9 95.6 95.5 95.0 94.0 90.0 100.0 99.3 99.0 99.0 98.9 98.6 98.2 96.9 95.7 94.1 94.0 91.6 98.0 91.3 89.7
70
80
90
100
Percentage
Source: WHO Regional Office for Europe, January 2007. Note: CIS: Commonwealth of Independent States. 19
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2. Organizational structure
2.1 Historical background
T
he organization and financing of health care services has long been considered a public responsibility in Finland. Municipalities have been responsible for providing basic medical services since the 1870s (Mattila Y 2006). Taxation developed as the principle method of collective funding from that time, until the introduction of statutory NHI in the 1960s. Before the Second World War, municipalities concentrated mainly on public health and the treatment of tuberculosis, other communicable diseases and mental health. After the War, a new act was introduced to regulate municipal health care services. According to the act, every municipality had to contract GPs, midwives and public health nurses, usually providing them with facilities and accommodation. Most of a GP’s income came from payments from patients, but midwives and public health nurses were salaried. As the overall number of doctors was small, they had to handle a wide variety of health problems. The right to maternal and child health care was fixed in law in 1944, irrespective of residence and financial situation. The provision of hospital care was fairly modest in the first half of the 20th century. Before the 1950s, the hospital network was rather fragmented and general hospitals, psychiatric hospitals and tuberculosis hospitals were separate. Some of the hospitals were state owned while others were managed by municipalities or a group of municipalities. Hospital physicians’ income was based on a monthly salary. In 1950 there were 10 000 beds in general hospitals, 9000 beds in psychiatric hospitals and 6000 beds in tuberculosis hospitals. The development of the hospital system was given a major push in the 1950s. The responsibility for central hospitals was transferred to municipalities. Municipalities received a state subsidy to run them. During the 1950s and 1960s, the number of hospital beds in general hospitals tripled. Later, in the 1960s, 24 21
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new district hospitals were built (generally smaller than central hospitals) on the initiative of municipalities. These hospitals were by definition small scale specialist hospitals. As tuberculosis became less of a concern, tuberculosis hospitals were either closed down or transformed to become part of general specialist services of the district. Management of psychiatric hospitals was transferred to federations of municipalities in the 1950s. Hospitals were at that time divided into two categories, acute and long stay hospitals. Between the 1950s and 1970s the number of beds in psychiatric hospitals doubled. The volume of beds per population at that time has been cited to have been the highest in Europe, about 4 beds per 1000 population. At that time psychiatric hospitals catered for large numbers of demented elderly patients, for persons with learning disabilities and for persons with substance abuse problems. In the 1950s and 1960s, the majority of public expenditure on health care was allocated to hospitals and a significant imbalance between hospital care and outpatient care developed. Almost 90% of total public health care expenditure was spent on hospital care and only 10% on what was then primary care. A network of specialized hospitals with high standards existed, but the supply of outpatient services and primary health care was insufficient. In addition, ambulatory care by municipal doctors was quite expensive for patients compared to hospital care, mainly because the state subsidy to ambulatory health care was small. In order to rectify the imbalance between inpatient and outpatient care the NHI scheme was introduced in 1963. All inhabitants were covered by this mandatory scheme. Part of the costs of drugs, medical care and some other services were reimbursed through the scheme. It also included sickness day and maternity allowance (see section 3.2.2.3). Before this, only workplace-related voluntary relief funds had provided this type of insurance coverage, covering only a small proportion of the population. Despite the introduction of NHI there remained striking inequities in the availability of health services, since most of the services were concentrated in urban areas. Furthermore, the scheme excluded funding for health promotion and prophylactic measures, such as family planning and vaccination. The imbalance between primary and secondary health care persisted. Consequently, there was a clear need to improve the situation. There was also political will to develop health care, and the stable growth in the national economy secured the necessary resources. All these factors led to the introduction of new policies around the beginning of the 1970s. Firstly, a national planning system for primary health care with a rotating five-year plan that was annually updated was introduced. 22
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This system of strong state level steering was reinforced through state subsidies, which covered about 40% to 70% of the operating expenses of tax-funded health services. Besides the state subsidy for operating costs, the state also quite generously funded the building and equipping of facilities. Furthermore, a new system of primary health care was established through the Primary Health Care Act in 1972 (see 10.2 in the appendices for a list of principal legislation relating to health care in Finland). This new legislation introduced municipal health centres as the foundation of primary health care, with the objective of offering primary care services free of charge. At first, the health centres were organizations that assembled the previously dispersed and fragmented services under one administrative roof. Later in the 1970s and 1980s physical roofs materialized, as building of the facilities proceeded. The tasks of primary health care were then defined by law to be: primary medical care; a variety of preventive services; home nursing; family planning; dental care; and environmental health services. Some years later occupational and student health services and rehabilitation were added to the list. This all now amounts to an internationally unique network of health centres with perhaps the broadest scope of services and also the largest multi-professional teams at their service. Income of physicians in health centres is based mainly on a monthly salary. The number of doctors in primary care tripled during a few years in the 1970s. As a transitory measure a small nominal user charge was kept for about 10 years for non-preventive services for adults. Following an impassioned national debate, user-fees were reintroduced in 1993 during the economic recession (see section 3.3.3). The building of the first municipal health services was focused especially in the rural areas around local small GP-run hospitals (described henceforth as “inpatient wards”) and the GPs’ offices. This legacy has led to a very distinctive feature of Finnish health centres: the majority of them still have GP-run inpatient wards. One reason for having, and retaining, these small inpatient wards was the long travelling distance to specialist level hospitals. Many remote municipalities cherished them as sites providing versatile services, which in the 1970s and 1980s provided some basic operative and obstetric care. GPs working in health centres ran these inpatient wards along with outpatient clinics without any special training. Gradually, however, most of the operative care was transferred to specialist level hospitals and the inpatient wards became a fundamental part of chronic nursing home type care (see section 6.3). In the 1970s and 1980s, increasing attention was also paid to occupational health care, with the aim of extending it to all workers. The introduction of the Occupational Health Care Act in 1979 obliged employers to provide occupational health services to their employees. Special attention was given to preventive measures. Between 1964 and 1995 occupational health care coverage 23
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increased from 20% to 80% of the workforce. Curative services were soon added to the occupational health services through agreements between labour unions and employers and through channelling sickness insurance reimbursement for these services (see section 3.2.2.4). Hospital care was included in the national planning of public sector health care in 1974, and in 1984 new legislation brought certain social services (for example, children’s day care and homes for the elderly) into the same planning and financing system as health care. Since then, the collaboration of social and health care has been emphasized at both local and national levels. In the 1970s, the main focus of dental care at health centres was on children and adolescents, and strong emphasis was placed on prevention. Dental care in schools also existed before the Primary Health Care Act. Gradually, the scope of dental care widened to, for example, conscripts, pregnant women and students, and finally in 2002 dental services were offered to the whole population (see section 6.10). Until the end of the 1980s, the development of the Finnish health service was marked by continuous growth and differentiating of services. Regional differences in the supply and availability of services diminished and the quality of services improved. One of the measures undertaken in this period to improve access and continuity of care was the introduction of the “personal doctor” system in 1986 (the direct translation from the Finnish word would actually be “my own doctor”). Municipalities have had the freedom to choose whether to implement the new system. The traditional system is that appointments are made to any physician in the health centre who is available. In the personal doctor system, a person or a family is assigned to one health centre doctor, usually on the grounds of their place of residence, and physicians are paid a combination of a basic salary, capitation payment and fee-for-service payment for visits. Currently, approximately half the physicians working in health centres belong to the personal doctor system (see section 6.3). In the 1980s, the balance in mental health care started to shift more towards outpatient care and the number of beds in psychiatric hospitals gradually decreased, while resources to outpatient care increased. This trend continued in the 1990s, the number of beds in psychiatric hospitals reducing by 50% between 1990 and 2003. The previously high volume of psychiatric beds was brought to the average European level of about 1 bed per 1000 population. However, the supply of outpatient services did not grow sufficiently and outpatient resources diminished (Lehtinen et al. 2006), partly because of the economic recession in early 1990s (see section 6.9). Until 1991 general hospitals, psychiatric hospitals and former tuberculosis hospitals each had different organizational structures. In 1991, a new act on 24
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specialist level care and on hospital districts (Act on Specialized Medical Care) resulted in the creation of the current multi-purpose hospital districts, which are owned and operated by federations of municipalities. According to the new law every municipality is required to be a member of one of the hospital districts. During the late 1980s and 1990s, state regulation gradually decreased. From 1993 onwards, a package of changes in legislation, planning and financial incentives was introduced, which increased decentralization (Häkkinen 2005; Häkkinen and Lehto 2005). The main objective was to create economic incentives for municipalities to improve the efficiency of services. In a nutshell, the reforms brought about three major changes: redesign of the state subsidy system; relaxation of the rules on service provision; and decentralization of detailed planning. Firstly, the redesign of the state subsidy system meant that the old retrospective and earmarked payments for primary and specialist level care, which were guaranteed to be paid as long as the costs were for services approved in rolling five-year plans, were replaced by a new system in 1993. The new state subsidies are prospective and capitated needs-based (mainly sociodemographic) payments (see section 3.3.1.1). The new state subsidies are now paid to the municipalities instead of municipal service providers, such as health centres or hospitals. Secondly, related to this, in 1993 a new ruling in the law meant that municipalities were given the possibility of purchasing services from private providers. However, purchasing services from private providers was initially very rare since it was more economical to purchase specialist level services from the hospital district, partly because the municipality was in any case obliged to pay hospital district membership fees. Purchasing from private providers increased only in more recent years (see section 3.5.1). Thirdly, the reforms led to the decentralization of detailed planning of health services to the municipalities and to municipal federations (see section 4.1.2). In 1993, the state gave up its earlier regulatory power and concentrated on setting general policy objectives and also on what is known as “guidance by information”. Guidance by information encompasses policy recommendations based on research and evaluation, through the development of national statistics and registers and other performance indicators (see section 4.1.1). The main agency for the administrative regulation of health care (the National Board of Health) was dismantled. The dismantling of the National Board of Health was linked to a major reform in the state administration of social welfare and health at the beginning of the 1990s. The rationale was the simplification and streamlining of social and health administration, and the strengthening of social and health policy at 25
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the ministerial level. In 1991, the National Board of Health and the National Board of Social Welfare, which until then had both been important in guiding state administration, were amalgamated into one organization and soon thereafter abolished (in 1992). By this process, several new state agencies and institutions subordinated to the MSAH emerged (see section 2.2.2). They took over some of the tasks that had previously been the responsibility of the two national boards: the NAM was founded to supervise pharmaceutical products; the National Authority for Medico-legal Affairs (NAMLA) to assure the quality of health care services through supervision of health care professionals; and the National Research and Development Centre for Welfare and Health (STAKES) to conduct research and development to promote health and social care planning and development. The reforms in the Finnish health care system in the 1990s were accompanied by numerous cuts in resources and unforeseen redundancies among health personnel, due to the exceptionally severe economic recession. This was accompanied by a rapid expansion in the demand for medical services in hospitals (related to the reforms described above) and reductions in intake into medical and dental training some years earlier. One result of these changes was a significant shortage of health personnel during the late 1990s, especially among physicians and dentists. The situation was particularly severe in health centres in remote rural municipalities (see section 5.2.1). During the last 10 years the national economy has been steadily growing, but growth in health expenditure has been slower (see section 3.1). However, in general, the health care system seems to have survived the recession fairly well and no changes in health indicators that could be attributed to it have been observed. In 2001 the Government initiated “the National Project to Ensure the Future of Health Care� in order to achieve national consensus on the development of health services (see section 7.1.1.2). Concerns related to problems with access, waiting times and waiting lists, availability of human resources in the future and of heterogeneity of service practices and patterns were all addressed in this intense process. This process resulted in a deal being struck between the state and the municipalities and municipal health services: the Government promised a clear rise in the level of state subsidies to the municipalities; the municipal level, in turn, committed to a number of structural changes and to new standards in access to services. Another highly visible outcome of this process was a legislative change where specific time limits were put on waiting times (see section 7.1.1.3). This part of the reform was implemented in 2005. The main milestones in the history of the Finnish health care system are summarized in Table 2.1 and in appendix 10.2. 26
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Table 2.1
Finland
Milestones in the history of the Finnish health care system
Period 1940s
Event New act introducing GP to every municipality Establishment of maternity and child care Measures to treat and prevent tuberculosis (tuberculosis districts)
1950s
Development of the hospital system
1960s
Introduction of the NHI scheme Strong increase in the number of medical doctors to be trained
1970s
1972 Primary Health Care Act and establishment of health centres Introduction of the national planning system Developments in occupational health care
1980s
Health care and social services into the same national planning and financing system “Personal doctor” system introduced in health centres Beginning of deregulation and decentralization
1990s
Increasing deregulation and emphasis on municipal autonomy Reforms in the state administration of health care 1993 state subsidy reform Maintaining health care services during and after economic recession
2000s
National Project to Ensure the Future of Health Care Specific time limits for waiting times Project to restructure municipalities and services
Notes: GP: General practitioner; NHI: National Health Insurance.
2.2 Organizational overview In practice, in Finland there are three different health care systems which receive public funding: municipal health care funded by taxes, private health care partly funded by NHI and occupational health care partly funded by NHI (Fig. 2.1). The role of the state is to steer the health care system at a general level mainly by legislation and financing. The provision of private health care is rather weakly regulated by the state. 2.2.1 Municipalities Municipalities (i.e. the local authorities) have, by law, the main responsibility for ensuring basic services such as education (except university education) and social and health services are provided for their inhabitants (see section 3.2.1.1). Currently there are 415 municipalities (in 2008). The number of municipalities has decreased in the last five years from 448. The population of municipalities (outside of Åland Islands) currently varies from 250 inhabitants to 560 000 (the 27
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Fig. 2.1
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Organizational chart of the statutory health system
Parliament
Government
Social insurance Institution Employers (occupational health care)
Ministry of Social Affairs and Health
Provincial State Offices
National Health Insurance
The Finnish Institute of Occupational Health Private providers
The National Authority for Medico-legal Affairs The National Agency for Medicines
Municipalities (Municipal health care)
Hospital districts (Specialist level health services)
Health centres (primary health services)
The National Public Health Institute The National Research and Development Centre for Welfare and Health Centre for Pharmacotherapy Development
Hierarchical relationship Regulation
smallest municipality, Velkua, will merge with neighbouring municipalities on 1 January 2009). The mean size is about 13Â 000 inhabitants and the median about 5Â 000 inhabitants. Municipalities have the right to levy income and real estate taxes. They also receive a subsidy from the state to enable them to organize the services they are obliged to provide. In addition to the state subsidy for health care, they receive state subsidies for social services and schooling. The state subsidy to municipal social welfare and health care expenditure is determined by the population, age structure and morbidity in the municipality plus a number of other computational factors. The subsidies constitute about 25% to 30% of municipal spending on health services. The main decision-making power in municipalities lies with the municipal council, which is elected every four years by the inhabitants of the municipality. The council appoints a municipal executive board, which is accountable to the council. The council also appoints members to the various municipal committees, according to the relative strength of political parties in the municipal council (every political party is granted the same proportion of the seats in a committee as it has in the council). The committees usually comprise those 28
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for health, social services, education, technical infrastructure and a number of others, and are appointed for four years. The municipal council, the municipal executive board and the committees are politically accountable to the inhabitants of the municipality. In addition, the municipal manager and a varying number of officials work in the administration of the municipalities. There are variations in detail and emphasis in the decision-making process in municipalities. The general trend has been towards delegating power from municipal councils to the various committees and leading officials. Decisions on the planning and organization of health care are made by the health committee, the municipal council and the municipal executive board. Here again there are variations. The leading persons of the municipal health centres are often also included in the planning and organization of health services. To improve the coordination of social and health services, the traditionally separate health boards and social welfare and services boards have been merged into a single board in most municipalities. In principle, the fact that social and health services are both organized and funded by the municipalities holds great potential for good coordination and integration of services, particularly for vulnerable groups (for example older people, people with mental health problems, and people with alcohol or drug abuse problems), but this potential has not always been fully exploited in practice. Primary health services provided by municipalities are defined in the Primary Health Care Act. The act states that every municipality must have a health centre which provides primary health services (see section 6.3). Municipalities can either provide these services independently or join with neighbouring municipalities in joint municipal boards which set up a joint health centre (a municipal federation-maintained health centre). There were 237 health centres in Finland (excluding Ă…land Islands), of which 58 were joint health centres in 2007. In larger cities, the services of health centres are provided through several health stations located in different parts of the city (for example Helsinki has 29 health stations around the city). Municipalities can also purchase some primary health services from private providers or hospital districts. Health centres provide occupational health care services for those employers who choose to purchase these services from health centres. About 86% of health centres also had inpatient wards in 2003 (see section 2.1). In 2006 there were 24.9 million outpatient visits to health centres and 7.3 million care days in inpatient wards (STAKES 2007d). Of all visits, 36% were to physicians and the rest were to other professionals such as nurses, public health nurses, midwives, physiotherapists and psychologists. Of all outpatient visits, 9% were to maternity and child welfare clinics, 15% were home nursing visits and 5% to occupational health care. In oral health care there were 4.9 million visits of which 79% were visits to dentists. 29
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Specialized care funded by municipalities is mainly provided by hospitals maintained by the hospital districts and regulated by the Act on Specialized Medical Care. Currently, the Act divides the country into 20 hospital districts (excluding Åland Islands). Each municipality must be a member of one hospital district (the number of member municipalities varies from 6 to 58). The hospital districts organize and provide specialist medical services for the population of their member municipalities. The hospital districts are federations of municipalities. These federations are separate from federations maintaining health centres. However, recently there have been local reforms to integrate these two organizations (see section 7.1.2.2). Each hospital district has a central hospital, five of which are university-level teaching hospitals. Hospital districts are managed and funded by the member municipalities. The catchment population of hospital districts varies from 65 000 to 1.4 million inhabitants. A referral from a licensed physician is needed for access to medical care provided at the hospital districts. Life-threatening emergencies are of course exempt from this requirement. The referring physician does not have to work in the municipal health centre and can be, for example, a private physician. Supreme decision-making power in hospital districts is exercised by the hospital district council, whose term of office is the period between municipal elections, i.e. four years. Each municipality has one to six seats in the council depending on the size of their population. Each municipality’s share of votes is the same as its share of total population within the district (but it cannot be more than one fifth of all votes). Practical administration is directed by the executive board elected by the council. Usually members of both the council and the executive board are local politicians and the composition of representatives of political parties reflects the support received by the political parties in municipal elections. The council adopts the annual budget, approves financial statements and makes decisions on major investments. The emphasis of the executive board is on strategic goals, coordination of activities, employer duties and administrative steering. The council meets twice a year, while the board generally meets monthly. The executive management consists of two to six permanently appointed officials (for example, the hospital district director, a medical director and a nursing director). There are different contractual or negotiation mechanisms between hospital districts and municipalities for agreeing on target volumes and payments which comprise elements of purchaser and provider separation, although ultimately the relationship is hierarchical and municipalities cover any deficits and retain any savings in their accounts (see section 3.4.1). 30
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2.2.2 National level The Government decides on general national strategies and priorities and proposes bills to be discussed by Parliament. Health care policy is primarily the field of the MSAH. The MSAH directs and guides the development and policies of social protection, social welfare and health care. It defines the main course of social and health policy, prepares legislation and key reforms and steers their implementation, and handles the necessary links with the political decision-making process. The general aims of social welfare and health care and the measures that will be taken in order to fulfil these aims are adopted in the National Development Programme for Social and Welfare (previously Target and Action Plan for Social Welfare and Health Care) that is drawn up for the whole period of office of each Government, normally for four years. The ministry’s work is led by two ministers: the Minister of Social Affairs and Health and the Minister of Health and Social Services. The ministry is divided into six departments: the Administrative Department, the Insurance Department, the Department for Family and Social Affairs, the Health Department, the Finance and Planning Department and the Department for Occupational Health & Safety. The Health Department is responsible for the development and steering of health promotion and disease prevention, health care services at all levels, occupational health services, pharmaceutical policies (except pricing) and environmental health, as well as for the drafting of legislation and budgeting regarding these areas. The Insurance Department is responsible for NHI among other things. The Pharmaceutical Pricing Board (PPB), which approves reasonable prices and the reimbursement status of pharmaceuticals, is also in this department. Decision-making is based on the applications of pharmaceutical companies (see section 6.6). Given the scope and volume of policies and programme, legislation and budgeting handled by the MSAH, its staff is relatively small. The Health Department, for instance, contains little over 70 staff. This is explained by the fact that the ministry relies on the extensive use of a well-functioning system of expert organizations and advisory bodies. The agencies and institutions subordinate to the MSAH are responsible for various issues related to social welfare and health care in Finland: • The STAKES (about 500 employees) monitors and evaluates activities in social welfare and health care services, and carries out research and development work in these fields. • The NAMLA (about 70 employees) guides and supervises the provision of health services in Finland. It also undertakes activities related to 31
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the registration of health care professionals, forensic psychiatry and licensing. • The NAM (about 200 employees) maintains and promotes the safe use of medicines, medical devices and blood products. It grants permissions for the sales of pharmaceutical products and assesses the quality and other documentation related to market authorization of medical products. It also supervises the manufacture, import and distribution of medicines and disseminates information on pharmaceuticals (see section 6.6). • The National Public Health Institute (KTL) (about 900 employees) carries out research on diseases and their prevention, collects data on communicable diseases, health behaviour and the effects of health promotion, and ensures the availability of vaccines in the country. • The Radiation and Nuclear Safety Authority (about 340 employees) sets the regulations for the use of radiation and nuclear energy and supervises implementation of the regulations. It is also an expert institute that carries out research on radiation and its effects, determines risks caused by radiation and monitors the radiation safety of the Finnish environment. • The National Product Control Agency for Welfare and Health (about 90 employees) handles the administration of licensing connected with the import, manufacture and sales of alcoholic beverages and tobacco products. It is also responsible for reports and other tasks as required by the Chemicals and Pesticides Act. • The Finnish Institute of Occupational Health (FIOH) (about 800 employees) carries out research, offers training for occupational health and safety professionals, provides advisory services and disseminates information on occupational health. • The Centre for Pharmacotherapy Development (Rohto) (about 10 employees) promotes rational drug use by gathering and distributing information on pharmacotherapy and promoting its use in clinical practice. This agency is still relatively small, having been founded only in 2003. The state has two psychiatric hospitals (mainly for forensic psychiatry). They are managed through STAKES. In addition the state operates special hospitals for military forces and prisoners. The Ministry of Employment and the Economy is also quite active in the field of health care, mainly from a commercial and business promotion perspective. For example, it governs the National Technology Agency of Finland (TEKES) which runs the Healthcare Technology Programme (see section 4.2.3), FinnWell (2004–2009). The programme has the objective of improving the quality and profitability of health care related industries, and promoting business activities and export (the value of the programme is 150 million euros). The ministry 32
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also governs the Finnish Competition Authority whose objective it is to protect sound and effective economic competition and to increase economic efficiency in both private and public-sector activity. The Ministry of Education is responsible for planning and subsidizing the education and training of health personnel as well as research. There is a further administrative level between the state and municipalities, the province. Since 1997 there have been five provinces (excluding the Ă…land Islands) in the country. The provincial administration is part of the state administration and promotes national and regional objectives. Each province has its own provincial state office with several departments, including a social and health department. The social and health departments are responsible for guiding and supervising both public and private health care as well as assessing basic services in municipalities. Their responsibilities also include the handling of appeals relating to health service provision. They also support and participate in various training and development activities in their respective provinces. Finland has eight Occupational Health and Safety Inspectorates. These are supervisory authorities within the state regional administration with responsibility for creating the necessary prerequisites for healthy and safe working conditions that promote working capacity. The Inspectorates report on related development needs to the Department for Occupational Health and Safety within the MSAH. The organizational structures of state governance in health and social services at a central and provincial level, including the research and development institutions, are currently under review. The Government is expected to decide on proposals during 2008. 2.2.3 National Health Insurance and the private sector The statutory NHI scheme finances 17% of the total costs of health care. The scheme is run by the SII, with about 260 local offices all over the country. SII falls under the authority of the Parliament. NHI covers all Finnish residents and it includes outpatient drug reimbursement, reimbursement of medical costs in the private sector, compensation of travel costs to health care units, sickness allowance, maternity leave allowance and compensation for some rehabilitation services (for co-payments see sections 3.3.3.2 and 3.3.3.3). In addition, NHI reimburses part of the costs of occupational health care. NHI is funded by employers (33% in 2006), the insured (38%) and the state (28%). The insured pay income-based insurance fees which are collected in connection with taxation (between 1.91% and 2.08% in 2008). 33
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The Private Health Care Act regulates the provision of private health services. The NHI scheme covers part of private health care costs (about one third, depending on the type of care). Private service providers can price services freely, but reimbursements are fixed (see sections 3.2.2.3 and 3.3.3.2). In terms of number of units, the most common private health care providers in Finland are physiotherapy units made up of 2–3 workers (about 1500 units in 2005) and medical doctors’ practices (about 1100). The largest provider units, a few hospitals and occupational health care units have several hundred employees. In 2006 there were 16 000 working age physicians in Finland, of which 1700 worked full-time as private physicians and 30% were employed in the public sector but held a private practice outside their regular working hours for an average of four hours per week (“dual practice”) (Suomen Lääkäriliitto 2006). Private health care in Finland mainly comprises ambulatory care, available mostly in the large cities. In 2006 there were 3.5 million outpatient visits to private doctors (compensated by NHI), of which 79% were visits to specialists (SII 2007a). In terms of the number of outpatient visits, the most important fields of specialty in private health care were gynaecology and ophthalmology (together comprising more than one third of visits to specialists). Private services funded by NHI comprised about 16% of total outpatient GP and specialist visits in 2005 (see Table 1.1). Private hospitals produced 71 700 inpatient care periods in 2005 which comprised about 5% of all inpatient care periods in Finland (STAKES 2006b; STAKES 2007b). About 36% of private sector outpatient visits are provided in the region surrounding the capital (SII 2007a). Nongovernmental organizations (NGOs) and foundations are active in the health care sector. These organizations provide a very broad spectrum of services. Municipalities and hospital districts can purchase services from these providers. These organizations can receive subsidies from the Finnish Slot Machine Association (which has a monopoly on gambling in Finland and is governed by the state) for providing health care services (see section 2.2.5). There is also a special foundation (Finnish Student Health Service) which provides ambulatory health care to university students. This organization is partly funded by the NHI scheme. 2.2.4 Occupational health care The Occupational Health Care Act enacted in 1979 obliges employers to provide occupational health care for their employees. The Act defines compulsory occupational health care as those health services that are necessary to prevent health risks caused by work (for details of entitlements see section 3.2.2.4). NHI reimburses employers 50% of the necessary and appropriate costs of 34
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occupational health care (maximum reimbursement is about 60 euros per employee per year for compulsory services and about 90 euros for voluntary services). Employers and employees participate in financing the scheme through their NHI payments. In 2004, about 84% of all employees in Finland were offered occupational health care by their employers (SII 2007b). Some small employers did not organize health care services for employees or did not apply for reimbursement from NHI (Kauppinen et al. 2007). About 13% of outpatient visits to physicians are provided by occupational health care (see Table 1.1). In 2004, employers purchased or provided 409 million euros worth of occupational health services and were subsidized 177 million euros (43%) for this from NHI (SII 2007b). Employers can supplement compulsory occupational health care by voluntarily organizing further medical services. Employers are free to decide the scope of these voluntary services. About 90% of employees receiving compulsory occupational health care also received voluntary services. Employees are not charged for using these services (but limits to services available are set by the employer). Sixty-one per cent of employers’ total expenditure was for voluntary services (these figures only include expenses which employers declared to NHI). Occupational health services can be provided by the employer itself, jointly with other employers or the employer can purchase them from another employer (in total accounting for 42% of occupational health expenses in 2004), or the employer can purchase services from municipal health centres (16% of expenses), from private health care providers (29% of expenses) or from other sources (12% of expenses). Because of the occupational health care system, the majority of the working population effectively has “double” coverage for primary care (i.e. care in both municipal health centres and occupational health services). Also, since private primary care is subsidized by the state, some have “triple” coverage. 2.2.5 Other organizations Pharmacies are privately owned by pharmacists (see section 6.6). There were 804 private pharmacies in Finland in 2006 including subsidiary pharmacies (NAM 2007). In addition to this, the University of Helsinki and the University of Kuopio have a special right to own pharmacies (in total 18 pharmacies). The Finnish Slot Machine Association has become quite an important financier of non-profit voluntary organizations in the health and social welfare sector. Annually, it gives around 300 million euros to support NGO work promoting health and social well-being. The association is governed by the state 35
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together with major NGOs related to social welfare and health. It operates slot machines, amusement machines and casino games in which it has a monopoly imposed by the state. A government decree regulates the administrative structure of the association and an act regulates the distribution of funds. The final decision on funding is made by the Government. The objective of the funding activities is to promote the health and social welfare of people in Finland. Groups targeted include, for example, older and disabled people, young families, people with chronic diseases and substance abusers. The association only supports third-sector organizations; it does not finance any municipal health services or private profit-making providers. Finland has a large number of patient organizations. It is estimated that there are about 130–150 national patient organizations with budgets up to 58 million euros. The main functions of these organizations are information dissemination, supporting patients, lobbying, producing services and supporting research. One major source of their funding is the Finnish Slot Machine Association. Other important public funding sources are the MSAH, the SSI and municipalities. All health care professionals have their own trade unions, for example the Finnish Medical Association for physicians, the Finnish Dental Association for dentists, the Finnish Pharmacists’ Association for professionals in the field of pharmacy, and the Union of Health and Social Care Professionals for nurses, midwives, dental assistants, medical laboratory technicians, radiographers, mental health nurses, emergency medical technicians and ambulance staff. In addition to trade unions there are many other active professional organizations. Perhaps the most important of these is a medical scientific organization, the Finnish Medical Society, Duodecim, which produces national Current Care Guidelines (see section 7.1.1.6), organizes consensus meetings about important topics in health care, maintains a comprehensive Evidence-based medicine (EBM) database, maintains widely used Internet health portals (Terveysportti for health care professionals and Terveyskirjasto for the public), and publishes handbooks for health care professionals in Finnish.
2.3 Decentralization and centralization Since the reforms of 1993, the Finnish health care system has been very decentralized. It has been argued that public responsibility for health care is decentralized in Finland more than in any other country (Häkkinen and Lehto 2005). As described in section 2.2.1, 415 municipalities are responsible for organizing and funding health services for their inhabitants. State level 36
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regulations and steering in health care service provision are not very detailed. Municipalities can set their own municipal income tax rates, and decide how much they invest in health care and how they organize services. Notwithstanding some discordant views, decentralization is widely accepted in Finland. The population is dispersed and local decision-making has always been regarded as important. One consequence of decentralization is wide differences in per capita expenditure on health care between municipalities (Hujanen, Pekurinen, Häkkinen 2006). These can only partly be explained by differences in determinants of need. Another consequence is variations in clinical practice and in the delivery of health services between municipalities and between hospital districts. For example, the number of inpatient cases and surgical procedures per capita vary markedly from region to region in the treatment of ischaemic heart disease (Häkkinen et al. 2002) and in orthopaedic operations (Mikkola et al. 2005). Significant variations in outpatient care are also observed (Häkkinen and Alha 2006). The differences can only partly be explained by different levels of morbidity or age and sex structure in the population. Recently this decentralization process has reversed slightly, as the state has become increasingly concerned about geographical inequalities in health. For example, in 2005 the MSAH enacted nationwide guidelines for access to treatment in non-urgent specialized care, based on a change in legislation (see section 7.1.1.3). The reform has significantly reduced waiting times, but there is as yet no formal evaluation on how the guidelines are being followed nationwide. Another potential mechanism for counteracting the negative consequences of decentralization is reconfiguring municipalities. More than 75% of municipalities have fewer than 10 000 inhabitants and 20% have fewer than 2000 and, as such, many could be considered too small for organizing and funding health services. The smallest municipal health centres are experiencing increasing difficulties with securing sufficient skills for providing services. Although hospital districts have a special funding pool between member municipalities to cover exceptionally high individual patient expenses (typically above 50 000 euros per individual patient or episode), the economic risks of hospital care expenses for a small municipality are commonly acknowledged. However, there has been no consensus on how to eliminate or lower this risk. Currently, a political debate is being prepared to address the issue of shifting to larger units either by reducing the number of municipalities or through creating new regional structures that would be responsible for the funding and provision of all health care services (see sections 7.1.2.1, 7.1.2.2 and 7.2.1). 37
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2.4 Patient empowerment 2.4.1 Patient rights An act on patients’ status and rights, the first such law in Europe, came into force in 1993 (the Act on the Status and Rights of Patients). It applies to every part of the health care system and to health care services provided in social welfare institutions. This act mainly concerns the patients’ right to information, informed consent to treatment, the right to see any relevant medical documents, right to complain and the right to autonomy. Specifically, the Act rules that: • treatment requires the consent of the patient; • patients must, if they so request, be given information on their state of health, the extent of the proposed treatment, any risk factors and possible alternative forms of treatment; • patients are entitled to see and correct the information entered in their own patient records; • those on a waiting list for treatment must be told the reason for the delay and its estimated duration; • patients dissatisfied with their treatment are entitled to lodge a complaint with the organization concerned; • organizations providing medical treatment must have a salaried patient ombudsman, whose duty is to inform patients of their rights and assist them, if necessary, in submitting a complaint, appeal or claim for indemnity; • the opinion of young patients (under the age of 18) must be taken into account if they have reached a stage of development at which they are able to express an opinion. A medical doctor or other professional person assesses the stage of development; • a child’s parent or guardian is not entitled to refuse treatment that would avert a health risk or save the life of an under-age person; and • the patient has the right to refuse treatment (except some exceptional cases). 2.4.2 Patient choice In theory, the population has the possibility of choosing between the three health care systems: municipal health care, private health care and occupational health care. However, in private health care substantial user-fees can be a barrier to access and occupational health care is available only to employed people. Furthermore, even if employers do organize health care for their employees, 38
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curative services might not be included (see section 2.2.4). Therefore, in practice, for poor unemployed people the municipal health care system is the only option. In the municipal health care system, patients have very limited freedom to choose between health care providers or physicians. The patient is treated only in the health centre of his/her own municipality, except in acute cases if the health centre of the home municipality is too far away. In some municipalities patients are permitted to choose a physician in the health centre. A referral from a licensed physician is needed for access to municipal specialist level medical care (i.e. hospital districts), where patients cannot usually choose the hospital or the physician. Patients may be offered the choice of going to a neighbouring hospital district to access health care if there are long queues in their own hospital district, although in many cases patients have been found to be unwilling to do this. On the contrary, under the NHI scheme patients can choose any private provider they like, but patients are only partly subsidized. In occupational health care, the provider is chosen by the employer. For treatment of injuries resulting from motor accidents under the motor liability insurance scheme and under the occupation accident insurance scheme, the provider is usually chosen by the insurance company. 2.4.3 Information for patients The most comprehensive source of patient information is the Internet. The majority of municipalities have web pages where patients can find information on the health care system in their municipality. Hospital districts also have their own web pages. State level administration has a portal named “suomi” where there is information on public sector services (see 10.3). These web pages contain, for example, information on services, contact information and information on decision-making. Since 2005, public sector health care providers have been expected to provide information on waiting times on their web pages. However, only half the providers have implemented this. Other quality indicators are not available for patients. Private providers have their own web pages containing information on their services, but there is no central information source relating to private health services in Finland. There are also many information sources on health in the Finnish language online. In 2006, the Finnish Medical Society, Duodecim, built an Internet portal “Terveyskirjasto” (“Health Library”) (see 10.3), containing thousands of patientcentred articles concerning diseases and treatments. Many municipalities and hospital districts have linked this portal to their own web pages. Additionally, 39
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many patient organizations have this type of information on their web pages and also distribute printed material. Direct-to-consumer advertising of prescription pharmaceuticals is forbidden in Finland, but pharmaceutical companies circumvent this ban by hosting disease centred portals targeted at patients. 2.4.4 Complaint procedures There are several mechanisms in place for patients to complain about health care services: • The first step is to make a complaint to the provider possibly assisted by a patient ombudsman (see section 2.4.1). • If the first step does not satisfy the patient, he or she can make a complaint to the provincial administration, which can, in severe cases, forward the complaint to the NAMLA. • In addition, patients can appeal to administrative courts if they think that they have not received necessary care in public sector health care services. • There is also a parliamentary ombudsman in Finland to whom people can make complaints about public authorities, including public health services. In Finland, the annual number of complaints relating to health care is approximately 800–900, most of which are dealt with by provincial offices. During recent years the number of complaints has increased. Complaints where treatment has led to death or severe injury of the patient are normally dealt with by the NAMLA, whereas other complaints are typically dealt with by provincial offices. If necessary, the NAMLA may undertake administrative supervision, precautionary measures, or disciplinary proceedings as a result of a complaint. Administrative supervision can involve instructing a health care professional to pay attention to the inadequacies or inappropriateness of performance evident in his or her professional practice or a health care professional may be given a warning. In the most severe cases, the NAMLA can limit or remove the right of a professional to practise his or her profession. In addition to professionals, the NAMLA can also instruct or warn provider organizations. 2.4.5 Patient safety and compensation The MSAH launched a project to enhance patient safety in 2005, prompted by the World Health Organization (WHO) World Alliance for Patient Safety programme. The project collects and disseminates information on good practices and coordinates the promotion of patient safety in Finland. It has produced guidelines, for example, on safety in drug therapy. The project has also involved 40
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the development of processes to aid health care provider units to respond to hazardous situations which have occurred in the unit. Several agencies are also involved in patient safety, for example the NAMLA (see section 2.4.4) and the NAM (see section 2.2.2). There are two insurance systems related to patient safety. According to the 1987 Patient’s Injury Act, amended in 1999, the patient has the right to compensation for unforeseeable injuries resulting from treatment or diagnosis. Notable in this act is the fact that health care personnel need not be shown to be legally responsible for the injury. To receive compensation, it is sufficient that an unforeseeable injury as defined by the act has occurred. According to the act, all health care providers must have this liability insurance. In 2005, patients received compensation in about 2300 cases (22.7 million euros). The most common treatments leading to a complaint were hip and knee endoprosthesis and some orthopaedic operations. In addition, hysterectomy, gall bladder and tooth removal operations were among the 10 most common operations leading to a complaint. Applications for compensation are handled by the Finnish Patient Insurance Centre. Medicines-Related Injuries Insurance indemnifies unexpected adverse effects caused to patients by pharmaceuticals distributed for consumption in Finland. The insurance also covers adverse effects caused by pharmaceuticals in clinical trials. This is voluntary insurance which is taken by the Finnish Pharmaceutical Insurance Pool representing pharmaceutical companies operating in Finland. In 2006 there were 227 claims of which 56% were qualified for compensation. 2.4.6 Patients’ participation Citizens can influence decision-making in the health care system through the right to vote every four years in both municipal and parliamentary elections. The most important channel for the public to participate in decision-making is through municipal councils and municipal health committees which represent the populations of municipalities. Hospital districts also have councils and executive boards, which are politically elected by municipal councils (see section 2.2.1). There are also various patients’ associations which lobby decision-makers on issues concerning the planning and management of health care locally, regionally and nationally (see section 2.2.5). In addition to this, many service provider units collect the opinions and experience of service users.
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2.4.7 Patients and cross-border care Due to language and geographical barriers, cross-border health care is insignificant in Finland (except for tourists needing unforeseen care). Statistics on this are scarce, both in terms of people living in Finland seeking care abroad and foreigners seeking care from Finland. Finnish residents are entitled to publicly financed unforeseen medical care in other EU/European Economic Area (EEA) Member States if they are entitled to NHI (see section 3.2.1.2). To receive publicly financed planned treatment in another EU/EEA Member State, the patient needs authorization (E112 form) from his/her hospital district or health centre (annually about 10–20 patients in Finland). The SII handles claims for medical expenses between Finland and other EU/EEA Member States. In 2006, SII reimbursed these claims to other countries at a sum of 3.7 million euros and received claims from other countries of 10.2 million euros. However, these figures do not include Nordic countries, the United Kingdom, Belgium, the Netherlands, Luxembourg and Austria since Finland has agreements with them on a full or partial waiver of reimbursements of medical expenses. Patients can also claim normal NHI reimbursement (see section 3.2.2.3) for costs of unforeseen medical care when staying temporarily in countries other than EU/EEA Member States. However, as the reimbursement is rather low, people normally opt for private insurance to cover these expenses.
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3. Financing
F
inland has two sources of public financing for health services (dual financing): municipal financing based on taxes and NHI based on compulsory insurance fees (Fig. 3.1). Municipalities fund municipal health care services (except outpatient drugs and transport costs). NHI funds private health care, occupational health care, outpatient drugs, transport costs and sickness allowance. Dual public financing creates some challenges for overall efficiency of service production which are described in section 8.3. Municipalities have the responsibility for organizing health services for their residents. For this, municipalities raise funding from municipal taxes, from state subsidies and from user-fees (Fig. 3.1 and Table 3.1). The main source of municipal funding for health care services is taxation. The majority of municipal health services are provided by municipal-owned health centres and hospital districts, but municipalities and hospital districts may also purchase services from the private sector (see section 2.2.1). There is no true purchaser–provider split in the municipal health care system, as municipalities both fund services and own the service provision organizations, although there are exceptions to this (see section 3.4.1). NHI is divided into two parts: sickness insurance and income insurance. Sickness insurance covers outpatient drug reimbursement (see section 6.6), reimbursement of medical costs for use by the private sector and rehabilitation services, and compensation of travel costs to health care units (including ambulance services). Income insurance covers sickness allowance, maternity leave allowance, rehabilitation allowance and reimbursement for employers for occupational health care services (see section 2.2.4). Sickness insurance is funded by employees and the state. Income insurance is funded by employees and employers (see section 3.3.1.2).
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Fig. 3.1
Finland
Financial flow chart Health insurance fee (employers and insured) Governmental agencies under MOH
The State Government/MSAH
Hospitals for military forces and prisoners
State subsidy
Municipal tax
State tax
Tax funding
SII
Municipalities (415)
Private providers
Employers occupational health care
Hospital districts (20) Health centres (237) Municipal hospitals or inpatient wards
Statutory accident insurance, Motor accident insurance and voluntary health insurances
Patients
Pharmacies (804)
Notes: MSAH: Ministry of Social Affairs and Health; SII: Social Insurance Institution. Table 3.1
Trends in health care expenditure
1980 1985 1990 1995 2000 2002 2004 2005 Total expenditure on health (TEH) TEH at 2005 prices (million euro) 7 515 9 094 10 815 9 354 10 052 11 058 11 547 11 854 TEH per capita USD PPP – – 1 419 1 430 1 716 2 012 2 235 2 331 TEH as a % of GDP 6.4 7.2 7.8 7.4 6.7 7.2 7.5 7.5 Public expenditure as % of TEH State Municipalities NHI
80 38 29 12
79 34 35 10
81 36 35 11
76 28 34 13
75 18 41 15
76 18 42 16
77 20 40 17
78 21 40 17
Private expenditure as % of TEH Households Private insurance Employers and relief funds
20 18 1 2
21 18 1 2
19 16 2 2
24 21 2 2
25 20 2 2
24 20 2 3
23 19 2 3
22 18 2 3
Sources: STAKES, 2007a. Notes: TEH: Total expenditure on health; PPP: Purchasing power parity; GDP: Gross domestic product; NHI: National Health Insurance. 44
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3.1 Health expenditure Health care expenditure in Finland developed in parallel with most other EU countries until 1990, rising steadily both in absolute terms and as a share of GDP (statistics used here include mental health care, dental care and public health expenses but exclude social care and long-term care). However, after 1990 health expenditure started following a different trend (Table 3.1), mainly because of the steep economic recession in the early 1990s (Häkkinen 2005). Total health expenditure in real terms dropped between the years 1991 and 1994 but increased after that returning to the 1991 level only after 10 years in 2001. Between the years 2001 and 2005 it has further increased by 12%. The out-of-pocket share of expenditure on health increased between the years 1991 and 1994 due to the abolition of the tax deduction for medical expenses and an increase in user-charges (Häkkinen 2005). During the 1990s, the amount allocated to state subsidies also fell, decreasing the state’s share of expenditure. At the beginning of the economic recession in 1990–1991, GDP declined markedly but health expenditure did not initially decrease at the same pace, meaning that, momentarily, the proportion of GDP spent on health care was one of the highest in the European Region at that time (9% of GDP). However, the proportion decreased sharply after that, reaching its lowest point in 2000 at 6.6%. Since then, the proportion has increased again reaching 7.5% in 2005. In 2003, Finland’s expenditure on health as a percentage of GDP placed it at the bottom of the EU15 country ranking, ahead only of Luxembourg in 2003 (Fig. 3.2). Figure 3.3 shows how the economic recession affected health care expenditure as a share of GDP in Finland, compared to other Nordic countries where the share of GDP steadily increased during the 1990s. In 2003, health care expenditure in Finland in US$ PPP per capita was about 9% below the EU15 average (Fig. 3.4), and was below that of other tax-financed countries such as Italy, Sweden, Norway and the United Kingdom. One of the possible explanations for the low total health care expenditure in Finland is the low salary of health care professionals, especially that of nurses (see section 3.5.2.2). Health care expenditure from public sources as a percentage of total health care expenditure was also lower in Finland than in these and other Nordic countries (78% in 2005 when it was 85% in Sweden, 84% in Norway and 84% in Denmark) (Fig. 3.5). From public expenditure, 4% was spent on private health care and occupational health care. Total health expenditure in Finland was 11.9 billion euros in 2005, the equivalent of 2255 euros per capita (STAKES 2007a). Table 3.2 shows that in Finland 36% of health care expenditure was spent on inpatient care and 31% on 45
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Fig. 3.2
Finland
Total expenditure on health as a percentage of GDP in Finland and selected other countries 2003 Western Europe 11.6 10.9 10.8 10.0 9.9 9.9 9.8 9.8 9.8 9.5 9.3 9.2 9.0 8.7 8.7 8.1 7.8 7.8 7.7 7.5 7.5 7.2 7.1 6.9 6.2
Switzerland Germany Iceland France Norway Monaco Portugal Netherlands Greece Sweden Belgium Malta Denmark Italy Israel United Kingdom Spain San Marino Turkey Finland Austria Ireland Andorra Luxembourg Cyprus Central and south-eastern Europe Bosnia and Herzegovina Slovenia Hungary Croatia Bulgaria Czech Republic The former Yugoslav Republic of Macedonia Albania Lithuania Poland Latvia Slovakia Romania Estonia CIS Republic of Moldova Belarus Ukraine Armenia Uzbekistan Kyrgyzstan Russian Federation Tajikistan Georgia Kazakhstan Turkmenistan Azerbaijan Averages EU Member States before May 2004 EU average CIS average
9.3 8.7 8.4 7.9 7.7 7.2 7.0 6.6 6.5 6.4 6.4 5.8 5.7 5.5 7.5 6.3 5.8 5.6 5.4 5.4 5.3 4.5 4.0 3.9 3.8 3.7 9.3 8.7 5.3 0
5
10 % of GDP
Source: WHO Regional Office for Europe, January 2007. Notes: GDP: Gross domestic product; CIS: Commonwealth of Independent States. 46
15
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Fig. 3.3
Finland
Trends in health care expenditure as a share of GDP(%) in Finland and selected other countries
12 11 10 9 8 7 6 5 4 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Denmark Sweden
Finland United Kingdom
Germany EU average
Norway
Source: WHO Regional Office for Europe, January 2007.
outpatient care (excluding dental care) in 2005. Expenditure on pharmaceuticals has grown rapidly, both in real terms and as a share of total expenditure, despite many measures taken to contain costs (see section 7.1.1.4). Pharmaceutical expenditure has increased mainly because of the increasing prices of new pharmaceuticals and the increasing use of pharmaceuticals in general. In 2006 total sales (including inpatient and outpatient use) were 2.4 billion euros, about 470 euros per inhabitant (NAM 2007). In 2005 sales of pharmaceuticals accounted for 20.5% of total health care expenditure, compared to 15.4% in 1994. Part of this increase is explained by the fact that during the economic recession municipal health care spending was reduced, but the NHI was unable to exercise similar control on provider expenditure. Municipalities spent, on average, about 1300 euros per inhabitant on health care in 2005. Health care accounted for, on average, about 25% of the municipal budget. However, the distribution of expenditure levels is broad, with striking variation across municipalities. Part of the variation is due to structural differences, for example there is variance between municipalities on the proportion of expenditure on long-term elderly care which is included in the health care expenditure figure (some municipalities arrange a substantial part of long-term elderly care in inpatient wards of health centres). However, even after reducing this effect (by combining expenditure on long-term elderly care and health care) expenditure varied from 940 to 2310 euros per inhabitant in 2004. After adjusting this expenditure for need, expenditure was still 2.5 47
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Fig. 3.4
Finland
Health care expenditure in US$ PPP per capita in the WHO European Region, 2003 Western Europe
Monaco Luxembourg Switzerland Norway Iceland San Marino Netherlands Germany France Belgium Sweden Denmark Ireland Andorra United Kingdom Italy Austria Finland Greece Israel Spain Portugal Malta Cyprus Turkey Central and south-eastern Europe Slovenia Hungary Czech Republic Croatia Slovakia Lithuania Poland Estonia Latvia Bulgaria Romania The former Yugoslav Republic of Macedonia Albania Bosnia and Herzegovina CIS Belarus Russian Federation Kazakhstan Ukraine Armenia Turkmenistan Republic of Moldova Georgia Kyrgyzstan Uzbekistan Azerbaijan Tajikistan Averages EU Member States before May 2004 EU average CIS average
4 797 3 992 3 954 3 862 3 508 3 172 3 056 3 052 3 016 2 922 2 875 2 838 2 619 2 581 2 531 2 424 2 365 2 275 2 106 1 972 1 908 1 903 1 686 972 589 1 760 1 334 1 333 897 829 816 810 776 751 635 566 411 409 359 740 571 393 361
321 224 202 193 177 169 160 82
2 645 2 268 444 0
1 000
2 000
3 000
4 000
US$ PPP
Source: WHO Regional Office for Europe, 2007. Notes: PPP: Purchasing power parity; CIS: Commonwealth of Independent States. 48
5 000
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Fig. 3.5
Finland
Health care expenditure from public sources as a percentage of total health care expenditure in countries in the WHO European Region, 2003
Luxembourg Czech Republic United Kingdom Sweden Norway Denmark Croatia Ireland France Finland Germany Malta Estonia Austria Slovenia Italy Lithuania Slovakia Turkey Portugal Hungary Belgium The former Yugoslav Republic of Macedonia Spain Poland Romania Netherlands Switzerland Bulgaria Latvia Greece Cyprus Averages EU 15 EU average CIS average
90.4 89.2 86.3 84.9 83.5 82.3 81.0 79.5 78.4 77.2 76.9 76.1 76.0 75.6 75.6 75.1 75.0 73.8 72.3 71.6 71.6 71.1 71.0 70.9 68.6 66.1 62.4 58.5 57.6 56.6 52.8 44.3 76.3 75.0 56.3 0
25
50 Percentage
75
100
Source: WHO Regional Office for Europe, 2007. Notes: CIS: Commonwealth of Independent States; EU: European Union; EU15: EU Member States before May 2004.
times higher in the most costly municipality when compared to least costly one (Hujanen, Pekurinen, Häkkinen 2006). The total expenditure of NHI was 3.5 billion euros in 2005 (SII 2006). Under Motor Liability Insurance bodily injuries were compensated for a total of 191 million euros in 2004 and under Statutory Accident Insurance injuries were compensated for a total of 593 million euros.
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Table 3.2
Finland
Health care expenditure by service category, (%) of total expenditure on health care, 2005
Inpatient care Outpatient care Dental care
Million euro 4 286 3 712 606
% 36.2% 31.3% 5.1%
Pharmaceuticals (outpatient care) Medical devices Environmental health Administration Public investments Transportation
1 930 389 129 228 387 187
16.3% 3.3% 1.1% 1.9% 3.3% 1.6%
Total health care expenditure
11 854
100%
Source: STAKES, 2007a.
3.2 Population coverage and basis of entitlement 3.2.1 Population coverage Every Finnish resident has the right to health services regardless of ability to pay or place of residence. The constitution states that public authorities shall guarantee for everyone, as provided in more detail by an act of the Parliament, adequate social, health and medical services and promotion of the health of the population. Asylum seekers, illegal immigrants, tourists, temporary students and workers (from non-EU countries) are not covered by municipal health care or NHI. However, municipal health care units provide essential emergency care to everyone. According to a specific act (Act on Adaptation of Immigrants and Reception of Asylum Seekers), asylum seekers are entitled to the same health services as permanent residents. These services must be organized by reception centres for refugees. 3.2.1.1 Municipal health care Municipal health care covers all people registered as permanent residents of the municipality. This also applies to migrants intending to live in Finland permanently who have a residence permit for at least one year (if required) (Act on Municipality of Residence). People who have lived outside of Finland for more than one year do not have an official municipality of residence. Asylum seekers without a residence permit, illegal immigrants and foreign temporary workers are not covered by the municipal health care system. Persons from other EU countries are entitled to the same services as Finnish residents (with 50
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some restrictions), but their care is paid for by their home country. However, essential emergency care is provided to all. 3.2.1.2 National Health Insurance NHI covers all permanent residents of Finland. NHI is compulsory and insurance fees are collected with taxation. Permanent residents in Finland receive an SII card which proves eligibility for social security (including health insurance) in Finland. The meaning of residency is defined by the Sickness Insurance Act. In order to be recognized as living in Finland, a person must have primary residence in Finland and must continually spend most of their time in Finland. People are considered to be living in Finland and eligible for benefits during a temporary stay abroad of one year or less. Immigrants are considered to be residents if they intend to live in Finland on a permanent basis and have a residence permit for one year (if required). Whether residence is considered to be permanent is determined by reference to the purpose of entry to Finland. The move is considered to be permanent if the immigrant is a refugee or full-time student, or if the immigrant comes to Finland for family reasons or has either a permanent work contract or a work contract for at least two years. Persons seeking asylum in Finland are not considered to be living in Finland while their case is under consideration. Since August 2004, workers and self-employed persons moving to Finland from a Member State of the EU/EEA or from Switzerland have been eligible for social security coverage from SII if they are employed in Finland for a period of at least four consecutive months. 3.2.1.3 Private health insurance There are three major types of private health insurance in Finland: voluntary health insurance, statutory motor accident insurance (compulsory for every motor vehicle) and statutory occupational accident insurance (compulsory for every employer). Voluntary health insurance can be divided into the following categories: sickness insurance for children, sickness insurance for adults, leisure time accident insurance, sporting accident insurance (mainly for some specific sports), insurance for medical expenses during travelling and sickness insurance taken by the employer. These types of insurance can be combined or may form part of another type of insurance, for example insurance on private property. Premiums are usually risk rated. Public regulation of these insurance schemes is limited and insurance companies can design their schemes and price premiums 51
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very freely. Voluntary private health insurance is not very common in Finland. In 2005, 375 000 children and 237 000 adults had voluntary private health insurance. By comparison it is estimated that 1.2 million people (about one fifth of the population) had leisure time and sporting accident insurance in the same year. The main reason for people to take out voluntary health insurance is to reduce out-of-pocket payments for private health care after NHI reimbursement and for outpatient drugs (complementary insurance). Out-of-pocket payment after NHI reimbursement of outpatient prescription drugs is rather high (on average 37% in 2006). The relatively high number of voluntary private health insurance policies bought for children is explained by the fact that children are not covered by occupational health care which is commonly used by the wealthy population as an alternative to municipal health care. In addition to this, there are voluntary employee relief funds in Finland, which provide additional benefits to NHI. Usually membership of a fund is restricted to employees of a specific company. The relief funds are not private for-profit companies but funds governed and owned by the members. Usually, the insurance premium (membership fee) depends on the salary of the individual. Employers may also fund these organizations. Coverage varies greatly between the funds. There are about 150 relief funds in Finland covering about 165 000 people (in 2004). Expenditures due to work accidents and occupational diseases are compensated through the statutory accident insurance system (Employment Accident Insurance Act). This insurance is provided by private accident insurance companies. Every employer is obliged to take out insurance for its employees. It covers work accidents, occupational diseases and commuting accidents. A work accident is defined as: an accident due to an unexpected, sudden external event which causes injury or illness to an employee while he or she is working, in circumstances related to his or her work or in his or her workplace, when going on errands for his or her employer or while protecting or trying to protect the property of his or her employer or while saving or trying to save human lives in the course of his or her work. An occupational disease refers to a disease which is probably primarily due to physical, chemical or biological factors associated with work done during a period of employment (The Federation of Accident Insurance Institutions, 2008).
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According to the Motor Liability Insurance Act, every motor vehicle in Finland is required to have motor accident insurance. Among other things, it covers treatment and rehabilitation from injuries suffered in traffic accidents (bodily injuries compensation). All persons injured in traffic accidents are covered by the insurance. Motor insurance is provided by private insurance companies. 3.2.2 Entitlement and benefits 3.2.2.1 Municipal health care system There is not any specific package of benefits in services provided by the municipal health care system. According to the constitution, public administration must provide sufficient health care services to everyone and promote the health of the population. The Act on Specialized Medical Care states simply that necessary services should be provided to everyone. The Primary Health Care Act defines types of services which must be provided, but not the specific benefits. Under the act the main functions of the health centre are: • to organize the provision of medical treatment for local residents and first aid in cases of emergency for anybody in the area; • to provide preventive services and offer health promotion, education and support; • to organize medical examinations and screenings; • to run maternity and child health clinics; • to arrange school, student and occupational health care services; • to organize the provision of dental health care; • to organize home nursing services; • to provide rehabilitation services; • to arrange provision of those mental health services which can appropriately be provided in health centres; and • to provide a local ambulance service. Municipalities and hospital districts have significant autonomy in defining and shaping the services they provide. There is variation in the basic profile and scope of services provided between municipalities which can be attributed to, for example, differences in financial situation, differences in shortages of professionals and differences in perceived need of services of the population. This variation is of growing concern in the country. One line of action to eliminate unacceptable differences has been to regulate access to services by law (Primary Health Care Act and Act on Specialized 53
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Medical Care). Since 2005, immediate contact with health centres during working hours by phone or personal visit must be guaranteed. If an appointment at the health centre is required, it should take place within three working days of contacting the centre (non-acute cases). If a patient is referred to hospital, treatment needs have to be assessed within three weeks of the hospital receiving the referral. Assessments can be made either based on referrals or by examining patients at the hospital. If a patient needs non-urgent hospital treatment, this treatment must be made available within six months of the assessment (see section 7.1.1.3). In connection with this reform, the MSAH has put together national guidelines on access to non-urgent specialized care based on expert proposals and previously developed national evidence-based clinical guidelines. These guidelines define which types of patients should receive the treatment guarantee. Some guidelines also use scoring systems to help determine the need for care. Guidelines have been prepared for about 190 diseases, treatment groups or conditions. This has been estimated to cover about 80% of non-emergency hospital care. One objective of the guidelines is to diminish variations between different municipalities and hospital districts in access to care. However, the guidelines are not binding, and physicians still autonomously decide whether a patient needs treatment or not (see section 7.1.1.3). If a health centre or hospital is unable to treat patients within the set time frame, the legislation requires the provider to purchase treatment elsewhere (public or private sector) within the stipulated time frame with no extra charge or travel cost to the patient. Patients can appeal to an administrative court if they feel that they have not received necessary care, although there is no explicit definition of the necessity of the care. These appeals have increased during recent years. Patients can also make complaints to the provincial administration, to the NAMLA or to the Parliamentary Ombudsman (see section 2.4.4). 3.2.2.2 Outpatient drugs Outpatient drug costs are reimbursed through NHI, administered by SII. In the scheme, there are three levels of reimbursement: 42% (limited or non-limited basic reimbursement category), 72% (limited lower special reimbursement category) and 100% (limited higher special reimbursement category). There is also a maximum annual out-of-pocket payment limit for drugs (about 630 euros in 2007), after which reimbursed drugs are free for the patient for the rest of that year. Pharmaceutical companies holding market authorization have to apply for a reimbursement and maximum wholesale price from the PPB of the Finnish 54
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MSAH. The PPB is made up of seven civil servants from different state agencies (defined in the National Health Insurance Act). Applicants must specify whether they are applying for limited basic reimbursement, basic reimbursement, or one of the limited special reimbursement categories. Applicants must also propose a reasonable wholesale price for the drug. When basic reimbursement is applied for a new drug substance, the application must contain a pharmacoeconomic evaluation. Reimbursement is granted for a maximum of five years. After that, reimbursement must be applied for again. According to the Sickness Insurance Act, basic reimbursement can be refused if the drug is used only temporarily or for the treatment of only mild diseases, the drug has insignificant benefits or the drug is not used for the treatment of disease. A drug is included in the reimbursement system if the PPB considers the price of the drug proposed by the pharmaceutical company to be reasonable. When making the decision on price, the cost of the drug is compared to its benefits, and to the costs and benefits of its therapeutic alternatives. In addition, the proposed price is compared to prices in other EU countries. In the non-limited basic reimbursement category, 42% of the cost of a prescribed drug is covered for all patients, regardless of the diagnosis. If a drug is very expensive or in very wide use and reimbursement would therefore incur expenses that are too great compared to the benefits, basic reimbursement is not granted, but limited basic reimbursement can be considered instead. In this category, drugs are 42% reimbursed only to a restricted group of patients with a certain condition or disease (for example interferon beta, dornase alfa and sildenafil are in this category). In addition to these basic reimbursement categories, some important drugs for chronic and serious diseases are selected for special reimbursement categories (72% or 100% of the price is reimbursed). This means that the drug has special reimbursement for a limited group of patients, while for the rest of patients the drug is still only 42% reimbursed. Before applying for special reimbursement, the drug must already be in a basic reimbursement category. The special reimbursement categories account for about half of total reimbursement expenses. According to the Sickness Insurance Act, drugs in the 72% reimbursement category must be essential and used in the case of severe and long-term diseases. Drugs in the 100% reimbursement category must have a corrective or supplementary effect, in addition to being essential. The Government specifies by legislative decree the diseases for which drugs can be reimbursed by 72% or 100%. The PPB decides which specific drugs are granted special reimbursement for these diseases. In order to obtain limited basic reimbursement or limited special reimbursement, patients have to comply with certain criteria which are 55
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decided by SII. For example, to obtain special reimbursement on hypertension, the patient’s level of blood pressure must exceed a specified lower limit of hypertension. In order to be eligible for the reimbursement, the patient’s physician must submit a medical certificate to SII stating that the patient has a specific disease and that the patient fulfils the criteria defined by SII. For more information on pharmaceutical care see sections 3.3.3.3 and 6.6. 3.2.2.3 National Health Insurance In addition to outpatient drug treatment, NHI provides partial reimbursement of all private health care costs (about 30% on average, depending on the type of care) (see section 3.3.3.2) and transport costs to health care units (including part of the ambulance service (see section 6.5)). The NHI scheme also compensates for loss of income during illness, pregnancy and childbirth, and for loss of income of the parents of a sick child during treatment and rehabilitation of the child. NHI also covers, through SII, rehabilitation costs in certain cases specified by an Act on Rehabilitation Benefits of the Social Insurance Institution. The sickness day allowance provides compensation for loss of earnings caused by incapacity due to an illness lasting less than a full year. It is paid to employed and self-employed persons aged between 16 and 64 years who are prevented from carrying out their regular job or a comparable gainful activity, for a maximum of 300 weekdays (including Saturdays). A waiting period, during which the allowance is not paid, comprises the day on which the illness begins plus the following nine weekdays. If incapacity to work continues for at least 55 calendar days, sickness allowance can be awarded even if the requirement concerning prior employment is not met. The amount of the allowance depends on the taxable income of the recipient. In terms of private health care reimbursement, NHI does not have any defined benefit package which it would cover (except that orthodontic or prosthodontic dental services are not covered). NHI covers a certain amount of all treatments which a physician has deemed necessary for treating a disease, pregnancy or childbirth. Private health services not treating a disease (for example cosmetic surgery) are not covered. The legislation does not precisely define which conditions are categorized as a disease and which are not. In terms of rehabilitation, SII is required by law to reimburse: vocational rehabilitation for persons with impaired functional capacity (33.6 million euros in 2005); and medical rehabilitation of persons with severe disabilities (104 million euros). The state budget also includes a special allocation for SII to reimburse other vocational or medical rehabilitation services (82 million euros). 56
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Vocational rehabilitation is covered if a person’s capacity to work and financial self-sufficiency significantly decline due to an illness or injury. The person must be given the opportunity to obtain: • essential vocational training in order to maintain or improve his or her capacity to work (e.g. basic education, further education and training); • assistance with running a business or self-employment; • basic training if it is a requirement for starting vocational training; or • for persons with severe disabilities, expensive and technically advanced aids necessary to help with work and study. Medical rehabilitation is covered for severely disabled persons, which includes extensive or elaborate out- or inpatient services which go beyond curative treatment and which are necessary in order to maintain or improve the person’s functional and work capacity. The person must be non-institutionalized and in receipt of either child disability allowance, disability allowance or pensioners’ care allowance (under 65 years of age). The SII can also reimburse, at its own discretion, vocational and medical rehabilitation services other than those described above, including services such as preventive rehabilitation measures geared to the requirements of a particular occupation, institutional rehabilitation services, training (to adapt to a sickness or disability) and psychotherapy. 3.2.2.4 Occupational health services Employers are obliged to provide preventive occupational health services for their employees. Specifically, they must provide sufficient information on health risks related to work and to advise their employees on how to avoid those risks. Furthermore, they are obliged to arrange physical examinations and first aid for their employees at the place of work. Employers are also obliged to check an employee’s health status when a job might endanger his or her health. In general, occupational health care is seen as preventive rather than curative. However, in addition to compulsory occupational health care, employers can voluntarily arrange additional health care services for their employees, so that now many employers also offer curative generalist level services. There are significant differences in the scope of curative services offered by employers. In 2004 about 84% of all employees in Finland were offered occupational health care by their employers (SII 2007b). Some small employers did not arrange services or did not apply reimbursement from NHI (Kauppinen et al. 2007). About 90% of employees receiving compulsory occupational health care services also received voluntary services (see section 2.2.4). 57
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3.2.2.5 Other types of insurance Coverage of voluntary private health insurance (both sickness insurance and accident insurance) is usually limited and there is great variation in this between different schemes. Insurance can include, for example, necessary medical treatment and compensation for permanent disabilities, loss of income or death. The usual restrictions apply, for example diseases diagnosed before the insurance has been taken, accidents related to alcohol use, treatments which are not standard medical practice, treatments of alternative medicine (such as homeopathy), medical treatments which are not a treatment of disease (for example normal child birth), dental care, rehabilitation, preventive drugs, physical therapies, eye glasses and so on. Private health insurance is usually not available for elderly people. Voluntary private health insurance covers costs to patients after they have received possible reimbursements from NHI, the statutory motor accident insurance and the statutory occupational accident insurance. Usually, voluntary insurance has deductibles and maximum annual limits of reimbursement. Compensation paid under the statutory motor accident insurance for bodily injuries due to traffic accidents covers, for example, medical treatment, compensation for loss of income, disability pension, compensation for pain and suffering, compensation for a permanent defect or disability, compensation for home care costs and compensation for rehabilitation costs. Statutory occupation accident insurance covers medical care expenses, daily allowances, an employment accident pension, inconvenience compensation, disability rehabilitation care and funeral costs. The cost of medical examinations necessary to establish the existence of an employment accident or occupational disease are also paid in full. These examination expenses are indemnified even where examinations prove that neither a work accident nor an occupational disease is concerned.
3.3 Revenue collection/sources of funds Municipalities finance 40% of total health care costs, with a further 21% being financed by the state, 17% by NHI and 22% by private sources (2005) (Fig. 3.6). The most marked change in the financing of health care has been the shift from state to municipalities. In 1990, the state financed about 36% and the municipalities about 35% of total health care expenditure. The state share has decreased radically since then, whereas the share of the municipalities has grown (Table 3.1). There has also been an increase in the amount provided by 58
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Fig. 3.6
Finland
Total expenditure on health according to source of revenue, 2005
State Municipalities National Health Insurance Households Private Insurance Employers and relief funds
Source: STAKES, 2007a.
NHI, although this is more moderate. Between the years 1990 and 2005, the share of private financing has increased only moderately (from 19% to 22%). The decrease in importance of state income tax as compared to municipal income tax in the overall mix of revenue collection has contributed to the decrease in progressivity of health financing over the last 20 years, since state income tax is progressive, whereas municipal income tax is flat rate (see section 3.3.1.1). Due to the recession the state Government decided to reduce public expenditure drastically across the board, which meant that state subsidies for health care were also severely cut. Municipalities, which have first-hand responsibility in arranging public sector health care services, were not able to reduce spending to the same extent as the state. 3.3.1 Compulsory sources of finance 3.3.1.1 Taxation Tax financing for health care comes from two different taxation systems: state taxation and municipal taxation. More than half of state tax revenue comes from the progressive gross income tax (about 20% of total tax revenue) and valueadded tax (VAT) (about 35%). Other major sources of tax revenues are corporate tax, capital income tax, alcohol tax, energy tax and car tax. In 2007, the highest level of state income tax (not including capital income) was 32% (deducted from the proportion of income exceeding 60 800 euros annually). State income tax is not paid on annual salaries below 12 400 euros. Out-of-pocket payments for health care and health insurance premiums are not tax deductible.
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State level financing of health care is largely in the form of state subsidies. On average, 16% of municipal revenue came from state subsidies which represented on average 24% of municipal budgets for health and social care in 2005. State subsidies to municipal social and health care services are calculated according to factors such as number of inhabitants, age structure, unemployment rate, remoteness and morbidity in the municipality. The amount transferred in the state subsidy is also in part determined by the potential of the municipality to raise tax revenue. In practice this means that municipalities receive a smaller subsidy if their residents have a higher average income. Because of the subsidy transfer, the total state subsidy varies greatly between municipalities. For example, the city of Espoo actually received no state subsidy in 2005 at all because of high tax revenue, while municipalities receiving the highest level of state subsidy received more than 2500 euros per resident. Municipalities also receive a general state subsidy and a state subsidy for education and culture. In addition to state subsidies, the state funds health through municipal social and health care development projects (about 40 million euros in 2007) and support to several state agencies (Fig. 2.1). The final decision on the state budget is made by the Parliament following the Government’s annual budget proposal. In 2005, 46% of municipal revenue came from municipal tax. The taxation rate is decided every year by each municipal council. Municipalities levy municipal income tax, real estate tax and they receive a share of the revenues from corporate tax, although income tax is by far the most important (87% of municipal tax income in 2005). Municipal income tax is a fixed proportion of gross wage, which varies between municipalities from 16% to 21% of taxable income (in 2007 the average was 18.5%). This has resulted in considerable variation in the amount of revenue raised from taxation between municipalities. 3.3.1.2 Statutory health insurance Part of the total cost of health care is financed by the statutory NHI scheme which reimburses, for example, occupational health care and part of the cost of private health care (see sections 3.2.2.3 and 3.2.2.4). NHI is funded by the state, employers and employees through income-based insurance fees collected with taxes. The funding of NHI is divided into two parts: sickness insurance and income insurance, and fees are set by Parliament. Sickness insurance is funded by employees (1.24% of income in 2008) and the state (approximately half of the expenses). Income insurance is funded by employees (0.67% of the income) and employers (1.97% of gross wages). For retired people the sickness insurance fee is 1.41% of income. The expenditures of both schemes 60
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are approximately equal. The total benefit payments of NHI was 3 billion euros in 2006 (SII 2007c). Regarding the other types of statutory insurance (see sections 3.2.1.3 and 3.2.2.5), in 2004 bodily injuries were compensated by motor accident insurance at a total of 191 million euros, while injuries were compensated by statutory accident insurance at a total of 593 million euros. 3.3.2 Voluntary health insurance Voluntary health insurance has a very marginal role in the Finnish health care system (see section 3.2.1.3). In 2006, Finnish private insurance companies collected 221 million euros (a little less than 2% of total health care expenditure) as premiums for all types of voluntary private health insurance. Premiums collected have increased by 61% from the year 2000. Relief funds collected insurance premiums totalling 45 million euros and employers financed funds by 20 million euros in 2004. 3.3.3 Out-of-pocket payments The share of out-of-pocket payments in total health care financing increased in the early 1990s (Table 3.1). This was partly due to the economic recession which forced the state to reduce public spending, meaning that the relative share of out-of-pocket payments increased. However, there has also been a real increase in out-of-pocket payments due to the abolition of tax deduction for medical expenses and the increase of user charges in public health care. User charges for curative outpatient services in health centres were reintroduced in 1993 (inpatient hospital care was already subject to daily fees). Before that, all visits to health centre doctors had been free of charge. The state has raised the maximum rate for user charges for health centre care several times since then. The maximum charges for hospital care and day surgery also increased several times. In addition to this, the reimbursement of NHI for private services has decreased, mainly because the level of reimbursement has not followed increases in service fees. However, the share of out-of-pocket payments has somewhat decreased again during the last five years (Table 3.1). Nevertheless, there has been concern about the consequences of high user charges, particularly their influence on the accessibility of services among lower income groups. Exemptions from user charges are not available to lowincome or any other groups. Rather, social assistance in the form of economic assistance is available when an individual’s or a family’s income is not sufficient to cover the cost of living, including health care costs. The payment of the 61
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benefit is stipulated by the Act on Social Assistance and is handled by the municipalities. Social assistance includes a basic sum of money in addition to special expenses that are taken into account separately (supplementary benefit). User charges for municipal health care and outpatient drugs can be covered under the supplementary benefit category. Under this system, user charges can be paid directly to the health care unit or pharmacy, or they can be reimbursed to the patient. The concerns that have been raised about high user charges led to the introduction of an annual ceiling for health care costs in the beginning of 2000. Within public sector health care, user charges have an annual ceiling of 590 euros, after which clients receive outpatient services free of charge. This ceiling is separate from the ceiling for out-of-pocket payments of outpatient drugs (see section 3.2.2.2). The payment ceiling applies to health centre outpatient physician’s appointments, physiotherapy, a series of treatments, hospital outpatient department fees and outpatient surgery fees. Fees for short-term institutional care in both social welfare and health care institutions are partly covered by this ceiling. After reaching the ceiling the daily charge for shortterm institutional care is reduced to 12 euros. The payment ceiling for parents also covers the fees for their children under 18 years of age. Health care service users are responsible for monitoring whether the payment ceiling is met. Clients may be asked to present original receipts before being issued a certificate to prove that the payment ceiling has been met. A certificate is issued by a health centre or other public health care establishment. 3.3.3.1 Municipal health services Legislation and Governmental decree defines the maximum fees which municipalities can charge for health care services and also the services which must be provided free of charge (Act on User-fees in Social and Health Care and Decree on User-fees in Social and Health Care). Municipalities are permitted to set lower fees than defined in the legislation, but usually municipalities use the maximum fees. Usually, user charges are not collected directly in the health care facility; instead patients are given a bill which is paid by bank transfer. Preventive health care, such as the services of maternity and child health clinics, is free of charge. Also immunization, examination and treatment of some communicable diseases specified by law (sexually transmitted diseases (STDs), tuberculosis, hepatitis and some others), medical aids such as wheelchairs and other moving aids, prostheses and transport from a health care unit to another when the treatment will continue at the other unit are free of charge. Persons under 18 years of age do not have to pay for health centre ambulatory services, such as an appointment with a physician or dentist, but may be required to 62
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pay a daily charge for up to seven days of treatment on an inpatient ward of a health centre or hospital. All the amounts and reimbursement rates mentioned in the following paragraphs are maximum user-fees defined in the governmental decree (Decree on User Fees in Social and Health Care, April 2008). The current Government intends to increase these fees during 2008. Health centre user charges A visit to the maternity or child health clinic, appointments with a public nurse, and laboratory and radiological examinations are free of charge at a health centre. A health centre may charge a single or annual payment for a physician appointment. A single payment is 11 euros, which can be charged for a maximum of three appointments, that is, 33 euros per calendar year. An alternative annual payment is a maximum of 22 euros per calendar year. A fee of 15 euros can be charged for a visit to the health centre emergency clinic on weekdays between 8 p.m. and 8 a.m., on Saturdays, Sundays and bank holidays. Clients aged 15 and above may be required to pay a penalty charge of 27 euros for unattended appointments. The basic fee for dental care is a maximum of seven euros. On top of this, a fee can be charged for the treatment administered (5–130 euros). The daily charge of inpatient care in a health centre inpatient ward is 26 euros per day. Hospital user charges Hospitals charge for a visit to an outpatient department, an outpatient surgery procedure, a daily hospital fee for inpatient care, a series of treatments and rehabilitation. A hospital outpatient department visit fee is a maximum of 22 euros per visit, while the fee for an outpatient surgery procedure is a maximum of 72 euros. The daily inpatient hospital charge is 26 euros in a general hospital and 12 euros in a psychiatric hospital, covering examinations, treatment, medicine and meals. A maximum of 80% of a patient’s monthly income (for example retirement pension) can be charged for long-term hospital or institutional care. Additionally, it must be ensured that at least 80 euros monthly remains available for the patient after paying user charges to the institution. With regard to a series of treatments, 6 euros is charged for each appointment for up to 45 appointments a year. A series of treatments can be, for example, dialysis treatment, radiographic or chemotherapy and medical rehabilitation. A daily fee of nine euros can be charged by an establishment for the rehabilitation of a physically or mentally disabled person. A maximum fee of 27 euros can be charged for a medical certificate, depending on the type of certificate. 63
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Home care charges The fees for care provided at home depend on whether the care is occasional or continual. A maximum of 11 euros per visit is charged for occasional treatment by a physician or a dentist, while 7 euros is charged for a visit by other types of health care professional. A monthly fee is incurred for continual treatment, which depends on the quality and extent of the service, as well as the patient’s monthly income and family size. 3.3.3.2 National Health Insurance and private sector In the private sector, patients pay all treatment costs themselves, but may claim partial reimbursement from NHI. Private health care providers can have a contract with the SII so that private health care units can charge the reimbursed proportion from the SII directly. Fees for private services (both outpatient and inpatient care) are reimbursed by NHI at a rate of up to 60% of the established basic tariff defined by the Government. The basic tariff for a 30-minute appointment with a GP, for example, was 18.50 euros in 2007. Treatment and examination ordered by a private doctor, such as laboratory tests and X-ray examinations, are reimbursed at a rate of 75% of the established basic tariff exceeding a deductible of 13.46 euros. Private health care providers are free to set higher prices than the basic tariff, and frequently do so. This means that NHI actually reimburses only on average a third of patient fees to private services. Outpatient drugs prescribed by a private physician are covered in the same way as those prescribed in municipal health care (see section 3.2.2.2). For ambulance services a patient must pay a fee of 9.25 euros (by cash or invoice) and the rest is paid by NHI directly to the service provider. NHI also reimburses the cost of other forms of transportation in connection with the treatment and examination of a disease or accident if this exceeds 9.25 euros (for example, a taxi). If the cost of transportation paid by patients due to disease or accident exceeds 157.25 euros per year, NHI reimburses all transport costs in excess of this limit. Private dentists’ fees are also partly reimbursed by the NHI. The reimbursement rate for examination, preventive care and basic treatment is 60% of the established basic tariff (prosthetics and orthodontics are excluded). 3.3.3.3 Pharmaceuticals Patients receive 42%, 72% or 100% reimbursement from NHI for the majority of prescription drugs. However, some pharmaceutical products are not included in the reimbursement system and some are reimbursed only to some specific 64
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groups of patients (see section 3.2.2.2). There is a maximum limit for drugs to be paid by patients per year (627.47 euros in 2007). All drug costs exceeding this limit are paid by NHI (except that after reaching the limit there is a fixed deductible fee of 1.50 euros per prescription). In international comparisons, the out-of-pocket share of outpatient prescription drug expenses in Finland is quite high, at 37% in 2006 (NAM 2007). Drugs administered during inpatient care in municipal health care units are covered by hospital daily fees or other user charges describe above.
3.4 Allocation of resources and purchaser– provider relations 3.4.1 Municipal health care system In the municipal health care system, resource allocation decisions are made at the municipal level. The state subsidy that is given to municipalities for arranging social and health care services (see section 3.3.1.1) is not earmarked. Municipal primary health care is provided by health centres which are directly governed by the municipality or local federation of municipalities. Specialized care is mainly provided by hospital districts. There is not a genuine purchaser–provider split in Finnish public health care, since municipalities both fund and own the service provision organizations. This is especially clear in primary health care, where the provider (health centre) is usually an integral part of municipal administration. However, very recently a few municipalities have introduced a purchaser–provider split to their administration (for example, the cities of Tampere, Oulu and Raisio). In 2007, there was one municipality which outsourced the provision of all services in primary health care. This municipality (Karjaa) has drawn up a contract for the next several years with a private NGO-based foundation to provide primary health care and elderly care to its inhabitants (see section 7.1.2.3). In addition to this, it is increasingly common for municipalities to purchase segments of services or specific service items from the private sector (for example, certain specialist care operations). The provision of municipal health services by municipalities’ own units without any purchaser–provider separation is subject to continuous debate in Finland. Some argue for full separation of the two roles, some argue for preservation of the integrated system. It is claimed that a true purchaser–provider split would enhance steering and make the municipal administration more transparent. It would also better allow the outsourcing of services to private 65
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providers, which has been argued to be a more efficient way to provide services. Introduction of a purchaser–provider split and outsourcing are most visibly backed by private health care providers, the Ministry of Employment and the Economy, the Finnish National Fund for Research and Development (Sitra) and right-wing politicians. Decisions on resource allocation, planning and organization of health care services are made by municipal health boards, municipal councils and municipal executive boards (see section 2.2.1). The health boards prepare the proposals for health budgets of the municipalities and the municipal councils approve them. Budgets are typically based on historical data and allocated without any specific targets or incentives. Municipalities usually have separate budgets or budget sections for primary health care (health centres) and specialized health care (hospital districts). There is great variation in terms of how resources are allocated between health stations (in larger cities the services of health centres are provided through several health stations located in different parts of the city) and inpatient and outpatient care. This is because there is no state level guidance on this level of resource allocation and the different systems in the municipalities have evolved independently over many decades. In hospital districts (see section 2.2.1 for details on their structure and function), it is the hospital district council which adopts the annual budget, approves the financial statements and makes decisions about major investments. There are different contractual or negotiation mechanisms between hospital districts and municipalities for agreeing target volumes and payments which comprise elements of purchaser and provider separation. These mechanisms have been under continuous change and development since 1993, when the new relationships came into effect (Act on Specialized Medical Care). A hospital district and its member municipalities usually negotiate on a yearly basis a target for volumes of services and subsequent costs. These two constitute the core of the operational plan and the budget for each year. Both the volumes and costs are planned on the basis of the previous year. In many cases views on the right size of the resource allocations differ between the municipalities and the hospital districts. There is a tendency for budgets to be too low and agreements are therefore sometimes revised during the year according to the actual amount and type of services provided by hospital districts. Usually there are no explicit sanctions if there is deviation from agreed plans and targets and municipalities cover any deficits and retain any savings in their accounts. Inside the hospital district resources are allocated between specialties and hospitals based on negotiations with municipalities on volumes of services. Particularly in the case of small municipalities, negotiations are shaped by the significant information and economic asymmetry between the municipality 66
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and the hospital district (Häkkinen 2005). In general, municipalities complain that they have too little influence on the volume and costs of hospital care of the hospital districts. For municipalities, it is much easier to contain the costs of their own health centres than it is to contain their share of the expenses of the hospital district. There are currently many ongoing development projects and natural experiments to address these issues (see section 7.1.2.2). In addition to contracting specialized health care services from their hospital districts, municipalities can organize specialist level services themselves, for example by using health centres as a base for consultative services. Municipalities can also purchase services from other hospital districts or from private providers. However, the volume of such arrangements is rather insignificant compared to services contracted from municipalities’ own hospital districts. In these cases service providers are usually paid on a case-by-case basis classified by the treatment given. 3.4.2 National Health Insurance and occupational health care The Parliament allocates resources to NHI by defining insurance fees (see section 3.3.1.2). The SII, which administers NHI, does not make purchasing contracts with private health care organizations; instead reimbursements are applied for directly by patients (except outpatient pharmaceutical reimbursements). NHI supervises neither the quality nor the efficiency of the private services which it funds (except by reminders in serious cases of obviously inappropriate drug prescriptions). Occupational health care services are usually purchased by employers from private providers or municipalities. In these cases there is clear purchaser– provider separation and employers define by contract the level and scope of services purchased for their employees. Some larger companies may also own their own service provision units so that they can provide health services inhouse.
3.5. Payment mechanisms 3.5.1 Paying for health services In primary health care, municipalities prospectively fund the budget of the health centres they maintain on their own. Usually budgets are set based on previous budgets. In federation-owned health centres the budgets are also prospective and 67
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built in a similar way but the sharing of costs to municipalities is determined usually by the volume of services given (see section 3.4.1). Hospital district invoicing and pricing is in a continuous process of change, varying from district to district (Häkkinen 2005) and at present, it is difficult to directly compare the services and prices between different hospitals and hospital districts. Apart from some special arrangements for maintenance of readiness for catastrophes (such as large scale traffic accidents or natural disasters) or pooling of exceptionally high costs, payments of municipalities are mainly based on price lists by either service item or a package of services (along the general principles of NordDRG (diagnosis-related group) pricing). In 2003, a survey found that eight hospital districts used NordDRG-based invoicing in somatic inpatient care and day surgery while the majority of districts used service groupings of their own (Punkari and Kaitokari 2003). Municipalities are charged prospectively but finances are balanced retrospectively according to actual services purchased. All hospital districts have also developed a special funding pool between member municipalities to cover exceptionally high individual patient expenses (typically above 50 000 euros per individual patient or episode). When municipalities and hospital districts make contracts to buy services from private providers, contracts and payment mechanisms vary considerably. These contracts must be arranged by open competition, due to anti-trust legislation. For private care patients, NHI reimburses costs for some services (see section 3.3.3.2) and some pharmaceuticals (see section 3.2.2.2). Occupational health care services are paid for by employers according to contracts between employers and providers (private providers or municipalities). Some larger companies may also have their own units to provide these services. Varying payment mechanisms are used in these contracts. Services are paid fully by employers and employers are partly reimbursed retrospectively by the NHI. NHI reimbursement is based on actual costs. 3.5.2 Paying health care personnel 3.5.2.1 Physicians The salaries of all physicians working in the public sector are negotiated by the physicians’ trade union (the Finnish Medical Association) and the Commission for Local Authority Employers. Other groups of health professionals have similar arrangements. The state plays no role in this procedure. Strikes by physicians are not very common. The last, by physicians in spring 2001 over pay and conditions of work, took five months to resolve. There has been only one previous strike episode by physicians, during the 1980s. 68
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The payment system of GPs in municipal health centres varies between municipalities. The traditional payment method, which currently applies to about 45% to 50% of health centre physicians, is through a monthly salary with some extra fee-for-service payments for selected time-consuming service items or minor procedures. In those health centres where the personal doctor system has been introduced (see section 6.3), doctors are paid a combination of a basic salary, capitation payment and fee-for-service payment for visits. During the last 10 years a new trend has emerged, that is outsourcing of the physician workforce (Vuorenkoski and Mikkola 2007). New firms have emerged which lease physicians to public sector primary health care. These firms are mainly owned by the physicians themselves. In these firms physicians are employed by the company and their salary is negotiated with the company. Municipalities use these services mainly when they have difficulties in recruiting physicians, especially for out-of-hour duties, although recently physicians have been leased by long-term contract for office-hour duties as well. These firms can offer better salaries and more flexible working conditions than municipalities and are therefore an attractive alternative for physicians. In 2004 about 5% of Finnish physicians worked in these firms (younger physicians are especially interested in these positions). Physicians in hospital districts are salaried employees. The basic monthly salary depends on the physician’s post and length of career. Various bonuses can be paid, such as for increased responsibility, but in practice this is little used. Usually there are no financial incentives for physicians to increase efficiency and quality. There is additional remuneration for being on call (it can also be taken as leave). Physicians receive some extra payments for issuing certificates of health status for various purposes. In addition, until recently there was a “special payment category” system in public hospitals. The same principle and practice occurs on the international scene, known as “semi-private beds”. According to this scheme, patients had the possibility to choose their medical doctor in public hospitals by paying extra fees, most of which go to the attending doctors. However, this special payment category was abolished in February 2008, and a new scheme has been introduced, in which private services can be offered in public hospitals during weekends and after 4 p.m. during weekdays. The system aims to compensate physicians for the loss of special payment category fees but in a way that will distribute earnings more equally among physicians and other hospital staff. The new system is also claimed to promote more efficient use of hospital facilities and equipment and to give the patients more freedom to choose their doctor and timing of care. The new scheme is a supplementary system and all patients still have their former rights to receive care at public hospital outpatient departments at defined fees during normal 69
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working hours. However, to date this system has not been implemented in any hospital district, because current legislation does not allow NHI reimbursement under it. Physicians’ earnings depend largely on how much they work out-ofhours, and how many bonuses they receive for experience, level of training, responsibility and so on. Specialists who work in private practice in addition to their work in public hospitals, and personal doctors who see a lot of patients and do a large amount of on-call work usually have a much higher income than those who work only during regular hours. The basic salary of primary care physicians was on average 5200 euros per month in 2006. The basic salary of hospital physicians was on average 4700 euros per month. These figures include the salary from working regular hours, but not for example payments for being on call or night duties. It is common that medical doctors working in public hospitals have a private practice in private facilities during evenings on a fee-for-service basis. In private health care, physicians usually work as autonomous practitioners. In these cases, practitioners are free to set their own rates. The SII has set a maximum level of reimbursement to the patient, but private practitioners are not obliged to set their fees at these levels and NHI has no contracts or negotiations on the level of charges. During recent years small private health care provider clinics have merged to form fewer, larger national level health care provider companies. An emerging trend is that physicians work for these firms as salaried employees rather than autonomous practitioners. 3.5.2.2 Nurses and midwives Nurses and midwives have a basic monthly salary and compensation for doing out-of-office hours work (which is set at about 30% extra). The basic salary depends on the competence and experience of the employee. The average monthly salary of nurses is low, at about 2400 euros in 2006, including extra compensations. There are not any major differences in nurses’ salaries between public and private health care, and between primary and specialized health care. Nurses have gone on strike several times in recent decades without results. In late 2007, their union took extreme measures and threatened not only a strike but also mass-termination of their contracts because of their low pay levels. The politically sensitive and publicly very high-profile and serious conflict ended with a compromise at the last moment.
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3.5.2.3 Pharmacists Pharmacies are privately owned by pharmacists (see section 6.6). From the difference of wholesale price and retail price (average around 26% of net sales) pharmacists must pay taxes (VAT at 8%), rent and salaries of employed personnel and so on. Pharmacies also pay a graded pharmacy fee to the state which depends on their net sales. The function of the pharmacy fee is to decrease the differences in income between pharmacies, but there are nevertheless major differences in profits between pharmacies (MSAH 2007a). In 2005, the average annual profit for a pharmacist was 280Â 000 euros (9.2% of the net sales), after overheads and running costs.
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4. Planning and regulation
4.1 Regulation
T
4.1.1 National level steering and regulation he MSAH directs and guides the development of health care at the national level. It defines the main course of social and health policy, prepares legislation and key reforms and steers their implementation, and handles the necessary links with the political decision-making process. In addition to legislation, health services are steered from the national level by programmes, information and resources. One of the most important tools in the national level steering process is the National Development Programme for Social Welfare and Health Care (previously the Target and Action Plan for Social Welfare and Health Care) which is drawn up for the whole period of office of each Government (normally four years). The general aims of the health care policy and the measures that will be taken in order to fulfil these aims are adopted in this document. The programme could be described as a cooperation plan between municipalities and the state. The Advisory Board of Social Welfare and Health Care is responsible for its preparation, implementation and follow-up. In addition, there are five regional steering groups. In relation to this programme the state funds local development projects in the social and health sectors (annually worth about 25 million euros). The programme also steers activities of KTL, STAKES, the Occupational Health Institute and provincial administration. The Government has also implemented a major measure for steering health care on a more ad hoc basis. In 2001 the Government initiated the ‘National Project to Ensure the Future of Health Care’, proposed by the Prime Minister and the Minister of Social and Health Services at the time. This was a response to several years’ debate concerning various problems in access to health care 73
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services. Based on the health-related needs of the population, the aim of the project was to ensure the availability, quality and appropriate volume of care throughout the country, irrespective of residents’ ability to pay. The main outcome of the project was the ‘Decision in Principle by the Council of State on Securing the Future of Health Care’ issued by the Government in 2002 (MSAH 2002), which focused on primary health care and preventive work, ensuring access to treatment, the availability and expertise of personnel, reforming functions and structures of health care, and augmenting the finances of health care (see section 7.1.1.2). A further example of Government programme steering is ‘Health 2015’, a public health programme enacted in 2001, which outlines the targets for Finland’s national health policy for the next 15 years (MSAH 2001a). The main focus of the strategy is on health promotion and the development of the health care system (see section 6.1.1). In addition, the MSAH has a wide variety of other projects to develop health care, for example for developing electronic prescriptions and nationwide electronic patient record systems (see section 7.2.2). Several bodies established at the national level have some direct regulatory functions (see section 2.2.2). The two most important of these in regard to health services in general are the health and social departments in the provincial administration and the NAMLA. In 2006, national level supervision was reinforced by expanding the functions of the NAMLA from supervising individual professionals to supervision of health care organizations, municipal health centres and hospital districts. Pharmaceutical markets are regulated by the NAM. STAKES has a central role in guidance through the provision of information (see section 4.2.2). STAKES produces statistical and comparative information and information on best practices in the field of welfare and health and forwards them to decision-makers and other actors in the field. For example, in recent years special quality guidelines have been developed for school health care and mental health care. Finland has been active in seeking external international reviews and evaluations to develop national health policy. The latest health policy review was conducted by OECD in 2005 (OECD 2005). 4.1.2 Regulation of municipal health care services Municipalities have a significant degree of freedom to plan and steer health care services. National legislation provides only a framework for the provision of health services at the municipal level. There are two main acts which set this 74
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framework, (the Primary Health Care Act, 1972 and the Act on Specialized Medical Care, 1991). Further legislation includes, for example, governmental decrees that explicitly define which vaccinations (Decree on Vaccinations and Screenings of Communicable Diseases During Pregnancy) and which screenings (Decree on Screenings) municipalities must provide free of charge. Legislation also defines explicit maximum waiting times (the Primary Health Care Act and the Act on Specialized Medical Care) and maximum user-fees (Act on Userfees in Social and Health Care and Decree on User-fees in Social and Health Care) for municipal services. The other main tools for steering municipal health services from the national level are information and local development programmes. STAKES has the main responsibility for managing information, and the application of EBM, local auditing and quality development programmes. By funding local development programmes the state can also attempt to influence services at the local level. However, the National Audit Office of Finland has conducted an audit of the system of development programmes in 2007 and found that it is not as efficient as it could be (Vuorenkoski 2007b). There have been some recent changes which have increased the possibility for stronger state regulation of municipal services (see section 7.2.3). Oversight of municipal health services is mainly in response to complaints or other highly visible problems in the operation of services. If the state level administration (either the ministry, the NAMLA or the provincial state authorities), detect overt violation or neglect of existing health service legislation, they can intervene. Usually this means raising problems to start a discussion, or issuing reminders or formal warnings. For example, in 2007 the NAMLA approached municipalities which did not comply with the maximum waiting time guarantee and urged them to fully implement the guarantee. There is another option of imposing a conditional fine in very special situations, but in general this is not used. Municipalities or municipal federations usually directly own and regulate health centres (see section 2.2.1). However, there has been a growing debate on whether municipalities should introduce a purchaser–provider split and outsource municipal administration, which would change this situation (see sections 3.4.1 and 7.1.2.3). Municipal regulation of specialized care is more complex. Hospital districts are governed by member municipalities which can influence hospital districts through their representatives on the executive board and the council of the hospital district (see section 2.2.1). Not including negotiations on volumes and costs (see section 3.4.1), municipal regulation of hospital districts is rather weak. This is particularly the case with small municipalities, where there is 75
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significant information and economic asymmetry between the municipality and hospital district (Häkkinen and Lehto 2005). 4.1.3 Regulation of National Health Insurance NHI is run by the SII which is under the direct supervision of the Parliament. The Parliament regulates NHI by legislation (the Sickness Insurance Act) and through a board of Parliamentary Trustees of the SII. The legislation defines which services SII reimburses. NHI is also controlled to some extent by the Insurance Department of the MSAH. For example, the department contains the PPB, which decides on the inclusion of drugs in the drug reimbursement system (see section 6.6). SII does not regulate the private health care providers to which it makes reimbursements. This has not generally been perceived as a problem. 4.1.4 Regulation of private sector and private insurance Regulation of private health care is stipulated in the Private Health Care Act, but is quite weak in Finland. Private health care providers must have a licence acquired from the provincial state administration. The provincial administration monitors the services to ensure they meet adequate standards and quality criteria. Independent private practitioners and private health care providers are also monitored by the NAMLA through patient complaints (see section 2.4.4). Private physicians who are members of the Finnish Medical Association are also regulated by the Association’s own codes of conduct, for example on the advertising of physician services to the public. If municipalities and hospital districts purchase services from the private sector, they regulate and control purchased services by contracts. Private health insurance is regulated by corresponding acts and the Insurance Department of the MSAH (see section 3.2.1.3).
4.2 Planning and health information management The MSAH has the main responsibility for national level planning of the health care system. The general aims of the health care system and the measures that will be taken in order to fulfil these aims are outlined in National Development Programme for Social Welfare and Health Care (see section 4.1.1). In addition to this, every year the MSAH draws up an administrative action and finance 76
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plan for the next four years. This document covers starting points and strategies, provides estimates and plans development. In addition to this general planning conducted at the national level, municipalities are responsible for more practical planning, for example concerning infrastructure, capital and personnel. STAKES supports planning at the municipal and ministry level by carrying out research and development projects and collecting register information. Municipalities’ planning activities are also supported by the Association of Finnish Local and Regional Authorities, of which municipalities are members. In primary care planning is performed by the chief physician and other senior individuals, the municipal council, the municipal health committee and the executive board. In hospital districts it is performed by chief physicians and other senior individuals, the council of the hospital district and the executive board. Citizens can participate in planning through the politically elected municipal council and municipal health committee (see section 2.2.1). It should be noted that the size of municipalities varies greatly and because of this there are significant differences between municipalities’ ability to carry out health care planning. 4.2.1 Health technology assessment The Finnish Office for Health Technology Assessment (Finohta) was established in 1995 within STAKES. The centre’s main objectives are to improve the effectiveness and cost-effectiveness of care and to promote the use of evidencebased methods in health care. Operation of Finohta is steered and regulated by the MSAH and STAKES as financiers. Finohta also has an Advisory Board on Health Care Technology Assessment which has representatives from organizations and communities that are relevant to their activities. The advisory board monitors the technology assessment system and the activities of Finohta and makes proposals to develop them further. Secondly, it has a Scientific Committee on Health Care Technology Assessment which has a broad representation of expertise in many scientific fields. The committee participates in selecting the technologies to be assessed and joins various scientific fields together in order to promote multidisciplinary assessment activities. The committee also produces expert statements and develops Finohta’s operations. Health technology assessment (HTA) of screening and rehabilitation is a priority, while pharmaceuticals are not a priority and are dealt with in assessments only as comparators to other methods. Finohta projects also investigate the social, ethical and legal aspects related to the technology in question. In addition, Finohta disseminates HTA information produced abroad and gives methodological and financial support to systematic reviews and 77
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research projects evaluating the cost-effectiveness of a given health technology. The Finnish branch of the Nordic Cochrane Centre is based within Finohta. In 2006, Finohta had a staff of 32 persons in Helsinki and Tampere covering a variety of professional expertise. In addition to this, national experts of various medical specialties are invited to participate in HTA projects as needed. The bulk of the yearly budget of 2.2 million euros is state funding. The resources available are quite limited meaning only a fraction of new technologies can be evaluated. Finohta has a major role in EUnetHTA, a large European collaborative project drafting a joint HTA methodology. Finohta completes between three and five major assessments yearly and between five and ten more limited HTAs, including systematic literature reviews (see section 5.1.3). The office disseminates assessment results both from Finland and other countries through several series of publications and the website (see section 10.3). In collaboration with other organizations, Finohta also provides education on HTA and evidence-based health care. The first Finnish language textbook of HTA was written by Finohta experts and published in 2007 (Mäkelä et al. 2007). 4.2.2 Information systems Information on the health care system and health status is collected in many different ways. This information is mainly collected by Statistics Finland, STAKES, KTL and the SII. 4.2.2.1 Health status Annual health survey on behaviour among the Finnish adult population, KTL Since 1978, KTL has annually monitored the health behaviour of the adult population through postal surveys. Each year a random sample (n=5000) of Finnish citizens aged between 15 and 64 years is taken from the population register. The average response rate has been 70% among men and 80% among women. The primary purpose of monitoring is to obtain information on health behaviour such as smoking and dietary habits and changes of habits. The questionnaire also includes questions about the consumption of alcohol, physical activity, dental health, perceived general health status and the use of health services. National Register of Infectious Diseases, KTL Physicians and laboratories are obliged by law to inform KTL about the incidence of certain defined infectious diseases. These diseases include infectious diseases which are severe and highly infectious and diseases which are included in the 78
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vaccination programme. In total there are approximately 30 diseases on the register, such as HIV, hepatitis, tuberculosis and measles. National Death Register Statistics Finland maintains a national death register based on death certificates issued by physicians. Registry of Occupational Diseases The FIOH has maintained the Registry of Occupational Diseases since the year 1964. All work accidents and occupational diseases which are reported to the statutory accident insurance system are registered. In addition, occupational diseases which are reported by physicians to occupational safety authorities are included in the register. National Health Insurance Statistics, SII The SII extensively collects and reports information concerning NHI. These include, for example, data on drug reimbursement (utilization), sickness allowances, disability pension, occupational health services, private care reimbursements and rehabilitation reimbursements (see section 2.2.3). Register of Congenital Malformations, STAKES The Register of Congenital Malformations contains data on congenital anomalies detected in stillborn infants and in live born infants before the age of one year. The register receives data from hospitals, health care professionals and cytogenetic laboratories as well as from the Birth and Care Registers maintained by STAKES and the Cause of Death Register maintained by Statistics Finland. The register contains data from 1963 onwards. Register of Visual Impairment, Finnish Federation of the Visually Impaired, STAKES The Register of Visual Impairment is maintained for STAKES by the Finnish Federation of the Visually Impaired. Notifications are sent to the register by the treating physician or another member of the care personnel. The register contains data on cases of visual impairment from 1983 onwards. Database on alcohol and drugs, STAKES This database contains data gathered from different authorities on the consumption and use of alcoholic beverages and drugs, the alcohol economy, the adverse health effects and social effects of substance abuse, and services for substance abusers. The database was established in 1995 (alcohol statistics have been gathered since the year 1932). Cancer Register, the Cancer Society of Finland, STAKES The Cancer Register is maintained for STAKES by the Cancer Society of Finland. Notifications on cases of cancer are sent to the register by physicians, pathological, cytological and haematological laboratories and Statistics Finland (death certificate data). The register was established in 1952. 79
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4.2.2.2 Health care services Hospital Discharge Register, STAKES The register contains client-specific hospital discharge data on institutional care in social and health care. Hospitals (both public and private hospitals) and health centre inpatient wards report the end of all periods of care (including ambulatory surgery) to the register. The register includes, for example, age, sex, diagnosis, treatments given and treatment period. In addition, client censuses are conducted concerning all clients that have received care at the end of the calendar year. Health Care Activity Statistics, STAKES These statistics relate to public ambulatory health care and support services. The data are collected as summary data from health centres and hospital districts. Between 1994 and 2001, the statistics were compiled by the Association of Finnish Local and Regional Authorities. After that, STAKES became responsible for the compilation. Before 1993, the MSAH maintained a report system for social welfare and health care. Municipal Database for Social and Health Statistics The Municipal Database for Social and Health Statistics (SOTKA) contains statistical data and indicators concerning welfare and health collected from different sources. Municipality-specific data concerns various items, including municipal finances, population, families, housing, social and health care personnel, use and expenditure of services. Statistics on Municipal Finances and Activities, Statistics Finland Statistics Finland gathers information on municipal finances and activities on a yearly basis. The statistics contain information on municipally funded services, meaning services that the municipality provides itself for its inhabitants or purchases from other municipalities, municipal federations, the state or private service providers. Statistics on Health Care Expenditure, STAKES The data on health care expenditure and financing is derived from a database maintained by STAKES. Data for the database comes from various health care statistics, inquiries and studies. The earliest data is from 1960. Register of Induced Abortions and Sterilizations, STAKES STAKES maintains a register on abortions and sterilizations from the reports of the treating physicians. Data on induced abortions has been collected since 1950 and on sterilizations since 1935. Infertility treatment statistics, STAKES The infertility treatment statistics contain data on advanced infertility treatments. Data is collected on the number of procedures, the background information of treated women or couples and the results of treatments (pregnancies, deliveries 80
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and births). STAKES has gathered this data from the year 1994 onwards. The data is obtained from all clinics giving infertility treatments. Medical Birth Register, STAKES The register contains data on mothers and children born in Finland. The data is gathered from hospitals and complemented by data obtained from the Cause of Death Register of Statistics Finland and by data from the Central Population Register. The register contains data from 1987 onwards. Register of Health Care Professionals, NAMLA The NAMLA is responsible for the authorization and registration of health professionals. Every year STAKES compiles statistics concerning these professional groups. Register of Municipal Employees, Statistics Finland The register contains data on personnel employed by municipalities and municipal federations. Statistics on Private Health Care, STAKES The statistics are based on activity reports submitted by private health care providers to the Provincial State Offices. The statistics contain data on ambulatory service provision and employees. Drug consumption statistics, NAM The NAM gathers drug consumption statistics. The sales figures are based on the sales of the three largest drug wholesalers in Finland, which together account for nearly 100% of total drug sales. The remainder (about 1%) is mainly comprised of hospital sales. Adverse effects of drugs and devices, NAM Information on adverse effects of drugs and medical devices is gathered by the NAM. The information is gathered from physicians, dentists and manufacturers. National Implant Registers, NAM The NAM keeps the Implant Register on Orthopaedic Endoprostheses and the Register on Dental Implants. 4.2.3 Research and development There are many organizations contributing to health care research and development in Finland. Main state level organizations are STAKES, the FIOH and KTL. The MSAH has a small research and development unit which is responsible for overall coordination of research and development activities in the social and health sector. 81
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STAKES produces and disseminates knowledge and expertise on the social and health sector to decision-makers and other actors in the field. STAKES is a centre of expertise, and its core functions lie in research, development and information resources. In 2006 STAKES had a staff of about 500. It had 25 million euros for operational expenditure from the state budget, which was 66% of its total funding. Every year an operational plan is negotiated and agreed with the MSAH which gives STAKES guidelines for the activities of the next year. STAKES has a Health Services Research division which has about 90 employees. The division includes the HTA unit (Finohta) (see section 4.2.1) and the Centre for Health Economics. Currently, health care related activities of STAKES include among other things research on: equity and quality in health care services; health economics; development of information systems; health promotion; mental health; and substance abuse. STAKES also has a separate division for maintaining national statistics and registers in the health and welfare fields. The WHO Collaborating Centre for Mental Health Promotion, Prevention and Policy Implementation (WHO-MH3P) has been in STAKES since 2006. Research and development work is also an important part of the activities of FIOH. The aim of this work is to generate new knowledge that can be applied to improve working conditions, to promote workers’ health and work ability, to ensure the smooth functioning of working communities, and to enhance wellbeing. Most of the research done by FIOH is applied research yielding results that can be quickly put to use in Finnish working life. Some of the research aims at more long-term results, seeking to understand, for instance, the causal mechanisms of diseases and determining the theoretical basis for occupational health-related phenomena. In 2006 FIOH had a staff of about 800. KTL monitors the health of the population and the factors influencing it. Additionally, it develops tools to promote public health and distributes information to decision-makers, actors and individual citizens. Together with the relevant authorities, organizations and health experts, the institute participates in the national and international tasks of health promotion. The institute maintains monitoring and information systems. It also modifies data, whether collected by itself or some other party, for the use by decision-makers and other actors. In 2006 KTL had a staff of about 900. The Rohto was established in 2003 to deal with the assessment of drugs, especially those used in primary health care, and the implementation of such information to develop pharmacotherapy in Finland. In addition to about 10 full-time employees, Rohto has part-time employees working in the field. Implementation of knowledge for promoting rational pharmacotherapy is based on local Rohto educational and development activities coordinated by regional facilitators in hospital districts and by local facilitators in health centres. 82
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The SII has a research department, which undertakes research and development projects focusing on social security and health provision of the Finnish population and on the benefit schemes, client services and other operations of SII. It has a staff of about 60 persons. Research is focused on for example, the following topics: the need for health services and rehabilitation and their outcomes; mental health problems as a cause of work disability; the funding of health care through insurance-based arrangements; the targeting of drug reimbursements according to needs; and the links between the availability of drug reimbursements and the use of prescription pharmaceuticals. The Academy of Finland, which works under the supervision of the Ministry of Education, provides funding for high quality scientific research, serves as an expert organization in science and science policy, and strengthens the position of science and research in society. One of the four councils of the Academy is the Research Council of Health. In 2005 the Academy of Finland funded research on medicine and health sciences to a sum of 42 million euros. The Academy of Finland also had a special Health Services Research Programme during the years 2003–2007. Sitra is an independent public foundation under the supervision of the Finnish Parliament. Its activities are designed to promote the economic prosperity of the Finnish people. The Fund was set up in conjunction with the Bank of Finland in 1967 in honour of the 50th anniversary of Finnish independence. The Fund was transferred to the supervision of the Finnish Parliament in 1991. Sitra has a Health Care Programme, the objectives of which are: to improve the status of customers in health services; to increase the profitability and effectiveness and the cooperation between the public and private sectors; to promote the comprehensive use of new technologies and services; and to generate new business in Finnish and international markets. In 2007 the programme included six projects: Health Fund, internationalization, paperless health care, multi-centre specialized health care, seamless services and support services. In addition to venture capital investments, approximately three million euros annually have been reserved for these development projects. Health Fund was founded in 2006 as a new venture capital fund which invests in health care and companies serving the health care industry. Investments can be made in either existing or start-up companies that apply the best practices in health care. The aim of the investments is to enhance productivity of the health care sector and the acceleration of structural change. The Health Fund had 28 million euros worth of capital in 2007 from which 10 million is invested by Sitra. TEKES, governed by the Ministry of Employment and the Economy, promotes the competitiveness and profitability of Finnish industry and the service sector by assisting in the creation of world class technology and technological know-how. From the perspective of the health care system the most important 83
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programme of TEKES is the Healthcare Technology Programme lasting from 2004 to 2009 (FinnWell). The objective of the programme is to improve the quality and profitability of health care, and to promote business activities and export in the field. The total value of the programme is 150 million euros, of which TEKES invests about half and the participants of the programme fund the other half. Three kinds of projects are funded by the programme: development of technologies for diagnostics and care; development of information technology products and systems that support care, follow-up or prevention of illnesses; and development of the operational processes of health care. TEKES also funds programmes for the biomaterial industry and pharmaceutical industry. Other important research organizations are the universities and polytechnics (also called universities of applied sciences). These organizations conduct for example, clinical research, nursing research, health economics and health care administration research, health policy research and health sociology. The main organizations which conduct clinical research are five medical faculties connected to five university central hospitals. Health service providers receive special earmarked contributions from the state which are intended to compensate for the research component of their work (49 million euros in 2006 from which 84% was given to university central hospitals).
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5. Physical and human resources
5.1 Physical resources
F
5.1.1 Infrastructure inland does not have an explicit national level planning system for health care infrastructure. Planning for health care services is decentralized: the 415 municipalities and 20 hospital districts are responsible for planning on a municipal level. At the national level, STAKES gathers information concerning infrastructure and provides this information on a regular basis to municipalities and hospital districts for planning purposes. Planning in private health care rests solely on the provider companies. In 2005 there were 46 episodes of inpatient care in health centres per 1000 inhabitants and 209 episodes in hospital districts per 1000 inhabitants (Table 5.1). Health centre inpatient wards cater mainly for the needs of elderly persons including long-term care services (see section 6.3). Finland no longer compiles data on general hospital bed numbers. However, we can estimate the number of beds based on the number of care days assuming a 100% occupancy rate: there are estimated 3.1 hospital beds per 1000 inhabitants in hospital districts, 3.8 per 1000 inhabitants in health centres and 0.3 per 1000 inhabitants in private health care facilities. The average length of stay (excluding psychiatric beds) was 5.4 days in hospital district hospitals and 30.4 days in primary health centres in 2006 (STAKES 2007d). There has been a shift from inpatient care to day surgery since the 1990s (see section 6.4). In the early 1990s there were 4.3 acute hospital beds per 1000 inhabitants (Fig. 5.1), comparable to the EU average. During the period 1990–2003 the number of acute care beds decreased to 2.3 per 1000 population, so that towards the end of the decade Finland (together with Sweden) had the lowest number of acute hospital beds among the Nordic countries (Fig. 5.2). Compared to western 85
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Table 5.1
Finland
Patients in inpatient care
1995/1996 2005 Municipal primary care (health centres) Periods of care (per 1000 inhabitants) 39 46 Care days (per 1000 inhabitants) 1371 1388 Municipal specialized care (hospital districts) Periods of care (per 1000 inhabitants) 210 209 Care days (per 1000 inhabitants) 1561 1149 Private health care Periods of care (per 1000 inhabitants) 10 14 Care days (per 1000 inhabitants) 97 92 Treatment of mental disorders Periods of care (per 1000 inhabitants) 14 14 Care days (per 1000 inhabitants) 500 397 Source: STAKES, 2006b.
Europe, the reduction in acute hospital beds in Finland was steep (Fig. 5.1). In 2003, the number of hospital admissions in acute care was similar to the EU average, while the average length of stay was among the lowest (Table 5.2). Between 1995 and 2005 inpatient psychiatric hospital care days decreased from approximately 500 to 397 days per 1000 inhabitants (Table 5.1). This reduction is largely due to declining average lengths of stay, since the number of inpatient episodes have not decreased during this period. During the 1990s many long-term patients were transferred from institutionalized care to outpatient care and ‘transitional’ services such as supported housing. 5.1.2 Capital stock and investments From the 1970s until the 1980s there was a special state subsidy system to support capital investments. From 1993 the state almost totally withdrew from funding capital investments. Currently, capital investment in health care is controlled by the providers: municipalities, hospital districts and private providers. The state level administration may only intervene in special situations, for example if an important building is removed from active use due to health and safety reasons. The municipalities and hospital federations are free to invest in technologies. Municipalities and hospital districts normally fund the investments from the annual budget (see section 3.4). Usually the hospital and health centre buildings are owned by the municipal service providers. Many of the hospital buildings were built in the 1950s–1960s, and health centre buildings 86
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Fig. 5.1
Finland
Hospital beds in acute hospitals per 1000 population in the European Union, 1990 and 2003 or latest available year (in parentheses)
EU Member States since 2004 or 2007 EU15 average (2005) EU United Kingdom (1998) Turkey The former Yugoslav Republic of Macedonia Switzerland (2005) Sweden (2005) Spain (2005) Slovenia Slovakia (2005) Romania Portugal (2005) Poland Norway Netherlands Malta (1997) Luxembourg (2004) Lithuania (1992) Latvia (1998) Italy (2005) Ireland (2005) Hungary Greece (2005) Germany (1991) France (2005) Finland Estonia Denmark (2004) Czech Republic Cyprus (2005) Belgium Austria 0
2.0
4.0
6.0
8.0
10.0
2006 1990
Source: WHO Regional Office for Europe, January 2007. Note: EU: European Union.
were built about 20 years later. Both hospitals and health centre facilities are increasingly requiring renovations. 5.1.3 Medical equipment Public sector health care units (health centres and hospital districts) fund medical equipment from their annual budget. There is no state level control over the acquisition of medical equipment, even concerning very expensive equipment. Because of this, it can be assumed that there is considerable variance in geographical distribution of equipment, although there is no data to support this. In 2005 there were 14.7 magnetic resonance imaging units and 14.7 computed tomography (CT) scanners in Finland per million population (Table 5.3). 87
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Fig. 5.2
Finland
Beds in acute hospitals per 1000 population in Finland and selected other countries
9 8 7 6 5 4 3 2 1 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Denmark Sweden
Finland United Kingdom
Germany EU average
Norway
Source: WHO Regional Office for Europe, January 2007. Note: EU: European Union.
Health care units can seek advice from Finohta (see section 4.2.1) when making decisions to acquire new medical equipment. In 2006 Finohta and hospital districts initiated a joint process to develop a structure for joint appraisal and decision-making with regards to the uptake of new medical technologies (MUMM-programme) (Kaila 2007). In 2007 a pilot assessment on five interventions was done (intravenous laser therapy for varicose veins, MARS – liver dialysis, vacuum treatment of wounds, long anti-thrombotic treatment in conjunction with joint replacement surgery, and 64 multislice-CT in the diagnosis of coronary disease). The second set of selected topics include: spinal cord stimulation for chronic back pain, radio-frequency ablation for snoring, vagus nerve stimulator treatment for treatment resistant depression and epilepsy, and treatment of macular degeneration with intravitreal anti-vascular endothelial growth factor injections. Over the next few years it will become evident whether this process improves the managed uptake of new medical technologies in hospital districts. 5.1.4 Information technology Almost all health centres and some hospital districts have electronic patient records and other information technology systems for data management. However, the Finnish health care system is decentralized and the development of health care information systems has been pronouncedly uncoordinated which 88
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Table 5.2
Finland
Inpatient utilization and performance in acute hospitals in the European Union, 2006 or latest available year
Hospital beds Admissions Average Bed per 1000 per 1000 length of occupancy population population stays in days rate (%) 26.1b 6.9b 79.6a Austria 6.4a a b b Belgium 4.7 16.2 8.0 67.3b h h h Bulgaria 7.6 14.8 10.7 64.1h b b b Cyprus 3.5 7.9 6.0 84.5b a a a Czech Republic 6.1 20.5 8.0 72.9a c f c Denmark 3.1 17.8 3.4 84.0f a a a Estonia 3.9 16.8 5.9 70.9a a c c Finland 2.4 19.9 4.2 74.0i b b b France 3.7 16.5 5.9 77.1c a a a Germany 6.2 20.3 8.5 76.3a b g d Greece 3.9 14.5 5.7 66.6g a a a Hungary 5.5 23.0 6.1 70.3a b b b Ireland 2.9 13.9 6.6 85.6b b c c Italy 3.4 14.3 6.7 76.4c a a Latvia 5.3 20.3 – – Lithuania 5.1a 20.7a 6.9a 76.1a Luxembourg 5.1c 18.4j 7.7g 74.3j a a a Malta 2.9 11.4 5.3 89.6a a f c Netherlands 3.0 8.8 7.0 58.4f e Poland 4.7 – – – Portugal 3.0b 11.3b 7.1b 73.2b Romania 5.1a – – – b b Slovakia 6.2 18.1 8.1b 67.2b Slovenia 3.8a 17.1a 5.8a 71.6a b b b Spain 2.7 11.6 6.7 79.1b b b b Sweden 2.8 15.1 6.0 77.5h g h h United Kingdom 2.4 21.4 5.0 80.8g a b b EU average 4.1 17.1 6.7 75.9b b c c EU 15 average 3.9 16.9 6.7 – Source: WHO Regional Office for Europe, January 2007. Notes: a 2006; b 2005; c 2004; d 2003; e 2002; f 2001; g 1998; h 1996; i 1995; j 1994; EU15: EU Member States before 1 May 2004.
has resulted in a situation where non-interoperable information systems are used even within individual health care organizations. However, national level steering has strengthened recently. Parliament decided in December 2006 that a statutory nationwide electronic patient record (EPR) system and nationwide electronic prescription system will be introduced in Finland following a fouryear transition period (see section 7.2.2). 89
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Table 5.3
Finland
Items of functioning diagnostic imaging technologies
MRI units CT scanners
per 1 million population 1995 2005 4.3 14.7 11.7 14.7
Source: OECD, 2007. Notes: MRI: Magnetic resonance imaging; CT: Computer tomography.
In terms of general Internet utilization in 2006 there were 477 Internet subscriptions per 1000 inhabitants (Statistics Finland 2006b) and 61% of Finnish people (aged 15–74 years) used the Internet weekly from home, workplace or from their place of study.
5.2 Human resources 5.2.1 Trends in health care personnel The majority of health care professionals working in the health care sector are employed in municipally operated health services (health centres and hospital districts). The distribution of municipal employees across the different professional groups is shown in Table 5.4. In 2005 there were 123 700 municipal employees in the health care sector of whom 71 400 (58%) were working in hospital care (STAKES 2007d). The number of employees has risen by 15% since 1995. In the private sector there were 28 400 employees in 2004. Some of the registered professionals work in other sectors or in other countries; in 2006, 840 doctors and 4010 nurses were employed outside Finland. Until the 1990s unemployment among physicians, dentists and nurses was practically non-existent, but the economic crisis led to a reduction in health care resources and significant unemployment. In addition, the yearly intake to medical schools was reduced in the early 1990s, as it was predicted that the need for medical doctors was decreasing. As the public sector gradually recovered from the economic crisis in the late 1990s, a significant physician and dentist shortage developed. In order to rectify this situation the yearly intake of medical students was increased from 365 to 627 in the period 1995–2005. However, this measure will take many years to significantly address the physician shortage. Until 2007 there have been considerable difficulties to recruit physicians and dentists, especially to rural health centres which have disproportionately fewer physicians. For example, in October 2006 9% of the physician posts in health centres were not filled but in the Kainuu region (northern Finland) this figure 90
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Table 5.4
Finland
Health care personnel (man years)
Municipal health care Registered1 Proportion in per 10 000 per 10 000 municipal 2005 population 1990 2005 population increase health care Health and social 3 320 3 310 6 0% services managers Other senior officials 520 440 1 -15% Physicians 17 101 33 8 070 10 340 20 28% 60% Dentists 4 537 9 1 960 2 040 4 4% 45% Senior nurses and 7 170 5 690 11 -21% ward sisters 120 17 190 31 890 61 86% 60% Nurses 62 333 Public health 14 024 27 4 520 5 140 10 14% 37% nurses Radiographers 3 327 6 1 420 1 740 3 23% 52% Midwives2 3 722 7 220 1 470 3 40% Dental hygienists3 1 456 3 210 650 1 210% 45% Auxiliary nurses 81 996 158 19 030 30 030 58 58% 37% Auxiliary mental 5 223 10 4 660 2 740 5 -41% 53% nurses Hospital and 2 033 4 710 670 1 -6% 33% ambulance attendants Dental assistants 6 123 12 2 430 2 600 5 7% 43% Physiotherapists 11 290 22 1 290 2 250 4 74% 20% Occupational 1 732 3 280 560 1 100% 32% therapists Medical laboratory 6 771 13 2 830 3 520 7 24% 52% technologists Assistant nurses 14 150 6 460 12 -54% and hospital ward assistants Sources: STAKES, 2006b; Statistics Finland, 2006b. Notes: 1Working age; 2Midwives were officially composed of a distinctive group from nurses in 1994; 3Statistical increase of dental hygienists is partly explained by the change in professional title.
was 26% (Parmanne and Vänskä 2006). Currently, the shortage is even more significant among dentists. About 12% of dentist posts in health centres were not filled in 2007 (MSAH 2008a). In addition, in spite of a significant increase in the number of nurses and auxiliary nurses since 1990, currently health care providers have increasing problems to recruit enough nurses. During the years 1990–2005 the number of registered working age physicians increased by 41%. The number of physicians working in municipal health care increased by 28% during the same time period (Table 5.4). In 2006 47% of physicians worked in hospitals, 23% in health centres, 5% in occupational health 91
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care, 6% in the academic field and 11% in full-time private practice (Suomen Lääkäriliitto 2006). The average age of working age physicians has increased by three years to 46 years during the last 10 years (Elovainio et al. 2007). In 2006 the number of physicians per capita was the same as the EU average, while the number of nurses was slightly higher (Fig. 5.3) (note that Fig. 5.3 shows active personnel while Table 5.4 shows registered personnel). Fig. 5.4 compares the trend in the number of physicians in Finland from 1990 to 2006 with selected other countries. In comparison to the Scandinavian countries, the number of physicians per 1000 population in Finland remains one of the lowest but it has steadily increased since 1990, reaching the EU average by 2005. During the years 1994–2005 the number of registered working age nurses increased by 33% and in 2005 there were 12 registered working age nurses per 1000 inhabitants (Table 5.4). More than half of Finland’s dentists, dental hygienists and dental assistants are working in the private sector, as the majority of services are provided there. During the years 1990–2005 the number of registered working age dentists increased by 1%. The number of dentists and dental assistants in the municipal sector remained almost the same during the same time period (Table 5.4). During the years 1990–2005 the number of registered working age pharmacists increased by 61%. In 2007 there were 1400 pharmacists and 3800 assistant pharmacists working in pharmacies (excluding hospital pharmacies). Very few pharmacists work in the municipal sector (those that do are mainly in hospital pharmacies). 5.2.2 Planning of health care personnel In Finland there is no state level mechanism to directly steer strategic human resources for health geographically or by level of care, except to influence the education of health professionals. However, in the last few years general level needs assessment and human resource planning have been conducted in the context of overall labour projections in collaboration with the Ministry of Education, the Ministry of Labour, MSAH, Statistics Finland and municipal organizations. The Ministry of Education is responsible for regulating and supervising the training of health care professionals. Universities are public, but autonomous. In theory, universities are free to decide on the number of students to be taken in, but in practice, the Ministry of Education and the universities reach an agreement on the budget and number of students. Polytechnics (institutions providing training for nurses) are governed by municipalities under the guidance 92
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Fig. 5.3
enmark Finland
Number of physicians and nurses per 1000 population in Finland and selected other countries
Monaco (1995,1995) Greece (2004,2004) Belgium (2003,2004) Switzerland (2005,2000) Italy Iceland (2005,2004) Israel Netherlands Norway Denmark (2004,2004) Austria Malta Portugal France Germany (2005,2004) Andorra Sweden (2004,2002) Spain (2003,2000) Finland (2003,2004) Ireland Luxembourg (2004,2004) San Marino (1990,1990) Cyprus United Kingdom (2002, –) Turkey (2003,2004) Central and south-eastern Europe Lithuania Bulgaria Czech Republic Estonia (2004,2004) Latvia Slovakia (2004,2004) Hungary Serbia Croatia Slovenia (2004,2002) Poland (2004,2004) The former Yugoslav Republic of Macedonia Romania Montenegro Bosnia and Herzegovina Albania (2004,2005) CIS Belarus Georgia Russian Federation Kazakhstan Azerbaijan Armenia Republic of Moldova Ukraine Uzbekistan Turkmenistan (2004,2004) Kyrgyzstan Tajikistan Averages CIS average EU Member States before May 2004 (2004,2004) EU average
6.6 4.9 3.5 4.4 13.4 3.9 8.3 3.9 7.0 3.7 9.4 3.7 6.1 3.7 14.5 3.7 15.3 3.6 9.8 3.5 6.1 3.5 5.5 3.4 4.6 3.4 7.5 3.4 7.7 3.4 3.4 3.2 10.2 3.2 3.7 3.2 7.6 2.8 15.4 2.8 9.5 2.5 5.1 2.4 4.0 2.1 1.4 2.6
16.2
4.0 7.4 3.6 4.0 3.6 8.5 3.2 6.4 3.2 5.4 3.1 6.6 2.8 8.8 2.6 5.4 2.5 5.2 2.3 7.2 2.2 4.6 4.8 2.2 3.7 1.9 1.9 4.9 1.4 4.4 1.2 3.6 4.7 4.5 4.2 3.7 3.6 3.5 3.1 3.0 2.7 2.6 2.5 2.0
3.9
4.1
4.7 5.8
11.9
8.0 6.4 7.2
7.1 7.8 10.2
4.4
3.7 3.4 3.2 0
Physicians Nurses
7.9 7.5 7.0 5
10
15
20
25
Number per 1000 inhabitants
Source: WHO Regional Office for Europe, January 2007. Notes: CIS: Commonwealth of Independent States; EU: European Union. 83 93
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Fig. 5.4
Finland
Number of physicians per 1000 population in Finland and selected other countries
4
3
2
1 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Denmark Sweden
Finland United Kingdom
Germany EU average
Norway
Source: WHO Regional Office for Europe, January 2007. Note: EU: European Union.
and financial support of the Ministry of Education. The Ministry of Education also consults the MSAH on the number of students needed. During the early 1990s, in connection to the economic recession, entrance places in medical schools were reduced. However, from the mid-1990s a significant shortage of physicians developed due to the gradual recovery of the public sector. To address this shortage, the yearly intake of new medical students was increased (Fig. 5.5). However, the impact of this measure takes a long time to take effect and there is still a lack of physicians in Finland. The same pattern can also be seen among dentists. Training for pharmacists and assistant pharmacists has also increased during the years 1995–2005. In the future the need of health care professionals will increase mainly for two reasons. Firstly, a significant proportion of health care professionals will retire in the near future. Secondly, the demand for health services will continue to increase with the ageing population and growing expectations for medical care. 5.2.3 Training of health care personnel Physicians are educated at five universities. Universities are public and education is free of charge. Entrance is based on grades from high school and on entrance exams. Basic medical education lasts six years and contains 94
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Fig. 5.5
Finland
New students accepted in universities (related to health care)
700
600
Students
500
400
300
200
100
0 1990
1992
1994
1996
1998
2000
2002
2004
Year Health scientist Physician Dentist Assistant pharmacist Pharmacist
Source: KOTA, 2007.
considerable guided practical training. After studies in university, two years of practical work and training is required, both in hospitals and in health centres, to obtain a licence to work independently as a physician. Part of this training may be completed in the private health care sector or by practising scientific research. Dentists are trained in three university medical faculties and their studies last five years in total. To become a specialist, physicians and dentists must register with a faculty of medicine for the relevant specialist training programme. Specialization lasts five to six years depending on the specialty. To obtain a specialist diploma, a specified amount of theoretical study is required and a national examination must be passed in addition to the required amount of clinical work. Specialization begins with the resident working as a junior hospital doctor at a central hospital or district hospital under the supervision of an experienced physician. This is followed by at least one or two years working at a university hospital 95
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in addition to a structured training programme which is required for most medical specialties. In 2006 about 63% of working age physicians had specialist training (the majority of the rest were working as GPs) and 22% had a PhD degree (Suomen Lääkäriliitto 2006). According to the statistics of the Finnish Medical Association, there were estimated 360 physicians licensed in Finland in 2007 who were not Finnish. The largest groups of foreign physicians were from Estonia and the Russian Federation. The training of nurses and other health care personnel such as physiotherapists, midwives and laboratory personnel takes place at polytechnic schools. In Finland general and specialized programmes of nursing have been combined: students have common training in general nursing, complemented with training from a specialty of their choice: nursing for surgery and internal medicine; paediatric nursing; anaesthetic and operating theatre nursing; or psychiatric nursing. The training programme for public health nurses lasts three and a half years and for midwives four and a half years. Assistant nurses used to be trained in a one-year programme, but this programme has been abolished. Instead, a new two and a half-year programme in basic care provision has been launched in both health and social services. Finnish universities also have programmes of nursing science and health sciences. Both of these lead to bachelor and master degrees. These programmes lead to administrative, educational and scientific careers. Training of pharmacists and assistant pharmacists takes place in three universities. Pharmacist education takes five years and assistant pharmacist three years. Training of psychologists also takes place in the universities. Legally, health centres and hospital districts are responsible for arranging continuous education for their personnel (Primary Health Care Act and Act on Specialized Medical Care). It is recommended that 3–11 days training per year is undertaken, depending on the type of profession. After graduation, continuous medical education for physicians is provided by employers, medical societies, universities and pharmaceutical companies. 5.2.4 Registration/licensing The NAMLA is responsible for licensing, registration and, together with the State Provincial Offices, supervising of health care personnel. It also undertakes disciplinary procedures (99 procedures in 2006) concerning health care personnel. Health care professionals in Finland are licensed for their entire active careers and systems of periodic relicensing are not in use.
96
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6. Provision of services
6.1 Public health
H
ealth promotion, including the prevention of diseases, has been the main focus of Finnish health care policy for decades. This has resulted in the eradication of certain communicable diseases, a decrease in several lifestyle-related diseases and an improvement in the health of the population. Health promotion is carried out on a national and municipal level. Many NGOs also implement extensive programmes for health promotion. Health promotion is funded primarily through municipal budgeting. In addition, the state budget includes a separate allocation for health promotion programmes (9.3 million euros in 2007) from which contributions are given upon application for projects arranged by municipalities, NGOs and other actors. NGOs are also eligible for financial support from the revenue of the Slot Machine Association (see section 2.2.5). 6.1.1 National level At the national level, the MSAH is the main actor to protect and promote public health. It has responsibility within the state administration for health protection, environmental health and chemical affairs, and tobacco and alcohol control. Several agencies and institutions subordinate to the ministry carry out some of these tasks (STAKES, KTL and the FIOH). The goal is to address health issues in all societal sectors and all policies. In 2007 the Government initiated a new four-year multisectoral Government Policy Programme for health promotion (see section 7.1.1.9). The aim of the programme is to promote health and reduce health disparities through coordinated actions of different ministries. The overall health promotion target is based on the Health 2015 public health cooperation programme, which was approved by the Government in 97
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2001 (MSAH 2001a). The programme outlines the targets for Finland’s national health policy for the next 15 years. The strategy design was based on the WHO Health for All programme, revised in 1998. The strategy is a continuation of the Finnish national Health for All 2000 programme which was adopted in 1986 (MSAH 1987). The public health cooperation programme provides a broad framework for health promotion in various component areas of society. It reaches across different sectors of administration, since public health is largely determined by factors outside health care. The concepts ‘settings of everyday life’ and ‘life course’ play a key role in the programme. The strategy presents eight targets for public health, which focus on important problems requiring concerted action by various bodies. Examples of these targets include: to increase average healthy years of life by two years, to cut accidental and violent death among young adult men by a third, to delay average retirement age by three years and to reduce smoking among young people. In addition, there are 36 statements concerning the lines of action underlined by the Government, incorporating challenges and guidelines related to citizens’ everyday environment and various actors in society. The programme was prepared by the Advisory Board for Public Health set up by the Government. The process involved consultation with specialists, analyses, seminars and group work. National level responsibility on the prevention of communicable diseases rests with KTL. The Institute also reports on communicable diseases to health authorities, health care providers, the mass media and the general public. KTL and the hospital districts maintain communicable disease registers. Doctors are obliged to report certain communicable diseases, including tuberculosis, diphtheria, hepatitis, malaria, HIV, poliomyelitis, cholera and rabies. Also, microbiological laboratories report any incidence of these infectious diseases and related observations. Additionally, KTL runs many programmes to decrease the burden caused by several other diseases, such as cardiovascular diseases and mental health problems. Occupational health promotion is arranged by employers. According to law (Occupational Health Care Act), employers must provide services that are necessary to prevent health risks caused by work. They must also provide sufficient information on health risks related to work and to advise their employees on how to avoid those risks. Furthermore, employers are obliged to check an employee’s status of health when a job might endanger his or her health. The FIOH carries out research, offers training for occupational health and safety professionals, provides advisory services and disseminates information on occupational health. 98
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Efforts have been made to reduce the consumption of harmful products, such as alcohol and tobacco. This has partly been achieved by taxation, which has kept the prices of alcohol and tobacco products at a high level. As in most other Nordic countries, the sale of alcohol has been a state monopoly, making it possible to regulate prices and sales. Smoking is reduced by smoking cessation campaigns, pricing and legislation. Since the 1970s, Finland has had extensive tobacco legislation, prohibiting tobacco advertising and smoking in public places. In 1995 smoking became prohibited at workplaces, and in 1999, restrictions were imposed on smoking in restaurants. The most recent reform of the Tobacco Act was enacted in June 2006. The new act bans smoking in pubs and restaurants, except in specific closed and ventilated rooms where food or drink are not permitted. Small pubs had to implement the reform by July 2007, whereas larger pubs and restaurants have a transition period until July 2009. The sale of tobacco to children under 18 is prohibited in Finland. Advertising of tobacco and strong alcohol is also prohibited. The state supervises, integrates and steers environmental health policy as a whole. The primary responsibility for environmental health policy, however, is devolved to the municipalities. Tasks at the national level are divided between several ministries. State Provincial Offices direct and supervise environmental health services on a regional level. Environmental health services in Finland include the following: the quality and hygiene of foodstuffs, health impacts of housing and public areas, noise abatement, the quality of drinking- and bathing-water, assessment of adverse environmental health effects and waste management. Furthermore, surveillance of gene technology, chemical control and protection from radiation are included under environmental health policy. 6.1.2 Municipal level At the municipal level public health is primarily the responsibility of the health centre, according to the Primary Health Care Act. In Finnish terminology, legislation and practice, ‘primary care’ carries the double meaning of primary health care and public health. In addition, environmental authorities, social welfare authorities, work health and safety authorities and local school authorities are responsible for some public health activities. Maternal and child health care and school health care are the most important municipal services for promoting public health (see also section 6.1.4). Maternal and child health care has a strong tradition in Finland pre-dating the establishment of health centres. Partly owing to the comprehensive network of maternal and child health care services and the great emphasis placed on them, 99
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infant mortality in Finland is one of the lowest in the world. Children and young adults also receive extensive publicly funded preventive dental care. Municipalities are also responsible for providing free immunizations for residents. The general immunization programme in Finland, which mainly follows WHO recommendations, covers the whole population. It starts with child health care in health centres and is continued in schools. The national vaccination programme includes diphtheria, tetanus, pertussis, measles, mumps, rubella, polio and Hib. The vaccination programme was last revised in 2006, when vaccination for tuberculosis only for children at risk was introduced. Vaccination coverage is relatively high in Finland (Fig. 1.3). In 2005, about 93% of children born in 1999 received all vaccinations included in the national vaccination programme (Joensuu et al. 2005). The decree of the MSAH also includes vaccination against influenza for certain high-risk population groups. KTL has defined that free influenza vaccinations should be provided to people aged over 65 and to younger people with specific chronic diseases. Municipalities are obliged by decree of the MSAH to provide breast cancer screening for all women between the ages of 50 and 69 in two-year intervals and cervical cancer screening for women aged 30–60 years in five-year intervals. Breast cancer screening was expanded to 60–69 year-olds at the start of 2007. In 2002, 88% of those who received an invitation participated in mammography screening and 72% in screening for cervical cancer (Cancer Society of Finland 2005). In addition, some municipalities are offering breast and cervical cancer screening to other age cohorts and also other screening services such as osteoporosis or bowel cancer screening (the latter may become a national programme depending on the results of an ongoing evaluation). The majority of municipalities provide antenatal screening for chromosomal and structural malformations (see section 6.1.4). Across all municipalities newborns are screened for hypothyreosis. Municipalities provide family planning and other reproductive health services. The prevention of STDs is based on the detection of all those infected and on easy access to treatment that is free of charge. All those possibly infected are to be identified and directed to a health centre or elsewhere to receive treatment. The largest cities have separate STD clinics in their health centres, but otherwise treatment is provided as part of general health centre services. Because of comprehensive family planning services provided by health centres and health education targeted to young people, the abortion rate in Finland is rather low, despite a liberal abortion law. Municipalities are responsible for the implementation of environmental health services in their respective areas. Environmental health activities can be either under the health centre or under the local municipal environmental 100
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protection authority. Municipal health inspectors ensure that environmental health legislation is complied with and provide consultation and guidance in environmental health issues. For wider environmental problems or catastrophes, the provincial or state authorities work together with the municipal level authorities. 6.1.3 Other organizations and programmes There are many NGOs working in the field of health promotion in Finland. The Finnish Centre for Health Promotion is an umbrella organization with 125 member organizations. Its aim is to promote cooperation between universities, officials and organizations performing health promotion work. The centre participates in several projects, programmes and campaigns (for example on promoting health in schools, prevention of domestic accidents, environmental health and drug abuse). It produces professional publications, guides, posters, reports and the health promotion magazine ‘Promo’. The main funding sources of the centre are the Slot Machine Association and the MSAH. The centre has a staff of about 25 persons. There have been several major public health campaigns in Finland to reduce mortality and risk factors related to chronic disease. For example, in 1972, the North Karelia Project was launched in the eastern province of North Karelia in response to a local petition to reduce the high coronary artery disease mortality rates among men (Puska et al. 1995). The North Karelia Project was launched as a community-based, and later as a national, programme to influence diet and other lifestyles that are crucial in the prevention of cardiovascular diseases. The original project period lasted from 1972 to 1977, but it continued operating beyond this period until the end of the 1990s. The prevalence of cardiovascular diseases among men in the eastern parts of Finland was higher than in other parts of the country and was one of the highest in the world. In cooperation with local and national authorities and experts, as well as with WHO, the project was designed and implemented to carry out comprehensive interventions through community organizations in the area, and the actions of people themselves. The project was integrated as far as possible into the local service system and social networks. Various methods were used in the project: provision of general information and health education (through materials, mass media, meetings, campaigns, etc.); development of referral and screening procedures in health services; encouragement of environmental changes (such as smoking restrictions, promoting vegetable growing, collaborating with food manufacturers); preventive work directed at children and young people; and training and education of health personnel. Much of the practical work was carried out by 101
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various bodies in the community itself, coordinated by hospitals and health centres. Over the 25-year period since the start of the project, major changes have taken place. Among men in North Karelia, smoking has greatly reduced and dietary habits have markedly changed. In 1972, a little more than half of middleaged men in North Karelia smoked. In 1997 the percentage had fallen to less than a third. By 1995 the annual mortality rate of coronary heart disease among men under 65 years old was reduced by about 73% from the pre-programme years (Puska, Pietinen, Uusitalo 2002). Among women, the reduction in deaths from cardiovascular diseases has been of similar magnitude. Broad community organization and the strong participation of people were the key elements of the success of the programme. Perhaps the greatest impact of the North Karelia Project was inspiring the whole country in the nationwide implementation and boosting primary health care in the country. The project also contributed to policy changes in health, agriculture and commerce within Finland as a whole. For example, the food industry collaborated with the project to promote low-fat dairy products, as well as salt reduction in several foods. On the other hand, smoking dropped dramatically among men but actually increased among women. Recently, the increasing prevalence of type 2 diabetes has been notified as a major current public health problem in Finland. As a result the National Programme for the Prevention of Type 2 Diabetes 2003–2010 (DEHKO) was set up (Finnish Diabetes Association 2003). The programme is coordinated by the Finnish Diabetes Association and a wide variety of other relevant organizations are participating. The programme comprises three concurrent strategies: the Population Strategy aimed at promoting the health of the entire population by means of nutritional interventions and increased physical activity so that the risk factors for type 2 diabetes, such as obesity and metabolic syndrome, are reduced in all age groups; High-Risk Strategy comprises measures targeted at individuals at particularly high risk of developing type 2 diabetes, providing a systematic model for the screening, education and monitoring of people at risk; the Strategy of Early Diagnosis and Management is directed at persons with newly diagnosed type 2 diabetes with the aim of bringing these people into the sphere of systematic treatment, thus preventing the development of diabetic complications that reduce the affected person’s quality of life and are expensive to manage. The food industry is increasingly taking recommendations on healthy nutrition into account in its product development. For example, the supply of milk products with a low percentage of animal fat has widened and the use 102
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of vegetable oil has increased. Healthy nutrition has also been supported by legislation. 6.1.4 Maternal and child health According to the Primary Health Care Act, health centres must have maternity and child health clinics. Free-of-charge child health clinics have existed in Finland since the late 1940s. The purpose of maternity clinics is to promote the health and well-being of parents, foetus and newborn child. The aim is to help parents in preparation for parenthood and for the changes brought on by the arrival of a child, as well as to promote a healthy lifestyle. Support is provided for the whole family, paying particular attention to parenthood and the relationship between the parents, with the father’s role and responsibility as a parent playing an integral part. Maternity clinics are also responsible for birth preparation, identification of complications relating to the pregnancy and referral of the mother for further treatment, as necessary. Women with normal pregnancies attend the clinic between 11 and 15 times. Most of the appointments are with a public health nurse, and two to three visits are with a physician. Most health centres provide ultrasounds between weeks 12 and 16 of pregnancy to screen for chromosomal and structural malformations (for example Down’s syndrome), but there are significant variations between municipalities in the provision of these screening services. However, a decree obliging municipalities to provide antenatal screening on a nationally uniform basis will come to force in 2010. Almost all pregnant women have a checkup at the maternity clinic in a health centre at least once before the end of the fourth month of their pregnancy, because this check-up is a precondition for receipt of the maternity grant. The objective of child health clinics is to promote the health of children and the welfare of families, and to reduce inequalities in health between families. The child health clinics monitor and support the physical, psychological and social development of under school-age children, and support parents in safe, child-centred upbringing, good child care and the relationships between parents. The focus is increasingly placed on identifying possible problems that families with children have at as early a stage as possible, and on arranging appropriate support. The national recommendation is that child health clinics arrange 16 periodic check-ups, five of which are appointments with a physician and the rest with a public health nurse. There are eight check-ups for under one year-olds, four check-ups per year for one and two year-olds, and one check-up per year for older children until the child attends school where she or he receives school 103
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health care. A public health nurse carries out a home visit before and after the birth, and at other times if needed. Additional support is provided through parent groups. Child health clinics are increasingly involved in multi-professional cooperation with other organizations that work with families with children. The clinics also administer the vaccinations provided under the immunization programme (see section 6.1.2). Maternity and child health clinics have been very successful in Finland. Infant mortality has decreased rapidly over the last 30–40 years. At the beginning of the 1970s, almost 15 out of every 1000 newborn infants died; since the mid1990s the rate has been less than 5 per 1000, one of the lowest in the world (see also section 1.5).
6.2 Patient pathways There are three main systems providing health care services in Finland: municipal health care, occupational health care and private health care. The advantage of the municipal system is that it provides comprehensive services and there are low user-fees. The advantage of occupational health care is that there are short waiting times and it is free of charge. The advantage of private health care is that there are short waiting times and the patient is free to choose the provider. Usually, employed persons can choose between these three systems (see section 2.4.2). According to a recent population survey, about 45% of physician visits by employed people were in occupational health care, 35% were in municipal health care and 15% were private health care (Perkiö-Mäkelä et al. 2006). For low-income, unemployed or retired persons or children from low-income families the municipal health care system is, in practice, the only option. Municipal health care is accessible for all permanent residents of the municipality (see sections 2.2.1 and 3.2.1.1). Patients cannot choose their health centre. In larger cities there are many health stations serving different geographical areas of the city and people are registered to one of these. Initially, patients should contact the health centre by phone to make an appointment. At this point the need for care is assessed. If a patient needs to visit a physician or nurse (see section 6.3), an appointment is made. In some municipalities patients can choose a physician in the health centre (see section 6.3). There can be long waiting times for health centre physician appointments in non-acute cases. If the physician in the health centre assesses that a patient needs secondary health services, the patient is referred to secondary care in the hospital district. Patients cannot choose the hospital they are referred to. There can be long 104
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waiting times for outpatient hospital appointments. After specialist level care is received the referring physician receives a discharge summary from the hospital district and is responsible for further follow-up. If the discharged patient is not fit to live at home, the patient is taken to the inpatient ward of the health centre. The municipality can also provide suitable home care or other institutional long-term care if necessary. Most employers provide voluntary curative services (see section 2.2.4). In these cases a patient can attend an occupational health care clinic assigned by the employer free of charge (there are different kinds of limitations on services employers provide). If the physician in occupational health care assesses that the patient needs secondary health services, the patient can be referred to the hospital district (municipal system) or to a private specialist or private hospital. Occupational health services are free of charge. If a patient wants to use private services, the patient can choose any private physician. The patient can go directly to an outpatient specialist provider. Usually, the patient has to first pay the full costs of the services and then receive reimbursement from NHI (on average 30% of expenses). If the patient has voluntary private sickness insurance, after NHI reimbursement she or he can claim part of the out-of-pocket expenses from their insurance company (see section 3.3.3.2). If the physician in private health care assesses that the patient needs secondary health services, the patient can be referred to the hospital district (municipal system) or to the private system. For the majority of NHI benefits (for example sickness allowance, higher drug reimbursement, rehabilitation and compensation of travel costs to a health care unit) a patient needs a medical statement from the treating physician (see section 3.2.2.3).
6.3 Primary care The current system of delivering municipal primary health services originated with the enactment of the Primary Health Care Act in 1972. This act represents one of the major milestones in the history of Finnish health care. It adopted a broader perspective on the provision of primary care than simply the provision of general medical treatment, covering primary medical care and public health. It obliged municipalities to provide these services to their inhabitants in what was a completely novel provider organization at that time, a “health centre�. A municipal health centre can be defined as a functional unit or an organization that provides primary curative, preventive and public health services to its population. It is not necessarily a single building or a single 105
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location; health centre activities can be organized at several locations, for example, maternal and child health care or school health might be provided at a separate location from the health centre doctor’s office. Large cities usually have activities organized at several health stations. Health centres are owned by one municipality or jointly by several municipalities through a federation. They do not aim to make a profit: they are publicly owned and run (see section 2.2.1). There were 237 health centres in Finland in 2007. In sparsely populated areas such as Lapland, the distance to the nearest health centre facility is much greater than in the more densely populated south. The size of a health centre varies, depending on the number of people it serves. When health centres were first set up, it was thought that they should serve a population of at least 10 000, but later health centre federations were permitted to divide, so the number of health centres went from 205 to a peak of 279. In January 2007, Parliament introduced a law outlining that primary health care services would be run by organizations covering at least 20 000 inhabitants, following a four-year transition period. Currently, only about one in four health centres has population base of 20 000 or more (see section 7.2.1). Health centres offer a wide variety of services: outpatient medical care, inpatient care in inpatient wards (in larger cities these can be classified more as a GP-run hospitals), preventive services, dental care, maternity care, child health care, school health care, care for older people, family planning, physiotherapy and occupational health care. Legislation does not stipulate in detail how the services should be provided, and in most cases this is left to the discretion of the municipalities, although for some services there are national guidelines (for example on maternity and child health clinics, for school health care and for screening). Health centres are usually well equipped with staff and medical technologies. In addition to the physicians’ and nurses’ consulting rooms, there are normally X-ray facilities, a clinical laboratory, facilities for minor surgery and endoscopic examinations and equipment such as electrocardiogram and ultrasound. The personnel of health centres consists of a wide selection of various health professionals: GPs, who can hold the specialty of general practice or sometimes also other clinical specialties, nurses, public health nurses, midwives, social workers, dentists, physiotherapists, psychologists and administrative personnel. The number of inhabitants per health centre physician varies, averaging about 1500–2000. According to Nordic principles, general practice is a specialty comparable to other clinical specialties, with six years of postgraduate training. However, it is not obligatory to be a specialist in general practice medicine to work as a 106
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physician in a health centre. Originally it was planned that health centres were to have permanent posts available only for specialists, but with the shortage of health centre physicians this was not possible. In 2006, approximately 30% of all physicians working in health centres specialized in general practice (Suomen Lääkäriliitto 2006). The main work of health centre physicians is to provide office-based general medical care to patients of all ages. They are also involved in maternal and child health care, school health services, occupational health care, family planning, care in the health centre inpatient wards, home nursing (although home visits by GPs are not very common; these are more often done by nurses), consultation at municipal nursing homes and in various public health and forensic activities. The tasks are often divided up among the health centre physicians according to the circumstances of the centre and the experience or interests of the physicians. Some health centres have arranged for specialists to come for regular consultations – for example, a radiologist from the nearby hospital to interpret X-rays. The GP-run inpatient department of a health centre works in much the same way as a hospital department. A typical health centre has between 30 and 60 beds. The number of inpatient departments within a health centre varies; large centres have several. The large majority of inpatients of health centres are older people with chronic diseases. The average age of these patients was 75 years in 2005 (STAKES 2006c). A significant part of the care provided in this setting is long-term care; in 2005 54% of inpatient days were for patients who stayed in the unit for more than six months (STAKES 2006c). In remote, sparsely populated areas, however, health centres provide comprehensive emergency and shortterm curative inpatient services to the entire population. During recent years, many municipalities have sought to curtail specialist hospital costs by quickly admitting post-operative surgical patients to health centre inpatient wards. Nurses play an essential role in Finnish health centres. There are nurses with a general nursing education who, in addition to assisting GPs, have their own consulting hours for giving injections, removing sutures and measuring blood pressure. The role of nurses is currently also expanding in acute care and in assessing new patients. Nurses do not act as formal gate-keepers to the physicians, but in practice, seeing the nurse first is becoming a common route to a physician appointment. Maternal and child care are largely carried out by public health nurses who have specific training in preventive services. In addition to maternal and child health care, public health nurses are engaged in family planning, school health care, occupational health care, home nursing and all kinds of health promotion activities. 107
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Occupational health care at health centres is offered to those employees whose employers have elected to use the health centre to provide this service (see section 6.2). Occupational health care is provided by one or more of the health centre physicians, along with one or several nurses. The physician may be a specialist in occupational health care (which is a medical specialty in Finland) or have additional training in occupational health care (see section 2.2.4). Employers are charged the full cost of these services by the municipality. Physiotherapy and rehabilitation in health centres are carried out mainly by physiotherapists by referral from a health centre physician. They give treatment to individual patients and arrange guidance and physical exercise for patients. The health centre physiotherapy department is usually also the place that provides medical aids and prostheses. Health centres often employ social workers to deal with various problems related to illness, such as helping patients to apply for benefits or arranging home help and other services needed by patients discharged from inpatient care. Health centres also work in cooperation with municipal social services. Health centres also provide outpatient mental health care services (see section 6.9). Health centres do not have a pharmacy for the sale of prescription drugs to patients, but they have a stock of pharmaceuticals for their own use: for minor surgery, for inpatient departments and for acute cases at night when pharmacies are closed. The management of health centres varies. Usually, the head of a health centre is the chief physician, but in large and middle-sized centres the management often includes several leading persons. There are often several chief physicians accountable to the medical director, one or several chief nurses and one director of finance and/or administration. Some municipalities have a personal doctor system, which was developed in the 1980s–1990s. Currently, approximately half the physicians working in health centres belong to this system. In this system, a person or a family is assigned to a specific health centre doctor usually based on place of residence. Physicians organize their practice so that patients on their list are able to see them within three days. Physicians can decide on their own working hours, but not on the work of other personnel. Physicians in this scheme remain public employees. Collaboration between different health care personnel has been encouraged in this model: physicians and nurses form a team that is responsible for the care of a geographically defined area covering between 1500 and 5000 people. The teams have not been given special budgets or financial responsibilities. The reforms were made in order to improve access (every patient has a specified physician who has responsibility for access to them) and continuity of care (physicians do not change between visits). In some municipalities the size of 108
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the population covered is so small that the principle of a personal doctor system already exists without a specific system. As a rule, patients must use the health centre of their own municipality of residence, except in emergency situations. If a patient wants to make an appointment with a health centre physician, he or she is assigned either to the physician he or she wishes to see or to any physician who is available. If the “personal doctor” model is in use, the patient is usually assigned to the list of the doctor responsible for the care of his or her residential area. This means that there is not usually much choice of physician, as the initial assignment is based on address. However, if a patient wishes to change his or her personal doctor, this can usually be arranged. About 13% of physicians working in health centres in 2006 also worked in the private sector (Suomen Lääkäriliitto 2006) (see sections 6.2 and 3.3.2.2 for details on private primary care). In 2005 there were 1.7 patient contacts to health centre physicians and 3.0 contacts to other health centre personnel per inhabitant, excluding occupational health services (STAKES 2006b). In municipal specialist level care (hospital districts) there were 1.3 outpatient contacts to physician per person, in occupational health care there were 0.5 outpatient contacts and in private health care there were 0.7 outpatient contacts (part of which were specialist visits). The number of outpatient physician contacts per person in Finland is lower than the EU average (Fig. 6.1; in Finland this figure includes all outpatient physician contacts). In part this may be due to different medical traditions such as the important role played by nurses, midwives and public health nurses, who may carry out tasks that physicians in other countries may do, especially in the field of maternal and child health.
6.4 Secondary care Secondary care is mainly provided by the municipality-owned hospital districts (see section 2.2.1). There are 20 hospital districts in Finland. About 10% of specialist level outpatient visits are provided by health centres (STAKES 2006a) (see section 6.3). In 2006 there were 897 000 inpatient episodes, 179 000 periods of care in day surgery and 6.9 million specialist level outpatient physician visits in the municipal health care system (STAKES 2007d). In addition, there are private specialized ambulatory services and 41 private hospitals (the majority being very small) (STAKES 2006e). Each municipality must belong to one hospital district. The largest hospital district in terms of population base has over 1.4 million inhabitants, while the 109
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Fig. 6.1
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Outpatient contacts per person in the European Union, 2003 or latest available year (in parentheses) Czech Republic Hungary Slovakia (2004) Switzerland (1992) Spain (2003) Germany (2000) Slovenia Belgium Croatia Estonia (2004) Lithuania Austria (2001) France (1996) Italy (1999) Poland (2004) Romania United Kingdom (1998) Netherlands Bulgaria (1999) Latvia The former Yugoslav Republic of Macedonia Finland Denmark Portugal Norway (1991) Sweden (2003) Luxembourg (1998) Turkey (2001) Malta Cyprus Averages CIS average EU average (2004) EU15 (1999)
15.2 12.9 12.5 11.0 9.5 7.3 7.2 7.0 6.9 6.8 6.8 6.7 6.5 6.0 6.0 5.9 5.4 5.4 5.4 5.2 4.3 4.2 4.1 3.8 3.8 2.8 2.8 2.6 2.6 2.0 8.6 6.8 6.4 0
5 10 15 Contacts per person
20
Source: WHO Regional Office for Europe, June 2007. Notes: CIS: Commonwealth of Independent States; EU15: EU Member States before May 2004.
smallest has only 65 000. The number of member municipalities covered by the hospital district varies from 6 to 58. Each hospital district has a central hospital and other hospitals as needed, depending on the size of the hospital district. Five of the central hospitals are university teaching hospitals offering more demanding forms of specialized medical care and tertiary care. Hospital districts are funded by the member municipalities mainly based on fee-forservice (see section 3.5.1). The state owns two psychiatric hospitals, which are subordinate to STAKES. Physicians and other personnel in public hospitals are salaried employees of hospital districts. About 37% of physicians working in hospitals in the public sector also worked in the private sector in 2006 (Suomen Lääkäriliitto 2006) (see section 3.5.2). 110
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Hospital districts provide specialized outpatient care, inpatient care and day surgery, usually in the same facilities. Patients need a referral from their health centre physician or any other licensed physician in order to access the outpatient or inpatient department in a specialized care hospital, except in emergencies. It is estimated that about 5% of visits to a health centre doctor lead to a hospital referral (Puhakka et al. 2006). In 2005, about 39% of the referrals to inpatient care in hospital districts came from health centres (STAKES 2007b). Most of the remaining referrals came from other hospitals’ physicians (22%) and private physicians (15%, including private occupational health care). Day surgery has become a very important form of operation in specialist care. Day surgery is defined as specialist level operations that do not require patients to stay overnight in the hospital. Day surgeries increased from 77 000 to 171 000 between 1997 and 2006. In 2006, day surgeries represented 40% of all surgical procedures (compared with 19% in 1997) (STAKES 2007d). Over half of operations on the eyes, ears, nose, larynx and mouth are day surgery operations. In general, patients cannot choose the hospital where they will be treated (see section 2.4.2). Health centres have guidelines on where patients with certain symptoms and diagnoses are referred to. Primary and secondary care is not always well coordinated as there are usually separate organizations providing these services (i.e., health centres and hospital districts). For example, health centres are not always given sufficient feedback information about the treatment of patients after their referral to hospital. However, the general aim is to organize one coordinator of care, for example the personal doctor, to maintain an overall view and responsibility of patients when they are treated at different levels of the health system. The planned national electronic patient record system should help achieve this goal (see section 7.2.2). Also, at the local and regional level there have been numerous reforms aiming to increase the coordination between the primary and specialized care (see section 7.1.2.2). The issue of continuity of care has been raised in various national health policy documents, often expressed as a “seamless chain of care”. There are few private hospitals in Finland, providing only 5% of the hospital episodes of care in the country (STAKES 2007b). The main reasons for choosing a private hospital are shorter waiting times, the possibility to choose a physician, and the perception of better quality services. Also, patients do not need a referral for private hospitals, and NHI reimburses part of the expenses to the patient. Some municipalities and hospital districts purchase some specific services from private hospitals; however, this is not very common. There are also physicians’ private practices that provide specialized outpatient care services 111
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that are partly reimbursed by NHI. These private outpatient services are much more common than private inpatient care. In private health care facilities there were 3.5 million outpatient physician visits in 2006 (compensated by NHI), of which 79% were visits to specialists (SII 2007a). The specialties with the most private outpatient visits are gynaecology and ophthalmology, together making up more than one-third of the total specialist visits.
6.5 Emergency care Emergency care is provided by health centres and hospital districts. Normally, every health centre has at least one physician on call for emergencies. It is common that a large proportion of physicians’ work on call in health centres is not genuinely medically urgent as many times patients have difficulties in getting ordinary daytime appointments. This is especially the case in municipalities with physician shortages. Currently, it is very common to lease physicians from private firms for out-of-office hour care, so they are different physicians than those working during the day (see section 3.5.2.1). Normally, patients should first go to the health centre emergency care to receive a referral to hospital if needed. In hospitals there are several physicians of different specialties on call. The arrangement for emergency care differs greatly between hospital districts as their size varies considerably. Municipalities are responsible for arranging ambulance services. Provision of ambulance services differs between municipalities. Services can be provided by health centres, private companies and municipal fire departments. In the majority of municipalities the ambulance services are outsourced to private companies. There are more than 200 private companies providing ambulance services in Finland, the majority of them being small with less than three ambulances. NHI reimburses expenses exceeding out-of-pocket payment of 9.75 euros (in 2007) directly to the service provider when a patient arrives to a health care unit by ambulance (see section 3.2.2.3). NHI does not cover costs when patients are transported from one health care unit to another. In that case the service is paid for by one of the health care units. In 2005 NHI reimbursed 60 million euros for ambulance services, averaging 137 euros per trip (SII 2006). This is about half of the total expenses (Kuisma 2007), with the remainder paid by municipalities, hospital districts and patients as user-fees. It has been argued that the emergency care system is fragmented and a large proportion of municipalities have population bases that are too small to provide good quality and efficient services themselves (Kuisma 2007). Very few municipalities place any strict quality standards on the providers and 112
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in the majority of the municipalities, regulation of service provision is very weak. There are considerable regional differences in the service and cost levels that cannot be explained by differences in morbidity or regional characteristics but that are partly linked to different ways of organizing services. In 2007 there were six ambulance helicopters in Finland operating from Helsinki, Turku, Oulu, Varkaus, Sodankylä and Vaasa. These helicopters also operate other rescue missions. Ambulance helicopters are funded by private donations, hospital districts and the state.
6.6 Pharmaceutical care Pharmaceutical products may enter the market by permission of the NAM, which is subordinate to the MSAH. New drugs can also enter the market by the integrated European market authorization system (the European Medicines Evaluation Agency). The NAM also decides what plants are considered as medicinal. Herbal products containing these plants, or products made of them must usually have a marketing authorization as herbal medicinal products from the NAM. Finland is TRIPS (Trade-related Aspects of Intellectural Property Rights) compliant, and it was one of the last countries in western Europe to introduce product patents for pharmaceuticals (in 1995). However, process patents were granted before 1995. In 2007, there were very few pharmaceutical products in the Finnish market with a product patent as it takes about 10 years or more from patent application to market introduction. Although there is 10-year data exclusivity in Finland, it is somewhat easier to introduce generic products in Finland than most other European countries because of weaker patent protection. Historically, the Finnish pharmaceutical industry has made almost solely generic products. There are two wholesalers of pharmaceuticals in Finland that provide pharmaceuticals to pharmacies and hospitals. The pharmaceutical manufacturer makes a sole-distribution contract with the wholesaler and the products are available only through that wholesaler (so called one-channel system). Certain products may be delivered through an alternative route directly from the manufacturer to hospital pharmacies. The wholesalers and hospital pharmacies are obligated to maintain stocks for a possible crisis situation (for use for 5–10 months). Outpatient pharmaceuticals can be sold to patients only by pharmacies (including over-the-counter (OTC) drugs). The only exception is nicotine replacement products which have been sold by grocery stores since 2006. 113
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Prescription drugs are sold based on the prescription of a physician, a dentist or a veterinary surgeon. Health care units can provide drugs to patients which are administered in the health care unit. There are no Internet pharmacies in Finland. Pharmacies are privately owned by pharmacists, but they cannot be owned by companies. One pharmacist can run only one pharmacy (and possibly two subsidiary pharmacies). As an exemption, the University of Helsinki and University of Kuopio have special rights to own pharmacies. Hospitals have their own hospital pharmacies (there were 24 in 2006). In 2006 there were 804 pharmacies in Finland including subsidiary pharmacies (NAM 2007). Pharmacies are regulated in many ways. The NAM decides which locations pharmacies can be placed and also selects the pharmacists to run them. The PPB sets maximum wholesale prices for each pharmaceutical substance included in the drug reimbursement system of NHI. Wholesale prices must be the same for all outpatient pharmacies (this does not apply to hospital pharmacies). Companies can change the wholesale prices every two weeks. The retail price is determined by a combination of the wholesale price, the pharmacy’s profit margin (the rate is set by the Government) and VAT (see section 3.5.2.3). Pharmacies pay a tax-like graded pharmacy fee to the state depending on their net sales. The function of the pharmacy fee is to decrease the differences in income across pharmacies, but still there exist major differences in profits across pharmacies. Because of this strong regulation there is hardly any competition between pharmacies (MSAH 2007a). The average annual business profit for the pharmacist after reduction of other running costs was 280 000 euros in 2005 (9.2% of net sales). The PPB is attached to the MSAH. It regulates which drugs are reimbursed by NHI and their maximum wholesale prices. There are no restrictions on pricing of other drugs with a marketing licence. This price limit does not apply to hospital sales, because reimbursement of NHI applies only to outpatient drugs; drugs used in hospitals are paid from the hospital budget. There is no clawback system in Finland. Pharmaceutical companies holding sales permits have to apply for reimbursement and the maximum wholesale price from the PPB (see information on the drug reimbursement system in section 3.2.2.2). The majority of prescription pharmaceutical products which have a marketing licence are reimbursed. There are three main categories of drugs that are not reimbursed: low cost drugs in which reimbursement is not considered important for patients, and to which companies want to freely set the price; where the PPB and the drug company have not reached an agreement on what is a reasonable price; and where the drug is used solely in hospitals. 114
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A pharmaceutical company is free to set the wholesale price lower than that which is determined by the PPB to be reasonable. Compulsory generic substitution was introduced in Finland in 2003 (voluntary generic substitution was in effect for a few years in the early 1990s without significant success). According to law (the Medicines Act), pharmacies are obliged to substitute a prescribed medicinal product that costs more than a certain defined maximum price limit with a product costing less than that limit containing the same substance. The NAM defines the list of substitutable medicinal substances. The majority of drugs are in this list, but, for example, insulin and anti-epileptics are not included. The price limits for generic substitution for each pharmaceutical substance are defined every three months by the SII. The SII calculates the maximum price by adding two euros to the price of the cheapest alternative at that moment (and 3 euros if the price of the drug is more than 40 euros). The prescribing physician may decline generic substitution for medical or therapeutic reasons. The patient does not need any reason in order to decline substitution and he or she is refunded by the NHI according to the actual costs of the prescription. Historically there has been no reference pricing system in Finland, although MSAH has planned to introduce it in 2008. Physicians rarely decline substitution and patients refuse only about 10% of the potentially substitutable prescriptions. Annual savings from the first year of generic substitution was about 5% of outpatient drug expenses, of which about twothirds has been attributed to price competition (Ahonen and Martikainen 2005). Price competition continued to lower prices after the first year (Paldán 2006). Hospitals and health centres usually have pharmaceutical boards which are expert bodies evaluating and recommending medicines to be approved for entry into the drug formulary. The drug formulary is intended to ensure safe and effective pharmacotherapy for medicines regularly needed in hospitals (Hermanson et al. 2001; Pekurinen and Häkkinen 2005). These boards also negotiate medicine prices and decide on procurement. Hospitals and health centres have also formed purchasing pools to strengthen their negotiation power. As in many other European countries, expenditure on pharmaceuticals has grown rapidly, both in real terms and as a share of total expenditure (see section 3.1). From the beginning of the 1990s, pharmaceutical costs grew on average 7–8% every year in Finland (Pekurinen and Häkkinen 2005). In 2006 total sales including inpatient and outpatient use were 2.4 billion euros and about 470 euros per inhabitant (NAM 2007). In 2005 total sales of pharmaceuticals was 20.5% of total health care expenditure (compared to 15.4% in 1994). Of the total sales, 74% was attributable to prescription medicines used in outpatient care, 115
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16% to medicines used in inpatient care and 10% to OTC medicines in 2006. The NHI reimbursed a total of 1.1 billion euros for outpatient drugs. Between 2005 and 2006 the total sales of pharmaceuticals decreased (by 1.6%) for the first time in Finland in the last two decades. The price decrease in early 2006 and the effects of generic substitution were the principal factors contributing to this (see section 7.1.1.4). Direct-to-consumer advertising of prescription drugs is not allowed in Finland. However, disease-oriented advertisements not specifying drugs are permitted. On the Internet, only text containing patient information can be presented. Direct-to-consumer advertising of OTC drugs is permitted, but regulated. The NAM and Pharmaceutical Industry Finland (a national industry association) enforce regulations concerning drug promotion to the public and to health care professionals. Rohto was established in 2003 to develop pharmacotherapy in Finland by disseminating independent drug information to physicians. The SII annually sends a letter to physicians reporting on the expenses for the drugs that particular physicians had prescribed in the last year and, for comparison, the average expenses of all physicians of the same specialty (Pekurinen and Häkkinen 2005). Prescribing is also guided by Current Care, which are guidelines produced by the Finnish Medical Society Duodecim. However, with very few exceptions these guidelines do not include economic information (see section 7.1.1.6). In outpatient care physicians do not have any financial incentives, such as holding a budget to assess costs, and NHI as a payer has few possibilities to directly influence physicians. However, prescription patterns can be somewhat regulated by limiting reimbursement. For example, in 2006 the PPB decided that the most expensive statins would only be reimbursed after less expensive statins are first tried and found to be inadequate. This significantly lowered the use of statins without a generic alternative, although it appears physicians do not follow this rule consistently for all patients (Martikainen and Maljanen 2007). In inpatient care, physicians need to assess costs more closely as expenditures are included in the departmental budget. Pharmaceutical policy in Finland is currently under review and a report about it was published in 2008 (Mossialos and Srivastava 2008).
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6.7 Rehabilitation Health centres and hospital districts provide medical rehabilitation in the form of rehabilitation counselling, tests to establish the individual’s need for rehabilitation, treatment and course of rehabilitation to improve functional and working capacity, the provision of various technical aids, adaptation training and rehabilitation guidance. Rehabilitation is provided in cooperation with the health centre and other agencies such as social welfare offices, employment offices, schools, the SII and insurance companies. Rehabilitation coordination in the municipalities is often provided by a special liaison team. In addition to municipal services, the NHI also reimburses part of the cost of medically prescribed private rehabilitation services (see section 3.2.2.3) (covering 106 000 persons in 2006; SII 2007c). NHI covers vocational rehabilitation for persons with impaired functional capacity and medical rehabilitation of persons with severe disabilities. The state budget also includes a special allocation that the NHI can use to reimburse other vocational services, including early rehabilitation measures geared to the requirements of a particular occupation, institutional rehabilitation services, adaptation training and psychotherapy.
6.8 Long-term care Long-term care for older people is mainly provided in the inpatient departments of health centres, in nursing homes and in service homes. The majority of nursing and service homes for older people are owned by municipalities, but there are also a number of private homes and homes provided by NGOs. Other long-term care services for older people and people with disabilities include home-care services, home nursing, day hospitals and other day-care centres and part-day nursing. In service homes, older and disabled people live in their own apartments but are offered different kinds of service in the same building, such as meals, nursing, alarming system and other assistance with daily living. Health centres have to work closely with municipal nursing homes; for example, a health centre physician takes care of the medical treatment once or twice a week. In 2005, 12% of over 75 year-olds were in regular home-care, 5% in service homes (of which little more than half had 24-hour assistance), 4% in nursing homes and 3% in long-stay care in inpatient wards of the health centres (STAKES 2006b). Long-term inpatient care at health centres has somewhat decreased since 1990. From the early 1990s, the volume of traditional nursing homes has decreased and the volume of service housing living has 117
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increased. This development has been prompted by financial incentives for the municipality. In service homes, the terms are similar to ordinary living with the help of community-based services and, for example, drug costs are covered by NHI and not by the municipality as would be the case in a nursing home. Various health and social policy documents have stressed the need for more support for older people and people with disabilities living in their own homes. As a result, an effort has been made to improve the supply of home support services offered. There is considerable variation across municipalities in the type of services provided and in some municipalities there have been concerns that the level of quality in nursing homes is poor. To address this situation national quality guidelines for elderly care were published by the MSAH in 2001 to help municipalities monitor their attainment of a set of targets for elderly care (MSAH 2001b). The quality guidelines, for example, recommend that municipalities should define the number or ratio of personnel per client needed for each service. However, the targets are recommendations rather than rules. Persons with other disabilities are also offered special residential services and other services by municipalities. Legislation requires that disability services must be provided according to need in a municipality, and that people with disabilities have a right to certain services. In 2005 there were 2500 persons (0.5 per 1000 inhabitants) in institutions for people with intellectual disabilities, 7500 (1.4) in housing with assistance, 1900 (0.4) in sheltered and supported housing and 2800 (0.5) in service housing for seriously disabled people (STAKES 2006b). Since the mid-1990s, there has been an increase in housing with assistance and service housing for seriously disabled people alongside a decrease in the number of persons in institutions for intellectual disabilities.
6.9 Mental health care Municipalities are responsible for providing mental health care services to their inhabitants; mental health is one of the task areas of the health centres according to the law (Primary Health Care Act). There is also a special act on mental health services (Mental Health Act) enacted in 1991, in which for example, rules on coercive measures are defined. In the 1970s and 1980s curative mental health outpatient services were under the administration of specialist level services, but health centres were funded to employ psychologists for preventive mental health services. These psychologists directed their work to children, schools, special risk groups, or they offered office-based services for common life crisis situations. 118
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Later, mental health services were actively shifted away from the hospital to the community. During the 1990s, gradually a significant proportion of mental health services were transferred under the administrative roofs of health centres in most hospital districts and many long-term patients were transferred from institutionalized care to outpatient care and to transitional services such as supported housing. During this time the average length of treatment periods in inpatient care decreased significantly. However, partly because of economic recession, the supply of outpatient psychiatric services as well as other supportive services and intermediate services has not increased to the same extent as hospital beds had been reduced (Lehtinen et al. 2006). There was also greater emphasis placed on public health in this period. Because of the high suicide rate (see section 1.5), the national administration carried out a suicide prevention programme during the years 1986-96. The programme, led by KTL, included a research project on suicide risk factors and an action plan based on the findings. The successful implementation of the action plan involved the extensive participation of stakeholders from national, provincial and municipal levels and may have contributed to the reduction in suicide mortality in Finland over the last twenty years. In 2006 there were about 73 000 episodes of inpatient mental health care and 2.1 million inpatient care days (2.5 million in 1996) (STAKES 2007d). That same year there were 1.4 million outpatient mental health visits in hospital districts (1.2 million in 1995) and 650 000 outpatient mental health visits in health centres (215 000 in 1995). In 2006 there were 217 child psychiatrists, 132 adolescent psychiatrists, 46 forensic psychiatrists and 977 adult psychiatrists (Suomen Lääkäriliitto 2006). Institutional care is provided in the psychiatric units of hospitals. Some units are physically located in general hospitals and some are separate psychiatric hospitals governed by hospital districts. Finland has two state-owned psychiatric hospitals that provide mental health examinations and treatment for criminals waived prosecution for mental disorders, and other patients whose care is considered dangerous or particularly complex. Outpatient services are provided by health centres, mental health offices and psychiatric hospital outpatient departments. Mental health offices are staffed by psychiatrists, psychologists, psychiatric nurses and social workers, among other professionals. Many mental health offices have been transferred to the administration of health centres but there has been no systematic national policy to do so. The overall picture is quite variable across the country in this respect. Outpatient services supporting long-term psychiatric patients consist of residential homes, rehabilitation homes, shared apartments, day hospitals and 119
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day-care centres, and sheltered housing. The organizations providing these services vary from region to region; from the municipal social or health service system, the private sector or NGOs, to specialized psychiatric hospitals. The SII reimburses part of the private psychotherapy fees incurred by over16s who are threatened by incapacity to work or study, or who are unable to return to employment or studies without the support of psychotherapy. In the case of the under-16s, the SII places importance on organizing and funding a diversity of family-oriented rehabilitation.
6.10 Dental care The population can access public dental services in municipal health centres or alternatively they can use private services. Private dental care is partly reimbursed by the NHI with the exception of orthodontic or prosthetic treatments. From the early 1970s onwards, when the Primary Health Care Act came into force, regular dental check-ups for children and adolescents were provided by health centres. In the 1980s this programme covered about 80% of children and adolescents (Nordblad et al. 2004). In the 1990s the length of time between check-ups was extended from one year to two years. During this period public financing of other dental services was very limited. Gradually, municipal dental services expanded to other population groups. By 2001, all children, adults born in or after 1956, veterans of the Second World War and adults with certain illnesses had access to municipal services or were reimbursed for private dental services. From December 2002 the age limits regulating access to municipal services or reimbursement of private dental services were abolished altogether. Before the reform there were significant local and regional variations in the dental care provided by health centres. Some municipalities managed to offer dental care to their whole population, while others offered fewer services than those defined in the legislation. In general, regular examinations of the child population including preventive dental care and orthodontics, and care of younger adults and some special groups were top priority in municipal services. Private services were concentrated in densely populated areas. Following the 2002 reform the use of municipal dental services increased and the number of persons receiving reimbursement for the cost of private care doubled (see section 7.1.1.5). However, some municipalities, mostly larger cities with a substantial private sector, have still had difficulties meeting the demand for dental care and waiting lists have become long. 120
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In 2006 there were 4.9 million dental visits to the municipal dental services, of which 3.9 million were made to dentists and the remainder to dental hygienists and dental nurses (STAKES 2007d). Approximately 41% of dentist visits in 2006 were made by under-18 year-olds. At the same time there were 2.8 million visits to private dentists of which 3% were visits by under-24 yearolds according to reimbursement statistics (SII 2007c). In relative terms, use of private services by adults is much more common in dental care than in the field of general medicine.
6.11 Health care for specific populations Municipalities provide health care services in primary schools, training colleges and high schools. Primary school health care includes medical examinations by a physician or nurse, health education, dental care, in addition to psychological and speech therapy services. Pupils are examined by a physician on two or three occasions, and other check-ups are carried out by a school nurse. Pupils can also visit a school nurse when needed. The nurse is also responsible for matters related to health education and the overall health care of pupils. In many schools the school nurse holds classes on relationships and sex education. The University Healthcare Foundation founded in 1954 is responsible for providing health care for 140Â 000 university students (including preventive health care, medical care, mental health care and dental care). The Foundation has 16 health centres in university cities. In 2006 its budget was 35 million euros which is financed by NHI (65%), the students and student unions (18%), the university cities (12%) and the Ministry of Education (5%). There are special health care services for armed forces and prisoners. In every prison there is an outpatient clinic and in addition there are three prison hospitals (one of which is a psychiatric hospital). Health care for prisoners is funded by the Ministry of Justice. For conscripts, the armed forces must provide full health care services free at the point of use. Until 2006 the armed forces Central Military Hospital provided specialized health care services, but since then these services have been contracted to hospital districts. For primary health care services the armed forces have 25 health centres within garrisons. For employed staff of military forces, health care services are arranged under the Occupational Health Care Act. According to the Act on Adaptation of Immigrants and Reception of Asylum Seekers, asylum seekers are entitled to the same health services as permanent residents. These services must be organized by reception centres for refugees. 121
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7. Principal health care reforms
T
he long-term objectives of Finnish health policy are to achieve the best possible health of the population and to reduce disparities in health across social groups. Until the 1970s, policy issues that concerned the health care delivery system had been mainly focused on employing the increased resources to develop the system and improving accessibility to services. The introduction of the Primary Health Care Act at the beginning of the 1970s formed the basis for the further development of the health care system and health policy in Finland. In the 1980s public health policy became particularly important (see section 6.1.1). The WHO Health for All programme contributed significantly to Finnish health policy. In the 1990s, developments in health care were influenced by “external” circumstances: severe economic recession, the 1993 state subsidy reform and Finland’s membership of the EU. The recent aim of Finnish health policy has been to reduce hospital and other kinds of institutionalized care and to expand outpatient and home care services. The growing number of older persons, together with pressure for cost containment, has also influenced this emphasis on outpatient care. While there has been no major reform of the health care system in Finland during the period 1997 to 2007, there have been a number of changes addressing specific issues. The most important reforms since 1995 are described in Table 7.1. Some of the earlier reforms are described in section 2.1.
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Table 7.1 Year 1995 1995 1998 1999 2000 2002 2002 2003 2003 2005 2005 2007
Finland
Major health care reforms and policy measures, 1995–2007 Event Founding of Finohta Beginning of the Current Care Guidelines project Economic evaluation of new drugs introduced Limited 42% reimbursement category for certain drugs introduced Internet portal Terveysportti set up National Project to Ensure the Future of Health Care launched Extension of public dental health care to all age groups Compulsory generic substitution of pharmaceuticals introduced The Centre for Pharmacotherapy Development (Rohoto) established Maximum waiting times defined Project to restructure municipalities and services launched Decision made on national electronic prescription and patient record systems
Note: Finohta: Finnish Office for Health Technology Assessment.
7.1 Analysis of recent reforms 7.1.1 National measures and development projects 7.1.1.1 State level four-year plans When a new Government is appointed it draws up a social welfare and health care programme for the next four years. The aim is that the Government, municipalities and other actors in the field of social welfare and health work towards the achievement of common targets, based on the Government programme (see section 7.2). These targets and development recommendations apply primarily to the municipalities, but the programme includes also recommendations for measures through which the state can support the municipalities in reaching their targets. Before 2007 this programme was called the Social Welfare and Health Care Target and Action Plan. In January 2007 Parliament reformed legislation in this respect (change of the Act on Social and Health Service Planning and State Subsidy) and the plan was replaced by the National Development Programme for Social Welfare and Health Care. The objective of the reform was to strengthen the steering function of the programme, for example by integrating the state funding of local development projects into the programme (see section 4.1.1). The Target and Action Plan for 2000 to 2003 emphasized the importance of prevention. The main objective of the plan was to increase cooperation between different sectors of society and between municipalities. Further, the plan emphasized the importance of ensuring there are sufficient staff with the appropriate skills within the social welfare and health care services. Particular 124
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attention was paid to the health and social welfare of children, older people and people with mental health problems. The Target and Action Plan for 2004 to 2007 was issued in December 2003. It included 75 different recommendations for action. The main goals for health care in the action plan were to improve access to care (especially to dental care), to reduce the differences in care provision between municipalities, to develop maternal and child health services, to reduce alcohol-related health problems and to improve the prevention of mental health problems. The current Government was appointed in April 2007 and the first National Development Programme for Social Welfare and Health Care was accepted in January 2008. The central theme of the programme is to strengthen the development activities of municipal services. The main targets of the programme are to decrease marginalization of vulnerable people; increase overall levels of, and decrease inequalities in, health and welfare; and increase quality, effectiveness and accessibility of services and decrease geographical differences therein. The main actions defined in the programme are to strengthen promotion of health and well-being; to secure sufficient human resources for services; to increase competence of personnel; to strengthen the position of users of services (patient empowerment); to reform the organization of services; to create a good practices network; to strengthen primary care services; and to further develop national quality guidelines (MSAH 2008b). 7.1.1.2 Securing the future of health care In 2001 the Government initiated the National Project to Ensure the Future of Health Care proposed by the Prime Minister and the Minister of Social and Health Services at the time. The project aimed to solve a variety of deficiencies identified in the Finnish health care system. The preliminary work of the project was divided between five working groups focusing on the following areas: • the reform of the operational and administrative structures of the delivery system and improvement in efficiency and productivity; • the need for an increased labour force, division of duties, and the improvement of working conditions and improved continuous medical education; • increasing the level and stability of health care financing and sources of finance and the improvement of steering mechanisms; • the development of the division of labour and cooperation between public health care, private health care and NGOs; and • the consolidation of treatment practices and improvement of access to treatment. 125
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The main outcome of the above project was the working group memorandum and “the Decision in Principle by the Council of State on Securing the Future of Health Care” issued by the Government in April 2002 (MSAH 2002). It focused on strengthening primary health care and preventive work, ensuring access to treatment, ensuring the availability and expertise of personnel, reforming of functions and structures and augmenting the finances of health care. The final action plan of the project included the following proposals: • to increase state level funding of health care services; • to embody the principle of access to treatment within a reasonable period in legislation by 2005 (see section 7.1.1.3); • to allocate funds for developing the service system (30 million euros annually); • to allocate funds for the current care guidelines project (1.4 million euros annually; see section 7.1.1.6); • to establish a centre for rational pharmacotherapy (1.3 million euros annually; see section 7.1.1.4); • to increase funding of Finohta (see section 7.1.1.6); • to increase the number of people educated for health care professions; and • to develop the division of labour within specialized medical care. A working group was set up by the MSAH to propose an implementation plan for the decision. The project has continued following the path set by the memorandum and the decision in principle. It has produced many reports and arranged several seminars. It has also distributed funding for local development projects. However, the overall impact of the project has been rather modest. The most visible reform has been the waiting time guarantee and founding of Rohto. Improvement has also occurred, for example, in the increase of students trained as health professionals, in developing the division of duties among health professions, in development of information technology and in strengthening continuous medical training. More detailed description of some of the reforms initiated by this process is presented in the following sections. The final report of the monitoring group of the project was published in February 2008 (MSAH 2008a). 7.1.1.3 Ensuring access to care As in most countries, one major challenge in the health care system in Finland has been the gap between available resources and increasing demand for health care services. This discrepancy has generated long waiting times for certain services in ambulatory and hospital care. There have also been considerable differences in waiting times between municipalities. The Decision in Principle 126
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by the Council of State on Securing the Future of Health Care issued by the Government in 2002 (MSAH 2002) stated that the principle of access to treatment within a reasonable period would be embodied in legislation by the year 2005 (Vuorenkoski 2006b; Vuorenkoski and Keskimäki 2004). According to the decision, in principle patients must be assured immediate contact with their health centre, and their need for care must be assessed by a health care professional (not necessarily a physician) within a maximum of three weekdays after their contact with the health centre. In non-acute specialized medical care, it is the responsibility of the hospital district that the patient’s need for care is assessed within a maximum of three weeks after receiving a referral, and any necessary medical care must be provided within three months, or at the very latest, six months. If the treatment cannot be provided within the time specified, treatment must be procured from another service provider at no extra charge to the patient. In 2004 the MSAH put together national guidelines defining the limits of access to non-urgent specialized care procedures based on expert proposals. The guidelines were made for 193 diseases or treatment groups comprising about 80% of non-emergency hospital care. The guidelines define which patients should receive the treatment guarantee, but they are not legally binding. Scoring systems are used in some of these guidelines. In March 2007, 87% of health centres reported that they used these guidelines. A change to the legislation (Primary Health Care Act and Act on Specialized Medical Care) containing these proposals came into force in March 2005. The legislative reform has had a significant positive impact in reducing waiting times, although some municipalities and hospital districts still fail to comply with the legislation. In April 2008, 62% of the population lived in municipalities not experiencing problems in obtaining immediate contact to primary health care (up from 37% in January 2005), and 95% of the population lived in municipalities where the assessment of the need of care by a public health care professional was provided within the enacted maximum of three weekdays in primary health care (up from 49% in January 2005). In December 2007, the number of patients who had waited more than six months for a specialized health care operation was 9700 (compared to 66 000 in October 2002 and 41 000 in January 2005). New legislation did not define the maximum waiting time for a physician appointment (the legislation refers to a “health care professional”) in non-acute cases, but this has improved somewhat also: in April 2008, 37% of the population lived in municipalities where patients did not have to wait more than two weeks for a physician appointment in non-acute cases (25% in September 2005). 127
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7.1.1.4 Pharmaceuticals The Government has long been concerned about the problem of increasing pharmaceutical expenditure and has introduced several measures to address this. However, no effective solution with long-term effects has been found. Pharmaceutical policy in Finland is currently under review and a report was published in 2008 (Mossialos and Srivastava 2008). The most important reforms from the past 10 years are described below. As of 1998, a holder of a sales permit applying for inclusion of a drug in the reimbursement scheme is required to carry out an economic evaluation and present it to the PPB as part of the application. However, the quality of these evaluations has been rather poor and of little value to the decision-making process. In 1999, a category of significant and expensive drugs was introduced in the drug reimbursement system. Drugs in this group have 42% reimbursement only if the illness of the patient fulfils certain criteria. For example, expensive drugs for treating erectile dysfunction (for strictly medical reasons), MS-disease and Alzheimer’s disease were included in this group. Rohto was established in 2003 to deal with the independent assessment of drugs and the dissemination of such information to develop pharmacotherapy in Finland. The implementation of treatment guidelines and other evidence-based knowledge in practice is the main goal for the agency’s training activities and information dissemination. The agency does not compile its own treatment guidelines, but uses existing treatment guidelines from Finland and other countries. Voluntary generic substitution was in effect for a few years in the early 1990s without significant success. Compulsory generic substitution was introduced in Finland in 2003. According to the legislation (Medicines Act), pharmacies are obliged to substitute a prescribed medicinal product that costs more than the defined maximum price limit with a product costing less than that limit containing the same substance. The prescribing doctor may forbid generic substitution for medical reasons. The patient does not need any reason in order to refuse substitution and she or he is refunded by the NHI according to the actual costs of the prescription (see section 6.6). Generic substitution appears to have significantly lowered pharmaceutical expenses and thus has been considered to be very successful. However, after the successful start of generic substitution pharmaceutical companies started lobbying the MSAH to restrict the list of substitutable drugs. They argued that in the worst cases they are not able to introduce drugs to the Finnish market and they also claim that the situation may restrict their research and development activities in Finland. Because of this drugs without 128
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a product patent but with a process patent in Finland and with product patents in five European countries were excluded from generic substitution in 2006 (Finland has somewhat weaker patent protection of pharmaceuticals than other EU countries in general; see section 6.6). Because of this generic substitution is not currently as effective as it could be. In 2006 two other important measures concerning pharmaceuticals were taken. Firstly, maximum wholesale prices were decreased by law by 5% at the start of 2006 (the Sickness Insurance Act). In practice this lowered the prices only of drugs which are sold at the maximum price set by the PPB. Generic products are usually already sold at much lower prices than the maximum and the reform therefore did not influence those prices. Nevertheless, partly as a result of this reform total pharmaceutical expenditure decreased by 1.6% between the years 2005 and 2006 (in the year before expenditure had increased by 6.7%). Secondly, as a result of a change in the legislation (Medicines Act), the sale of nicotine replacement products was allowed for shops, kiosks and gasoline stations (only those in which tobacco products are also sold). The reform decreased prices of these products by 15% on average and considerably increased their availability. 7.1.1.5 Dental Care Publicly funded dental care was offered to the whole population from December 2002 onwards (Keskimäki 2003b). The reform is based on the legal amendments passed in 2000, which extended public funding from those born in 1956 or later to all age groups (Primary Health Care Act, Act on Specialized Medical Care and the Sickness Insurance Act ). This reform concerned both public dental services and the NHI reimbursement of private dental services. However, prosthetic and orthodontic services, and technical works are not publicly provided or refunded by NHI except in cases when they are offered due to other diseases. Besides socioeconomic equity, a major objective of the reform was to equalize municipal differences in the coverage of dental services. Before the reform, one third of the Finnish population lived in municipalities providing dental services for all age groups in their health centres, and one third lived in municipalities providing public services for those born in 1956 or later which was stated as a minimum in the legislation. Due to vague wording of the law, several, mainly urban, municipalities with the remaining third of the population had more strictly limited the age groups for whom they provided dental services. According to the reformed legislation, municipalities are obliged to provide basic dental services for all their inhabitants. The municipalities can provide 129
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services themselves or contract them out to other municipalities or private providers. Persons using private dental services are eligible to be refunded by NHI. The reform for expanding NHI coverage was accepted already in the 1991 amendment of the Sickness Insurance Act, but the enforcement of the legislation was temporarily postponed several times due to economic reasons. The increased expenditure of municipalities due to the reform is partly compensated by higher state subsidies. After the reform the use of municipal dental services increased and the number of persons receiving reimbursement for the cost of private care doubled (WidstrÜm 2006). The proportion of adults using municipal dental services increased from 22% to 24% and those receiving reimbursements for private dental care increased from 12% to 25% between 2000 and 2004. At the same time dental care expenses increased by 12% (STAKES 2007a). However, larger cities with little tradition of treating adults in public dental services have had difficulties supplying the services and queues have become long. A number of municipalities have had serious difficulties in carrying out the reform. A shortage in dentists is one important obstacle in the implementation of this reform, which is being addressed partly by the delegation of tasks from dentists to dental hygienists. 7.1.1.6 Information for clinical and administrative decision-making In 1995, an independent centre for HTA, known as Finohta, was established within STAKES. The centre’s main objective is to promote evidence-based medicine and to improve the effectiveness and cost-effectiveness of care (mainly non-drug diagnostic or treatment methods). Finohta coordinates HTA research, disseminates information and gives methodological and financial support to research projects aiming at evaluating the clinical effectiveness or cost-effectiveness of a given health technology. The majority of the funding for Finohta comes from the state. As a result of the decisions that were made based on the National Project to Ensure the Future of Health Care, the annual state funding of Finohta has doubled from 1.1 million to 2.2 million euros between 2004 and 2007. In 1995, the first Current Care Guidelines were made by the Finnish Medical Society Duodecim and various medical specialty associations. Since then the work has continued with increasing resources. The guidelines are devised in working groups in which Finnish experts of a particular field are selected. The guideline development process follows the principles of evidence-based health care, and recommendations are graded according to the level of evidence. The draft guidelines are widely circulated to relevant stakeholders for comments and are then reviewed. By June 2007 guidelines had been developed for 76 130
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different diseases and conditions. The guidelines are meant to be updated every two or three years. The guidelines are primarily intended for clinical practitioners, but they are also used for developing local care programmes and care pathways. The secretariat of Current Care Guidelines is situated in the Finnish Medical Society Duodecim. For the period 2003 to 2007 the MSAH allocated 1.4 million euros yearly from the funds of the Finnish Slot Machine Association for the development of these guidelines. In 2000, the Finnish Medical Society Duodecim opened the Internet portal Terveysportti (Health Portal) for health care professionals. From the portal health care professionals can access, for example, EBM guidelines, the Current Care Guidelines, short product characteristics and prices of pharmaceuticals sold in Finland, the Cochrane Library, several leading international medical journals, ICD-10 codes, the drug interaction database, the comprehensive Finnish Medical Terms book and two leading Finnish medical journals. Almost all municipalities and hospital districts have purchased this service for their employees. It has been rather successful having on average 35Â 000 front page openings per day in 2006. 7.1.1.7 Information technology The development of health care information systems has been pronouncedly uncoordinated partly because of a very decentralized health care system. This has resulted in a situation where non-interoperable information systems are used even within individual health care organizations. To promote the utilization of information technology the MSAH launched the MacroPilot project in 1999. The objective of MacroPilot was to develop social welfare and health care services, in particular to produce clientoriented seamless service chains and to develop and test relevant information technologies. Among other things the goal of the project was to create a preliminary technical framework for a regional information system. However, the project did not meet its goals in terms of the development of information technology. The objectives of the MacroPilot were too broad with regard to the period of time reserved for the project, and the development of the social welfare and health service system with focus on information technology proved to be a slower process than had been expected. A major milestone in the development of information technology was achieved in December 2006 when the Parliament accepted new legislation on the electronic prescription database and the patient record database (Act on Electronic Prescription and Act on Electronic Management of Information on Users of Social and Health Services) (see section 7.2.2). According to the acts new electronic databases will be maintained by the SII. All service providers 131
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are obliged to join these systems and they should be fully functional after a four-year transition period in 2011. 7.1.1.8 Project to restructure municipalities and services The project to restructure municipalities and services was first introduced in February 2005 as one solution to the problems of municipalities’ increasing financial difficulties and the future impacts of the ageing population in the future (Järvelin and Pekurinen 2006). The ageing population will reduce the availability of the workforce as a significant number of personnel within social and health services will retire in the next decade or so, and at the same time, it will increase the need for health care professionals. The purpose of the planned public sector reform is to create a firm structural and financial basis within municipal services so that the organization and provision of services will be secured in the future. At the same time, quality, effectiveness, availability, efficiency and technological change of services are taken into consideration. The project concerns all services organized by municipalities, not only health care services. After extensive discussion with relevant actors, the Parliament passed an act on how to continue the process in January 2007 (see section 7.2.1). 7.1.1.9 Policy programme for health promotion In 2007, the Government initiated a new four-year multisectoral Government programme entitled the “policy programme for health promotion”. The objectives of the health-promotion programme are to improve the general state of health of the population and to reduce health inequalities. The policy programme continues with efforts to promote health and prevent health hazards beyond conventional administrative boundaries. Issues to be addressed in the context of the programme will include developing measures to promote health and related legislation, promote the well-being of children and youth, improve the health, functional capacity and workplace welfare of people of working age, promote the health and functional capacity of older people, assign responsibility for preventive efforts and allocate related resources, stress the importance of physical activity and culture for well-being and increase the health of the environment. 7.1.2 Local development projects A marked feature of recent structural developments in the municipal health care system is the emergence of a number of local projects and experiments around the country. These reforms could be roughly divided into three different types: 132
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enhancing regional cooperation between municipalities; integration of primary health care and specialized health care; and cooperation with the private sector. Currently, these local projects are an integral part of the national project to restructure municipalities and services (see section 7.2.1). 7.1.2.1 Regional cooperation The underlying aim of enhanced regional cooperation is to increase efficiency. Recent mergers of administrative units in Finland took place at different levels of the health care system (i.e. municipalities and hospital districts) and in diverse areas (information technology, secondary care and primary health care). Some examples of these reforms are described below. In the capital, Helsinki, a new hospital district (known as ‘HUS’) was formed in 2000 by merging two hospital districts in the capital area (Helsinki and Uusimaa) and the Helsinki University Central Hospital. The new HUS covers a population of 1.4 million which is about 27% of the Finnish population. The member municipalities vary from the capital to the small rural municipalities. The goal was to merge two geographically proximate hospital districts and the Central University Hospital of Helsinki in order to achieve more effective organization and to avoid the duplication of services. However, it has been found that old structures are hard to change rapidly in an organization of this size. Since 1972 when the Primary Health Care Act was brought in, some municipalities have merged to provide primary health care services. Recently there have been an increasing number of mergers. For example, six municipalities in north-west Finland formed the “Siikalatva Health Service District” in 2005 by uniting their health centres under one administration. The new organization provides primary health care services for the municipalities but specialized health care services are still purchased separately by every municipality from hospital districts. These six municipalities have a total of 16 500 inhabitants. Regional data systems for sharing patient information were created, for example, in the Pirkanmaa and Satakunta hospital districts. Since the year 2004, Pirkanmaa hospital district has had a regional data system providing the hospital district access to electronic patient records of health centres from seven member municipalities. In Satakunta, the hospital district and health centres initiated a project (Salpa project) that aims to provide health centres with access to patients records from the hospital district. The second target of the Salpa project is to provide hospital districts with access to patient records from health centres. The hospital districts of Etelä-Karjala and Kymeenlaakso have a similar joint project (KAAPO).
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There have been many other projects to improve regional cooperation, for example primary health care call centre services, pharmacy services for health care units, ambulance services and radiological imaging services. 7.1.2.2 Integrating primary and specialized health care Several local reforms have been conducted to improve cooperation between primary and secondary health care and social welfare services by integrating organizations (Vuorenkoski and Mikkola 2007). These reforms are also meant to promote cooperation between small neighbouring municipalities and to create a better structural and financial basis for the provision of municipal health services. This development is further endorsed by a national project to restructure municipalities and services (see section 7.2.1). In addition, to lower the barriers between primary and specialist health care and improve cooperation, the Government plans to combine the Primary Health Care Act and the Act on Specialized Medical Care into a comprehensive Health Care Act. These reforms are controversial because of the diminishing power of single municipalities and the shifting of power relations between primary and secondary services. Separate organizational structures for primary and secondary care negatively influence the extent of cooperation between these levels of care. This separation can hinder the optimal organization of care from both clinical and economic perspectives. For example, transmitting patient records and other information between primary and secondary care can be difficult. The separation of organizations can also lead to a situation where primary health care is in too weak a position as regards resource allocation, since when faced with difficult financial situations municipalities are better able to limit health centre costs than the hospital districts. The most innovative reform of this type is the new administrative pilot in the Kainuu region (north-east Finland), started in 2005. It covers nine municipalities having a total of 85 000 inhabitants (Keskimäki 2003a). The experiment created a new regional self-regulating mid-level administrative body with its own regional council elected for a four-year term at the same time as the general municipal councillors’ election. The new administrative body cannot levy taxes but receives funding from municipalities. It is responsible for several welfare services that were previously run by the municipalities: upper secondary schools and vocational education, primary health services, specialized health care, and a large part of social services. In this pilot, provision of primary health care and specialized health care (municipal health centres and Kainuu central hospital) were merged into the same organization. Among other things, this has provided the possibility to unify electronic patient record systems. 134
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Two of the most recent reforms of this type were in the Itä-Savo and Päijät-Häme regions (Vuorenkoski and Wiili-Peltola 2007). In both regions municipalities formed new organizations to provide primary and secondary care and social services (since January 2007). The new organizations replaced hospital districts that had provided only secondary medical services. Like hospital districts the new organizations are municipal federations governed and funded by member municipalities. The Itä-Savo district, located in eastern Finland, has nine municipalities and a total population base of 60 000. One of the municipalities is a small city and others are small rural municipalities. All member municipalities purchase secondary care services from the new organization, seven of the municipalities purchase primary health care services (for 80% of population) and three of the municipalities also purchase some social services such as elderly care and services for alcohol and drug abusers (for 62% of population). The district has eight health centres and one hospital. The Päijät-Häme district, located in southern Finland, has 15 municipalities and a total population of 210 000 inhabitants. One of the municipalities (city of Lahti) is the seventh largest city in Finland. The new organization is responsible for providing secondary care services for all member municipalities, and primary health care and social welfare services for eight member municipalities with a total population of 51 000. 7.1.2.3 Municipalities’ cooperation with the private sector Traditionally all municipal health services have been delivered by municipally owned organizations, health centres and hospital districts. In 1993, municipalities were given the freedom to purchase services from private providers. This has become more popular since the mid-1990s, but only a small fraction of municipal services is currently purchased from private providers. Some municipalities and hospital districts have introduced a purchaser–provider split to their administration which improves the possibilities to purchase services from private providers (for example, the cities of Tampere, Oulu and Raisio, and Pirkanmaa Hospital District). At present, there is controversy among politicians about the appropriate role for the private sector in municipal health care: in general, left-wing politicians oppose and right-wing politicians support purchasing services from private providers. Cooperation with private providers is promoted especially by the Ministry of Employment and Sitra. Below are some examples of cooperation between municipalities and the private sector. The highly specialized hospital, Coxa, was founded in Tampere in 2002 to carry out endoprosthetic operations. Coxa works as a limited company, 135
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and it was founded by Pirkanmaa hospital district (and three other hospital districts), four cities, one Finnish foundation (Invalidisäätiö) and a German private hospital company, Wittgensteiner Kliniken AG, which originally had 20% ownership. All elective endoprosthetic operations of Pirkanmaa hospital district are carried out in Coxa hospital. In addition, it provides these services for patients from other hospital districts as well as private patients. Private patients are operated on only after regular working hours and physicians do this work as private practitioners. About 10% of the hospital’s activities were for private patients in 2005. In 2005 Wittgensteiner Kliniken AG sold all its shares to Sitra (see section 4.2.3). The municipality of Karjaa agreed with Samfundet Folkhälsan (a non-profit “third sector” organization) in 1998 that Karjaa would purchase all primary health care and geriatric services from Folkhälsan. Folkhälsan founded a company which it owns in its entirety to provide the services, renting facilities from Karjaa. The objective of Karjaa was to reduce health care spending, but during the first few years costs increased and there were some disagreements between Karjaa and Folkhälsan. However, after a few years spending stabilized and currently is at the average level in Finland. At present, the company also provides services in the same facilities for other municipalities. In 2004 the City of Lahti made a contract with the Finnish private company MedOne to provide all the services of one of its health stations (Vuorenkoski and Mikkola 2007). The business activity of MedOne concentrates on outsourcing health care services, mostly leasing health care professionals (mainly physicians) to public health care (see section 3.5.2.1). The personnel of the health station were transferred to this private company. The primary reason for the reform was difficulty in acquiring personnel (mainly physicians). More recently, many other health stations have also been outsourced to private firms (for example in the cities of Kotka and Kouvola). Other types of service packages have also been outsourced (for example primary health care, emergency services and polyclinics). Some hospital districts have transformed laboratory services into publicly owned companies, which can provide services to hospital districts, municipalities and also to the private sector. Also, some nonclinical services are outsourced in some hospital districts such as catering and laundry services.
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7.2 Future developments Following the parliamentary elections in March 2007, a new Government was appointed in April 2007 (see section 1.4). The Prime Minister is Mr Matti Vanhanen (the Finnish Centre Party). Compared to the previous Government, the most notable changes are the shift of the Social Democratic Party from Government to opposition and shift of the National Coalition Party from opposition to Government. As a consequence the new Government is more right-leaning than the previous Government. The current Government’s programme is “A responsible, caring and rewarding Finland” (Prime Minister’s office 2007). It identifies about 25 different actions related to health policy. Actions related to organizational structure: • Steps will be taken to guarantee the attainment of the objectives defined in the project to restructure local Government and services and to prepare the necessary legislative amendments (see also section 7.2.1). • The development of electronic information systems will be continued (see section 7.2.2). • To lower the barriers between primary and specialist health care and improve cooperation, the Primary Health Care Act and the Act on Specialized Medical Care will be combined into a comprehensive Health Care Act. • The role of primary health care will be reinforced. In order to restructure services, special measures will be taken to develop primary health care, social work, emergency care, and mental health and substance abuse services. • Seamless service chains in primary care, secondary care and closely related social services, including preventive measures, will be improved. • Steps will be taken to improve the evaluation of the quality and effectiveness of services and their supervision and guidance. • Municipalities’ capabilities for research, product development and service innovations will be enhanced. • A social and health care services innovation project will be carried out aimed at improving patient empowerment, effectiveness and cost-efficiency of services, developing the division of duties and expanding the diversity of services. • The availability of sufficiently qualified personnel will be ensured by means of on-the-job training, competitive compensation plans, and developing the content of work and management systems. Actions related to access to services:
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• The system of guaranteed access to health care will be reviewed, and the necessary changes to time limits and procedures will be made (see section 7.1.1.3). • Citizens’ right to seek care across municipal borders will be expanded. •
• •
• • •
Actions related to costs/financing: A revision of user-fees for social and health care services will be carried out to adjust for inflation. At the same time, a system will be created under which charges will, in future, be adjusted to reflect actual cost levels and that the charges do not induce people to select inappropriate forms of treatment. The payment ceiling system will be reformed. In order to raise cost awareness, the transparency of the pricing and financing of municipal services will be increased, the objective being that the customer is informed not only of his or her own share of the cost but also of the total cost of the service provided. The outpatient drug reimbursement system will be reformed so that cost containment is more efficient. A special working group will be appointed by the MSAH to address this issue. The state contribution to NHI will be included within the general state spending limits (previously they were not included). Municipal finances will be strengthened by increasing state subsidies to municipalities.
Actions related to health promotion: • The multisectoral Government programme “Policy programme for health promotion” will be started (see section 7.1.1.9); • Taxes on alcoholic beverages and tobacco products will be raised in an attempt to promote public health. • • • •
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Actions related to private provision: Government promotes partnerships between the public, private and third sector in the provision of services. The adoption of a purchaser–provider split will be encouraged (see section 7.1.2.3). The use of municipal service vouchers will be extended to include social and health care services. Service vouchers will be accepted in home nursing from the beginning of 2008 (Vuorenkoski 2007c). NHI reimbursement for dentists’ fees will be increased from 30% to 40%. More efficient use of public health care facilities for private health care provision will be promoted.
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• Commercialization and exports of health care innovations will be encouraged in the social and health care services innovation project. The Government programme, the National Development Programme for Social and Welfare and Health Care, was devised for the next four years (see section 7.1.1.1). The Advisory Board of Social and Health Care is responsible for its preparation, implementation and follow-up. Key stakeholders are represented in this legislative board which is chaired by the Minister of Health and Social Services. The development programme will be strongly implementation oriented. Three major developments that are likely to have a significant impact on health services in the future are described below. 7.2.1 Restructuring of municipalities and services One of the most discussed future developments of the public sector health care system is to create a secure structural and financial basis for municipal services by creating organizations serving a larger population base. At the moment there are 415 municipalities (in 2008) with a median of about 5000 inhabitants. Although the number of municipalities has already decreased in the last five years from 448, the Government aims to further decrease the number. Some municipalities have already formed health centre federations to provide primary health care services (there are currently 65 federations). Secondary and tertiary level health care services are provided mainly by 20 hospital districts which are municipal joint federations. There are numerous ongoing local projects to increase regional cooperation (see section 7.1.2.1). To promote this process the Government initiated a project to restructure municipalities and services in 2005 (Järvelin and Pekurinen 2006). The project made three different proposals for organizing basic services in the future: a model of basic municipalities, a regional model and a district model. In January 2007, the Parliament accepted an act (Act on Municipal and Service System Reform) which directed the process according to the basic municipalities model. According to the act, the state will financially support mergers of municipalities. The act states also that primary health care and social services closely related to health services should be organized by organizations covering at least 20 000 inhabitants. This would not necessarily require mergers of municipalities smaller than 20 000 inhabitants, but forming of for example municipal joint federations. Currently, only about one in four health centres has a population base of 20 000 or more. Additionally, according to the act, the responsibility of organizing and funding forensic psychiatry examinations and examinations related to child sexual abuse will be transferred to the state by no later than 2009. 139
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In autumn 2007, all the municipalities made detailed plans for the state administration on how the stated goals are to be achieved. However, the state administration was satisfied only with a minority of these plans. The majority of the municipalities are required to further specify their plans or have been summoned for negotiations with the state administration. Plans reveal that municipalities intend to form about 70 cooperational regions involving about 300 municipalities. About half of these would work as joint municipal federations. Another proposed model is that one municipality would have the administrative responsibility of organizing services and others would have a contract with that municipality related to the organization of services for their residents (currently about 20 municipalities have arranged services according to this model). In February 2008, decisions on municipal mergers were made so that the number of municipalities will be reduced by 62 by January 2009. Additionally, there are another 12 ongoing merger processes involving 29 municipalities. The Government will produce a report to the Parliament on the progress of the project during 2009. Municipalities are obliged to make final decisions on the implementation of the law before that. The target for this process is to be completed by 2012. 7.2.2 Electronic information systems In December 2006, the Parliament decided to introduce a nationwide EPR system in Finland (Vuorenkoski 2007a). Currently, every service provider has chosen their patient record system individually and systems are usually not connected to each other. According to the new act (Act on Electronic Management of Information on Users of Social and Health Services), the SII will set up a national digital archiving service for health service providers. In the new system every provider organization will still have their own patient record archive in the archiving system of SII. However, the structure of the archives will be uniform. All public service providers are obliged to have their patient record archive in the new system and private providers have to join the system if they have electronic archives. Every service provider will have access to all archives through the national index service. Consent from the patient is needed for accessing patient records from the archive of other service providers. Individuals will have access to their own patient records and will be able to see who has accessed their records and when. According to law, the system should be fully functional in 2011. The introduction of the national EPR system will probably significantly change the current situation and lead to more integrated information technology solutions in health services. 140
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Linked to the development of the national EPR system is the development of a national electronic prescription system. A pilot programme was implemented between 2003 and 2006. In December 2006, the Parliament accepted a new act (Act on Electronic Prescription) on how to develop the system further (Vuorenkoski 2007a). According to the act a national electronic prescription database will be maintained by SII. In this system prescriptions are sent electronically from the physician’s office to the central database to which pharmacies have electronic access. All service providers are obliged to make prescriptions electronically by 2011. However, patients can refuse the electronic prescription and receive a conventional paper prescription instead. 7.2.3 National level steering of health services In Finland the responsibility for the organization of public health services is decentralized to over 400 municipalities. Currently, the delivery and quality of health care services varies considerably across municipalities which can lead to conflict with the constitution assuring equal access to health services according to need for all Finnish residents. One reason for this variation is that direct national level steering mechanisms have gradually been weakened since the 1980s. At present, the municipalities are rather independently able to organize health care services because legislation (in particular the Primary Health Care Act and Act on Specialized Medical Care) provides only a loose framework for municipal health service provision. During the last fifteen years the main national level steering mechanisms have been steering by information, for which STAKES has had the main responsibility. However, this approach is not considered as effective as it was intended. The main responsibility for national level supervision of health care providers is currently held by the five provincial state offices, to which patients can make complaints (see section 2.4.4). In severe cases these complaints are forwarded to the NAMLA. Citizens can also appeal to the administrative court if they do not receive appropriate health services from the municipalities. These appeals have increased somewhat since the year 2000. Several recent reforms have shifted towards centralization after a long line of actions to decentralize decision-making in public health care services. In 2005, Parliament enacted maximum waiting times for public sector health services (reformed Primary Health Care Act and Act on Specialized Medical Care) and the MSAH put together national level guidelines defining the limits of access to non-urgent specialized care procedures (see section 7.1.1.3) addressing the considerable differences in waiting times across municipalities and services.
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The second major reform took place in 2006, when national level supervision was reinforced by expanding the functions of the NAMLA from supervising individual professionals to supervising health care organizations, health centres, hospitals and other institutions providing health services (Vuorenkoski 2006a). This supervision is based mainly on complaints of the patients. But the agency can also take necessary actions without specific patient complaints. For example, in summer 2007 the NAMLA approached municipalities that did not comply with the maximum waiting time guarantee and urged them to fully implement the legislative guarantee. The third major reform to strengthen national level steering was a legislative change by Parliament in January 2007. The four-year Target and Action Plan for Social Welfare and Health Care (see also section 4.2) was replaced by the “National Development Programme for Social Welfare and Health Care� which is devised by each Government for a four-year time period. The first National Development Programme for Social Welfare and Health Care was produced in January 2008. This programme aims to be more implementation-oriented than the previous plans. In the future state funding for local development projects in the field of social and health care will be closely tied to the development programme. The responsibility for preparation, implementation and follow-up of the plan has been given to a new Advisory Board of Social and Health Care as defined in the new legislation. Fourthly, in recent years the Government has regained legal powers to regulate by using lower level decrees to make changes in specific areas of concern, such as school health care, care of people addicted to opiates, maternal and child health and screening. Sometimes these changes have been accompanied by earmarked state contributions in the municipal budget.
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8. Assessment of the health system
8.1 Stated objectives of the health system
F
innish health policy seeks to incorporate health into all policies and all aspects of public decision-making. In addition to a broadly based preventive health policy, Finnish health policy also stresses the importance of efficient and accessible health care services for the entire population. More specifically, Finnish health policy aims to reduce premature deaths, extend people’s active and healthy lives, ensure the best possible quality of life for all and reduce inequalities in health (MSAH 2004). These aims have been stated, for example, in the Finnish National “Health for All by the year 2000” strategy, which was adopted by Parliament in 1986 (MSAH 1987). Finland’s health policy has been broadly successful. For example, life expectancy increased by nine years between 1970 and 2005, infant mortality has decreased rapidly over the last 30–40 years, age-standardized mortality from coronary heart disease among working age people dropped by more than 50% between 1984 and 2005 (Statistics Finland 2006a) and the PYLL rate lowered in Finland between 1992 and 2004 by approximately 25% (Vohlonen, Bäckmand, Korhonen 2007). However, problems still remain. For example, differences in health status remain between different sections of the population and socioeconomic inequality in mortality has even increased (Häkkinen 2005). During the years 1971–1995 life expectancy at age 35 increased by about four years, but more among the upper class than lower class population (Martikainen, Valkonen, Martelin 2001) (see section 8.2.2). The health care system is one important tool to improve mortality and morbidity trends. The basis of the health care system is laid down in the Constitution of Finland (section 19). According to the Constitution:
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Everyone shall be guaranteed by an Act the right to basic subsistence in the event of unemployment, illness, and disability and during old age, as well as at the birth of a child or the loss of a provider. The public authorities shall guarantee for everyone, as provided in more detail by the Act, adequate social, health and medical services and promote the health of the population.
The following sections discuss the extent to which these and other normative criteria commonly employed to evaluate the performance of a health system have been met in Finland.
8.2 Distribution of the health system’s costs and benefits across the population 8.2.1 Distribution of costs The majority of health care financing stems from municipal and state taxes. The income tax of the state is progressive and income tax of municipalities is proportional (a flat percentage in each municipality). NHI is funded by tax payers, the state budget and employers. The insurance premium for tax payers is proportional, being a flat percentage of income. Since the share of the progressive source of state finance has decreased (from 36% to 21% of total health expenditure between the years 1990–2005; Table 3.1) the total financing of health care has become more regressive, that is, financing has been shifted relatively more to low-income groups. The most regressive part of the financing system is user-fees (see section 3.3.3). For municipal services legislation sets the maximum user-fees and an annual ceiling for health care charges. About 7% of health care financing in municipalities derives from user-fees. Outpatient drugs are not covered by the municipal health care system but by NHI. On average, 63% of the costs of outpatient prescription drugs are reimbursed to the patient (NAM 2007), which is much lower than for municipal health care services. In extreme situations when an individual’s or a family’s income is not enough to cover the userfees of municipal health care services or outpatient drugs, social assistance is available. NHI covers about one third of the actual costs of private health services and users have to pay a large proportion of expenses out-of-pocket. Poorer people have less opportunity than wealthier people to use private health care as the reimbursement rate is low, but they can use the municipal services instead. Statistics show that, for example, unemployed people do not use private services 144
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as much as employed people (MSAH 2007b). There are also geographical differences in the use of private services since in rural municipalities there are less private services available. It may be considered inequitable that NHI covers a portion of private health care costs while some parts of the population (e.g. poorer people and those living in rural areas) do not use these services. 8.2.2 Distribution of benefits In terms of distribution of benefits there are two major challenges in the Finnish health care system: geographical inequities and inequities between socioeconomic groups. Another future challenge is the ability to provide own language and culturally sensitive health services to ethnic minorities with the expected continued increase in immigration. Data on inequities between population groups are not collected routinely (except geographical differences) but some information can be obtained from empirical research (Teperi et al. 2006). There are significant differences between municipalities in service provision (for example GP visits, dental care, mental health care, elective surgery in specialized care) and waiting times. The numbers of inpatient cases and surgical procedures per capita vary markedly between hospital districts (adjusted by age and sex), for example, in treatment of ischaemic heart disease (Häkkinen et al. 2002) and in orthopaedic operations (Mikkola et al. 2005). Significant ageadjusted variations between five university hospital regions in outpatient care have also been observed (Häkkinen and Alha 2006). There are also significant differences between municipalities in resources invested in municipal health care, which persist after needs adjustment (see also section 8.3). Needs can be difficult to assess since statistics on morbidity are not routinely collected (except cancer and communicable disease register data), but there are some proxy indicators collected on mortality, use of special drug reimbursement, working age recipients of sickness allowance, recipients of disability pensions and recipients of disability benefits. For example, the proportion of working age recipients of sickness allowance varies between 7% and 18 %, which implies that there are significant differences in morbidity between municipalities (SotkaNet 2008). Several factors may explain the differences in delivery and utilization of municipal health services. It is important to highlight that the Finnish health care system is decentralized and national steering is rather weak (see section 2.3). There are also differences in age structure, morbidity, physician shortage (more severe in rural municipalities) and access to private health care services and use of occupational health care services (more common in cities) which 145
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may explain these variations. However, it is clear that some of the variation leads to geographical inequities in quality and scope of municipal services. To tackle geographical inequities in access to care, maximum waiting times were defined in the Primary Health Care Act and Act on Specialized Medical Care in 2005 and the MSAH put together national guidelines defining the limits of access to non-urgent specialized care procedures (see section 7.1.1.3). The legislative reform has had a significant impact on reducing waiting times, although there are still problems in some municipalities and hospital districts. In addition, there are national treatment guidelines and quality guidelines for services to standardize practices across the health care system. There are also significant socioeconomic differences in the use of health care services (Häkkinen and Alha 2006). Among OECD countries pro-rich inequity in doctor visits was found to be one of the highest in Finland in 2000 (along with the United States and Portugal) (Van Doorslaer, Masseria, Koolman 2006) despite the fact that inequality of distribution of physician visits between socioeconomic groups has decreased somewhat in Finland between 1987 and 2000 (Teperi et al. 2006). There are also significant pro-rich differences in screening, dental care, need-related coronary revascularizations and in some elective specialized care operations (for example hysterectomy, prostatectomy, lumbar disc operation) (Teperi et al. 2006). These differences are amplified by the fact that there are persistent socioeconomic inequalities in health status: white-collar workers are healthier than blue-collar workers, employed people are healthier than the unemployed, and people with high income and the highest educational level are healthier than low-income people with only a basic education (Koskinen 2004; Martelin, Koskinen, Lahelma 2006). Perhaps one of the most important reasons for the socioeconomic differences in the use of services is that the private sector and occupational health care, which are less accessible to the low-income population, offer better access to services (e.g. a major difference is waiting times) than the municipal sector. As opposed to municipalities, NHI does not set any financial limits for providers which would lead to rationing of services. Additionally, NHI funds services without any assessment of need or efficiency. By contrast, services provided in the municipal system usually have strict budgets. There are clear gaps in the coverage of municipal services in some areas, for example in dental services and psychotherapy. Inequities arise also from the fact that occupational health care is free for patients compared to municipal health care which has user-fees (see section 3.3.3). In general, private health services and occupational health are more commonly used by the wealthiest part of the population (Häkkinen 2005). Also, in some disease groups the pro-rich distribution of private and occupational 146
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health services may lead to a pro-rich distribution also in municipal services since private outpatient services are an important pathway to specialized care in municipal health services (for example, for cataract operations and several other surgical treatments). Better access for private patients also may derive from the fact that private health care does not have the financial incentive for gate-keeping as municipal health centres have. During the last ten years private and occupational health services have grown faster than municipal health services. During the years 1996 to 2006 the number of physicians in occupational health care has increased by 69% and in private health care by 62%, whereas in municipal health centres the increase in physicians has only been 9% (Suomen Lääkäriliitto 2006).
8.3 Efficiency of resource allocation in health care Allocative efficiency in the municipal health care system has not been analysed in Finland. However, it has been estimated that mental health services are underfunded (Lehtinen et al. 2006) and specialized health care services in general are overemphasized in comparison to primary care services (Mattila K 2006). Generally, municipalities do not have much influence on the volume and costs of hospital care of the hospital districts. This leads to the situation in which it is easier to limit the costs of primary health care than specialized health care and hence increase the resources of specialized health care compared to primary health care. The number of physicians in health centres has increased by 9% and in hospitals by 21% between 1996 and 2006 (Suomen Lääkäriliitto 2006). There are striking variations between municipalities in terms of per capita health care expenditure. Health expenditure including long-term care varied from 940 to 2310 euros per inhabitant in 2004 (Hujanen, Pekurinen, Häkkinen 2006) and needs-adjusted expenditure was 2.5 times more in the “most expensive” municipality when compared to the “least expensive” municipality. These differences have existed for a long time, although during the last 10 years they appear to have narrowed. Differences in the organization of the delivery system is one of the major factors explaining this variation in expenditure. The system of dual public financing (municipalities and NHI) creates challenges for the overall efficiency of the service production. For example, in pharmaceutical care dual financing leads to cost-shifting problems as municipalities pay drugs used in inpatient care and NHI funds drugs used in outpatient care. Health centres and hospitals have financial incentives to use outpatient drug therapy instead of drugs administered in the health care 147
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unit (intravenous drugs) or specialist level operations, even when it is not the economically or even clinically optimal choice. Municipalities also have incentives to treat older patients in sheltered accommodation rather than nursing homes as they have to pay for drugs used in nursing homes. At a more general level, health care service providers do not have financial incentives to reduce outpatient drug spending. In a recent OECD country report of Finland in 2005 it was suggested that some financial incentives should be introduced for physicians to contain outpatient pharmaceutical expenditure (OECD 2005). More information on the advantages and disadvantages of dual financing are discussed in the OECD report on Finnish health care system (OECD 2005).
8.4 Technical efficiency in the production of health care The measurement of technical efficiency of the Finnish health care system has been in practice for some time. The largest projects analyse productivity in hospitals (Linna 2006) and in elderly care (Noro 2005); they are carried out by STAKES. A research and development project to produce benchmarking information on hospital performance and productivity (Hospital Benchmarking) was launched in 1997 (Linna 2006). At the beginning, the main aim of the project was to develop a new measure to describe the output of hospitals better than traditional measures such as admissions or outpatient visits. A further aim was to provide the management of hospitals with benchmarking data for improving and directing activities at hospitals. After a few years the project expanded and at present, nearly all publicly delivered specialized health care in Finland is included. Hospital Benchmarking data were integrated into the production of national statistics in 2006. The data allows regional measurement of productivity and costs indicating, for instance, how much the costs of a hospital district or a municipality deviate from the national average and how much of this deviation reflects the inefficient delivery of services and the per capita use of services. Hospital Benchmarking data have increasingly been used for appraising and directing hospital activities. Hospital Benchmarking data indicate that productivity of hospitals has decreased somewhat from 2001 to 2005 and that there are significant differences in productivity between hospitals (STAKES 2007c). A clear increase in productivity in the Finnish health care system was observed between 1990 and 1994 connected to the economic recession (Häkkinen 2005). One possibility to increase technical efficiency, or at least to increase 148
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transparency, is to develop a uniform national method for pricing the services of hospital districts, which would allow comparisons across providers (OECD 2005). Finnish researchers have also made path-breaking progress in outcomeevaluation based cost-effectiveness evaluation under the PERFECT project. The project aims to develop indicators and models that can be used to systematically monitor the effectiveness, quality and cost-effectiveness of treatment episodes in specialized medical care across regions, hospitals and population groups. The first stage of the analysis comprises stroke, hip fracture, low birth weight infants, breast cancer, schizophrenia, acute myocardial infarction, and hip and knee replacements. For example, in acute myocardial infarctions (Häkkinen et al. 2007) the project has found significant differences in clinical practices, effectiveness and costs between hospital districts. Technical efficiency in pharmaceutical care has been promoted recently by generic substitution, introduced in Finland in 2003. Pharmacies are obliged to substitute a prescribed medicinal product that costs more than a certain defined maximum price limit with a product costing less than that limit containing the same substance. The policy has been very successful with annual savings of about 5% of outpatient drug expenses (see section 6.6). In international comparisons Finnish health care expenditure appears relatively low compared to other OECD countries while levels of human and capital resources are comparable. One important reason for this is the low salary of health care personnel.
8.5 Accountability of the health care system In the public sector health care system decentralization offers many possibilities to ensure the accountability of health services to local citizens. This has been considered to be one of the most important benefits of decentralization in Finland. The municipalities are also accountable to the state by following legislation, national level policies and guidelines. In municipalities the main decision-making power lies with the municipal council, which is elected every four years by the inhabitants of the municipality. The council appoints a municipal executive board and various municipal committees, including a health committee. The most important decisions on public sector health services are made in these bodies which are politically accountable to the residents. Primary health care is usually directly supervised by these bodies, and specialized services through the council and the executive board of the hospital district. However, although these political bodies are rather 149
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active in financial and structural issues, explicit priority setting is left to the administrative and clinical personnel. In addition to the accountability of the health care system through the political system, two important official mechanisms through which citizens can influence health care services are complaints to the provincial administration, which can, in severe cases, be forwarded to the NAMLA, and appeal to the administrative court. Organizations providing medical treatment must have a patient ombudsman, whose duty is to inform patients of their rights and assist them, if necessary, to submit a complaint, appeal or claim for indemnity (see section 2.4.4). From the perspective of the patient, one major problem of the health care system has been long waiting times for certain services in ambulatory and hospital care. These waiting times vary considerably between municipalities which led to state-defined maximum waiting times for health services in 2005. The legislative reform has had a significant impact in reducing waiting times (see section 7.1.1.3). In the private health care system providers are mainly accountable directly to the individual patients. NHI, which partly reimburses private health care costs, has a very limited role in overseeing the quality of these services.
8.6 Contribution of the health system to health improvement Analysis of the contribution of the health sector to the population’s general health has been scarce in Finland, but it is clear that technological advances in medicine and preventive measures during the last decades have had some influence in improved life expectancy and functional capacity. One indicator of health status that is directly connected to the health care system is mortality amenable to health care (avoidable mortality). During the 1980s and 1990s the improvements in life expectancy in Finland were mainly due to a decline in amenable mortality and especially in mortality from ischaemic heart disease, although in the 1990s the contribution to the health care system was somewhat smaller (Nolte and McKee 2004). The PYLL rate reduced in Finland between the years 1992 and 2004 by approximately 25% (Vohlonen, Bäckmand, Korhonen 2007). Contrary to the equity goal of Finnish health policy, the differences between socioeconomic groups in avoidable mortality is large and in some cases seem to be widening (Arffman et al. 2007). In a comparative study (Nolte and McKee 2003) using an aggregate measure 150
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of amenable mortality (not including ischaemic heart disease) from the year 1998, Finland ranked eighth among 19 OECD countries, behind, for example, Sweden and Norway. Another example of the possible contribution of the health system to health improvement is cancer care. Five-year cancer survival has significantly increased during the last decades (Cancer Society of Finland 2005). This is probably at least partly due to improved health care. Health promotion, including the prevention of diseases, has been the main focus of Finnish health care policy for decades. Public health efforts have resulted in the total eradication of certain communicable diseases, a decrease in several lifestyle-related diseases and an improvement in the health and functional capacity of the population. Several national measures have been implemented to reduce smoking, alcohol consumption, harmful dietary habits, road traffic accidents and occupational diseases (see section 6.1). Partly owing to the comprehensive network of maternal and child health care services, infant mortality in Finland is one of the lowest in the world. Children and young adults receive extensive preventive dental care (see section 6.10), which may have contributed to the observed improvements in oral health (see section 1.5). Vaccinations have been effective in reducing the prevalence of diseases; vaccination coverage in Finland is very high (see section 6.1). In the last few decades perhaps the most significant programme to improve population health was the North Karelia Project launched in the 1970s, which was associated with a 73% reduction in the national annual mortality rate of coronary heart disease among men under 65 years old in 1995 from the pre-programme years (see section 6.1).
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9. Conclusions
T
he Finnish health care system provides relatively good quality health services for reasonable cost with quite high public satisfaction. The most visible problems are long waiting times and personnel shortages in some municipalities. An ageing population, new medical technology and drug innovations alongside increasing public expectations are creating challenges for the Finnish health care system. There are also some features of the Finnish health care system that are perceived as problematic: high level of decentralization, weak position of primary care compared to secondary care, relative lack of coordination between primary and secondary care, and dual financing. In addition, there exist significant inequalities in health and access to health care services. These problems are summarised here. Following the reforms of 1993, the Finnish health care system (municipal services) was decentralized. More than 75% of municipalities have fewer than 10 000 inhabitants and 20% have fewer than 2000. It has been stated that public responsibility for health care has been decentralized in Finland more than in any other country (Häkkinen and Lehto 2005). State level regulations and steering on municipal health care service provision are not very detailed. Municipalities can rather freely set their own municipal income tax rates, decide how much they invest in health care and how they organize services. The advantages of decentralization are strong local democracy, local ownership of public services and better responsiveness to local needs (OECD 2005). However, in recent years growing concerns have been raised that the problems of decentralization outweigh the advantages. Problems created by decentralization are diseconomies of scale, lack of expertise, geographical inequalities in access to services, increase in problems relating to random shifts in expenditure (e.g. the possibility that a few expensive treatments can seriously hamper the annual budget of a municipality), difficulties in securing a sufficient workforce and lack of regional and national cooperation. The limited 153
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coordination across municipalities has led to increasing regional variations in care. In addition, population movement from rural municipalities to cities and ageing of the population especially in rural areas have made small rural municipalities more and more vulnerable while being solely responsible for the organization of the health services. Indeed, there are signs in recent years that decentralization is reversing slightly. The MSAH has tightened the regulative steering of municipalities (for example, defining maximum waiting times for municipal health services) and national level supervision has been reinforced by expanding the functions of the NAMLA from supervising individual professionals to supervision of health care organizations, health centres, hospitals and other institutions providing health services. Additionally, the Government started a project to restructure municipalities and services in 2005 which will lead to a decreasing number of municipalities and increasing cooperation between municipalities. In January 2007, Parliament accepted an act defining how to continue the process which stated that primary health care and social services closely related to health services should be organized by organizations covering at least 20Â 000 inhabitants. In response to this municipalities have made plans to increase cooperation in many regions and in February 2008 decisions on municipal mergers were made so that the number of municipalities will be reduced by 62 by January 2009. It is, however, difficult to estimate what the final outcome of this process will be. The principle of municipal autonomy has a strong tradition in Finland and municipalities value highly their independence in arranging basic services, so the reform will not be easy. Mergers of municipalities can be an especially difficult process for local politicians, municipal employees and residents. However, the general view is that this is the right direction in which to develop the organization of health services in Finland. The municipal health care system has different structures in place for primary and secondary services. There are also separate acts governing the provision of these services. Having separate organizational structures has clearly hindered the cooperation between these levels, both from clinical and economic perspectives. For example, transmitting patient records and other information on patients between primary and secondary care can be difficult. During the last 10 years several local reforms have been conducted to enhance cooperation between primary and secondary health care and social welfare services by integrating organizations. The new Government appointed in April 2007 will promote this process further as it announced that the Primary Health Care Act and the Act on Specialized Medical Care will be combined into a comprehensive Health Care Act. The central aim is to reinforce the role of primary health care. It will be necessary in the future to carefully assess whether municipal primary and secondary services should be structured and financed by the same 154
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organizations. In any case it is evident that primary health care services need to be strengthened relative to secondary care services. There is a dual system of public financing for health care services in Finland: municipal financing based on taxes and NHI financing based on compulsory insurance fees. Municipalities fund municipal health care services (except outpatient drugs and transport costs) and NHI (partly) funds private health care, occupational health care, outpatient drugs, transport costs and sickness allowances. This dual public financing creates challenges for the overall efficiency of service provision, for example as evidenced by cost-shifting in pharmaceutical care. Public funding for private services and curative occupational services is problematic from many perspectives: part of the insured population (lowincome people, unemployed people and people living in rural areas) has fewer possibilities to use these services; the SII does not regulate the quality or efficiency of the services provided; and private services provide the possibility to bypass municipal primary care gate-keeping for municipal specialist level services. It is not the most efficient use of resources for these three somewhat overlapping systems to be publicly funded. One possible danger is that in the future the Finnish health care system will provide different levels of publicly financed services for different population groups which goes against current general health policy objectives. There are significant socioeconomic differences in the use of health care services, including physicians, screening, dental care and some elective surgeries. Although overall mortality has fallen, socioeconomic inequality seems to be increasing. Indeed, even though the Nordic welfare state model served as an important guide when the health care system was being developed, socioeconomic inequalities are still one of the major challenges facing the Finnish health care system. However, despite these challenges, the Finnish health care system has made considerable strides in improving public health, both through preventive and curative measures. Infant and maternal mortality in Finland is one of the lowest in the world and there have been significant improvements in life expectancy, amenable mortality, eradication of communicable diseases, cancer survival and the functional capacity of the population.
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10. Appendices
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Prime Minister’s office (2007). Government Programme of Prime Minister Matti Vanhanen’s second Cabinet. Helsinki, Prime Minister’s office (http:// www.vn.fi/hallitus/hallitusohjelma/pdf/en.pdf, accessed 25 April 2008). Puhakka M et al. (2006). Lähete erikoissairaanhoitoon Lääkäripaneelin arvio lähetteiden laadusta, seuraamuksista ja niiden tuottamasta hyödystä potilaalle [Referral to specialised care. Assessment of a physician panel on quality and consequences of referrals]. Suomen Lääkärilehti, 61:5205–5209. Punkari J, Kaitokari P (2003). A plan to reform the hospital billing system [In Finnish]. Working group memorandums. Helsinki, Ministry of Social Affairs and Health, 2003:1. Puska P, Pietinen P, Uusitalo U (2002). Influencing public nutrition for noncommunicable disease prevention: from community intervention to national programme – experiences from Finland. Public Health Nutrition, 5(1a):245– 251. Puska P et al. (1995). The North Karelia project. 20 year results and experiences. Helsinki, National Public Health Institute. Reunanen A (2004). Tyypin 2 diabetes Suomen kansansairaus [Type 2 diabetes is a major Finnish public health programme]. Kansanterveys, 3: 5–6. Rimpelä A et al. (2004). Suomalaisten nuorten terveys 1977–2003 [Health status of Finnish adolescents in 1977–2003]. Suomen Lääkärilehti, 59:4229– 4235. SII (2006). Statistical yearbook of the Social Insurance Institution 2005. Helsinki, Social Insurance Institution (http://www.kela.fi/it/kelasto/kelasto. nsf/alias/Vk_05_pdf/$File/Vk_05.pdf?OpenElement, accessed 25 April 2008). SII (2007a). Kelan sairausvakuutustilasto 2006 [National health insurance statistics of SII 2006]. Helsinki, Social Insurance Institution (http://www.kela. fi/it/kelasto/kelasto.nsf/alias/Sava_06_pdf/$File/Sava_06.pdf?OpenElement, accessed 25 April 2008). SII (2007b). Kelan työterveyshuoltotilasto 2004 [Occupational health care statistics of SII 2004]. Helsinki, Social Insurance Institution, Suomen virallinen tilasto, Sosiaaliturva 2007 (http://www.kela.fi/it/kelasto/kelasto.nsf/ NET/170407103116AS/$File/Tth_04.pdf?OpenElement, accessed 25 April 2008). SII (2007c). Statistical yearbook of the Social Insurance Institution 2006. Helsinki, Social Insurance Institution (http://www.kela.fi/it/kelasto/kelasto. nsf/alias/Vk_06_pdf/$File/Vk_06.pdf?OpenElement, accessed 25 April 2008). 163
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Soininen H (2005). Muistihäiriöiden varhaisdiagnostiikka kaipaa tehostamista [Early diagnosis of memory disorder needs to be intensified]. Suomen Lääkärilehti, 60:523. SOTKAnet Indicator Bank (2008) [web site]. Helsinki, National Research and Development Centre for Welfare and Health (http://www.sotkanet.fi, accessed 23 April 2008). STAKES (2006a). Erikoissairaanhoidon avohoito vuosina 1994–2004 [Outpatient care in secondary care in 1994–2004]. Helsinki, National Research and Development Centre for Welfare and Health, Tilastotiedote 3/2006 (http://www.stakes.fi/FI/tilastot/aiheittain/Terveyspalvelut/avohoito/ erikoissairaanhoito.htm, accessed 25 April 2008). STAKES (2006b). Statistical yearbook on social welfare and health care 2006. Helsinki, National Research and Development Centre for Welfare and Health. STAKES (2006c). Terveyskeskusten perusterveydenhuollon vuodeosastohoito 2005 [Inpatient care in health centres in 2005]. Helsinki, National Research and Development Centre for Welfare and Health, Tilastotiedote 26/2006 (http://www.stakes.fi/FI/tilastot/aiheittain/Terveyspalvelut/ terveyskeskustenvuodeosastohoito.htm, accessed 25 April 2008). STAKES (2006d). Yearbook of alcohol and drug statistics 2006. Helsinki, National Research and Development Centre for Welfare and Health. STAKES (2006e). Yksityiset terveyspalvelut 2005 [Private health services in 2005]. Helsinki, National Research and Development Centre for Welfare and Health, Tilastotiedote 30/2006 (http://www.stakes.fi/FI/tilastot/aiheittain/ Terveyspalvelut/yksityisetterveyspalvelut.htm, accessed 25 April 2008). STAKES (2007a). Health care expenditure and financing in 2005. Helsinki, National Research and Development Centre for Welfare and Health, Statistical Summary 2/2007 (http://www.stakes.fi/tilastot/tilastotiedotteet/2007/Tt02_ 07.pdf, accessed 25 April 2008). STAKES (2007b). Hospital discharge register, HILMO. Helsinki, National Research and Development Centre for Welfare and Health (http://www.stakes. fi/FI/tilastot/nettihilmo/index.htm, accessed 25 April 2008). STAKES (2007c). Sairaaloiden tuottavuuden kehitys 2001–2005 [Development of productivity in hospital care 2001–2005]. Helsinki, National Research and Development Centre for Welfare and Health, STAKES tilastotiedote 5/2007 (http://www.stakes.fi/tilastot/tilastotiedotteet/2007/Tt05_07.pdf, accessed 25 April 2008). STAKES (2007d). Statistical yearbook on social welfare and health care 2007. Helsinki, National Research and Development Centre for Welfare and Health. 164
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STAKES (2008) [web site]. Perfect. Helsinki, National Research and Development Centre for Welfare and Health (http://info.stakes.fi/perfect/EN, accessed 23 April 2008). Statistics Finland (2004). Causes of death 2003. Helsinki, Statistics Finland. Statistics Finland (2006a). Causes of death 2005. Helsinki, Statistics Finland, Health 2006. Statistics Finland (2006b). Statistical yearbook of Finland 2006. Helsinki, Statistics Finland. Suomen Lääkäriliitto (2006). Lääkärikysely 2006. Tilastoja [Physician survey 2006. Statistics]. Helsinki, Suomen Lääkäriliitto (http://www.laakariliitto.fi/ files/laakarikysely2006.pdf, accessed 25 April 2008). Suomi.fi (2008) [web site]. Helsinki, Government Information Management Unit of the Ministry of Finance (http://www.suomi.fi/english/, accessed 22 April 2008). Teperi J et al. (2006). Riittävät palvelut jokaiselle. Näkökulmia yhdenvertaisuuteen sosiaali- ja terveydenhuollossa [Sufficient services for all. Perspectives on equity in social and health care]. Helsinki, National Research and Development Centre for Welfare and Health. TIN (2007). Global corruption report 2007. Cambridge, Transparency International and Cambridge University Press (http://www.transparency.org/ publications/gcr, accessed 24 April 2008). Van Doorslaer E, Masseria C, Koolman X (2006). Inequalities in access to medical care by income in developed countries. Canadian Medical Association Journal, 174(2):177–180. Vohlonen I, Bäckmand H, Korhonen J (2007). Menetetyt elinvuodet. PYLLindeksi väestön hyvinvoinnin mittana [Potential years of life lost PYLL-rate in monitoring the wellbeing of a population]. Suomen Lääkärilehti, 62(4):305– 309. Vuorenkoski L (2006a). Centralizing supervision of health services. Bertelsmann Foundation, Health Policy Monitor, April 2006 (http://www. hpm.org/survey/fi/a7/2, accessed 24 April 2008). Vuorenkoski L (2006b). Ensuring access to public health care - follow-up. Bertelsmann Foundation, Health Policy Monitor, April 2006 (http://www. hpm.org/survey/fi/a7/3, accessed 24 April 2008). Vuorenkoski L (2007a). Electronic prescriptions and patient records. Bertelsmann Foundation, Health Policy Monitor, April 2007 (http://www. hpm.org/survey/fi/a9/4, accessed 24 April 2008).
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Vuorenkoski L (2007b). State funding for local development projects. Bertelsmann Foundation, Health Policy Monitor, October 2007 (http://www. hpm.org/survey/fi/a10/2, accessed 24 April 2008). Vuorenkoski L (2007c). Vouchers in social and health care - follow-up. Bertelsmann Foundation, Health Policy Monitor, October 2007 (http://www. hpm.org/survey/fi/a10/4, accessed 24 April 2008). Vuorenkoski L, Keskimäki I (2004). Ensuring access to health care. Bertelsmann Foundation, Health Policy Monitor (http://www.hpm.org/survey/ fi/a3/3, accessed 24 April 2008). Vuorenkoski L, Mikkola H (2007). Outsourcing in primary health care. Bertelsmann Foundation, Health Policy Monitor (http://www.hpm.org/survey/ fi/a9/3, accessed 24 April 2008). Vuorenkoski L, Wiili-Peltola E (2007). Merging primary and secondary care providers. Bertelsmann Foundation, Health Policy Monitor, April 2007 (http:// www.hpm.org/survey/fi/a9/1, accessed 24 April 2008). WHO Regional Office for Europe (2007). European Health for All database [online database]. Copenhagen, WHO Regional Office for Europe (http:// www.euro.who.int/hfadb) (January 2007 update). Widström E (2006). Extension of publicly funded dental care to all. Bertelsmann Foundation, Health Policy Monitor, October 2006 (http://www. hpm.org/survey/fi/a8/2, accessed 24 April 2008). World Health Organization (2004). World Health Report 2004. Geneva, World Health Organization.
10.2 Principal legislation Employment Accidents Insurance Act 608/1948
Motor Liability Insurance Act 279/1959 Primary Health Care Act 66/1972 Act on Social Assistance 710/1982 Patient’s Injury Act 585/1986 Medicines Act 395/1987 Act on Specialized Medical Care 1062/1989 Mental Health Act 1116/1990 Private Health Care Act 152/1990 Act on Social and Health Service Planning and State Subsidy 733/1992 Act on User-fees in Social and Health care 734/1992 Act on the Status and Rights of Patients 785/1992 166
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Act on Municipality of Residence 201/1994 Act on Adaptation of Immigrants and Reception of Asylum Seekers 493/1999 The Constitution of Finland 731/1999 Occupational Health Care Act 1383/2001 The Sickness Insurance Act 1224/2004 Act on Rehabilitation Benefits of Social Insurance Institution 566/2005 Act on Electronic Prescription 61/2007 Act on Electronic Management of Information on Users of Social and Health Services 159/2007 Act on Municipal and Service System Reform 169/2007
10.3 Useful web sites The Association of Finnish Local and Regional Authorities: www. localfinland.fi Centre for Pharmacotherapy Development: www.rohto.fi Finnish Centre for Health Promotion: www.health.fi Finnish Institute of Occupational Health: www.ttl.fi/English Finnish Government: www.vn.fi/english Finnish Legislation Database: http://www.finlex.fi/en/ Finnish Medical Association: www.laakariliitto.fi/e/ Finnish Slot Machine Association: www.ray.fi/inenglish Finohta (Finnish Office for Health Technology Assessment) http://finohta. stakes.fi/en The Ministry of Social Affairs and Health: www.stm.fi/english The National Agency for Medicines: www.nam.fi/english The National Authority for Medico-legal Affairs: www.teo.fi The National Product Control Agency for Welfare and Health: www.sttv.fi The National Public Health Institute: www.ktl.fi/english The National Research and Development Centre for Welfare and Health: www.stakes.fi/english The Parliament: www.parliament.fi Pharma Industry Finland: www.pif.fi The Radiation and Nuclear Safety Authority: www.stuk.fi/english The Social Insurance Institution: www.kela.fi/english SotkaNet Indicator Bank www.sotkanet.fi Statistics Finland: www.stat.fi/index_en.html Suomi (public sector portal) http://www.suomi.fi/suomifi/english Terveyskirjasto (health library) www.terveyskirjasto.fi Terveysportti (health portal for professionals) http://www.terveysportti.fi/ 167
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10.4 HiT methodology and production process The Health Systems in Transition (HiT) profiles are produced by country experts in collaboration with the Observatory’s research directors and staff. The profiles are based on a template that, revised periodically, provides detailed guidelines and specific questions, definitions, suggestions for data sources, and examples needed to compile HiTs. While the template offers a comprehensive set of questions, it is intended to be used in a flexible way to allow authors and editors to adapt it to their particular national context. The most recent template is available online at: http://www.euro.who.int/observatory/Hits/20020525_1. Authors draw on multiple data sources for the compilation of HiT profiles, ranging from national statistics, national and regional policy documents, and published literature. Furthermore, international data sources may be incorporated, such as those of the Organisation for Economic Co-operation and Development (OECD) and the World Bank. OECD Health Data contain over 1200 indicators for the 30 OECD countries. Data are drawn from information collected by national statistical bureaux and health ministries. The World Bank provides World Development Indicators, which also rely on official sources. In addition to the information and data provided by the country experts, the Observatory supplies quantitative data in the form of a set of standard comparative figures for each country, drawing on the European HFA database. The HFA database contains more than 600 indicators defined by the World Health Organization (WHO) Regional Office for Europe for the purpose of monitoring Health for All policies in Europe. It is updated for distribution twice a year from various sources, relying largely upon official figures provided by governments, as well as health statistics collected by the technical units of the WHO Regional Office for Europe. The standard HFA data have been officially approved by national governments. With its summer 2004 edition, the HFA database started to take account of the enlarged European Union (EU) of 25 Member States. HiT authors are encouraged to discuss the data in the text in detail, including the standard figures prepared by the Observatory staff, especially if there are concerns about discrepancies between the data available from different sources. A typical HiT profile consists of 10 chapters. 1 Introduction: outlines the broader context of the health system, including geography and sociodemography, economic and political context, and population health. 2 Organizational structure: provides an overview of how the health system in the country is organized and outlines the main actors and their decision-
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making powers; discusses the historical background for the system; and describes the level of patient empowerment in the areas of information, rights, choice, complaints procedures, safety and involvement. 3 Financing: provides information on the level of expenditure, who is covered, what benefits are covered, the sources of health care finance, how resources are pooled and allocated, the main areas of expenditure, and how providers are paid. 4 Regulation and planning: addresses the process of policy development, establishing goals and priorities; deals with questions about relationships between institutional actors, with specific emphasis on their role in regulation and what aspects are subject to regulation; and describes the process of HTA and research and development. 5 Physical and human resources: deals with the planning and distribution of infrastructure and capital stock; the context in which IT systems operate; and human resource input into the health system, including information on registration, training, trends and career paths. 6 Provision of services: concentrates on patient flows, organization and delivery of services, addressing public health, primary and secondary health care, emergency and day care, rehabilitation, pharmaceutical care, long-term care, services for informal carers, palliative care, mental health care, dental care, complementary and alternative medicine, and health care for specific populations. 7 Principal health care reforms: reviews reforms, policies and organizational changes that have had a substantial impact on health care. 8 Assessment of the health system: provides an assessment based on the stated objectives of the health system, the distribution of costs and benefits across the population, efficiency of resource allocation, technical efficiency in health care production, quality of care, and contribution of health care to health improvement. 9 Conclusions: highlights the lessons learned from health system changes; summarizes remaining challenges and future prospects. 10 Appendices: includes references, useful web sites, legislation. Producing a HiT is a complex process. It involves: • writing and editing the report, often in multiple iterations; • external review by (inter)national experts and the country’s Ministry of Health – the authors are supposed to consider comments provided by the Ministry of Health, but not necessarily include them in the final version; 169
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• external review by the editors and international multidisciplinary editorial board; • finalizing the profile, including the stages of copy-editing and typesetting; • dissemination (hard copies, electronic publication, translations and launches). The editor supports the authors throughout the production process and in close consultation with the authors ensures that all stages of the process are taken forward as effectively as possible.
10.5 About the author Lauri Vuorenkoski is a senior researcher in STAKES (National Research and Development Centre for Welfare and Health) in the Health Services and Policy Research Group. He is also trained as a medical doctor and received a PhD in child psychiatry from the University of Oulu in 2001.
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The Health Systems in Transition profiles A series of the European Observatory on Health Systems and Policies
T
he Health systems in transition (HiT) country profiles provide an analytical description of each health care system and of reform initiatives in progress or under development. They aim to provide relevant comparative information to support policy-makers and analysts in the development of health systems and reforms in the countries of the WHO European Region and beyond. The HiT profiles are building blocks that can be used: • to learn in detail about different approaches to the financing, organization and delivery of health services; • to describe accurately the process, content and implementation of health reform programmes; • to highlight common challenges and areas that require more in-depth analysis; and • to provide a tool for the dissemination of information on health systems and the exchange of experiences of reform strategies between policy-makers and analysts in countries of the WHO European Region.
How to obtain a HiT All HiT country profiles are available in PDF format at www.euro.who.int/observatory, where you can also join our listserve for monthly The publication of the European Observatory updates of the activities of the European on Health Systems and Observatory on Health Systems and Policies, Policies are available at including new HiTs, books in our co- www.euro.who.int/observatory published series with Open University Press, Policy briefs, the EuroObserver newsletter and the Eurohealth journal. If you would like to order a paper copy of a HiT, please write to:
info@obs.euro.who int
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HiT country profiles published to date: Albania (1999, 2002 a,g) Andorra (2004) Armenia (2001g, 2006) Australia (2002, 2006) Austria (2001e, 2006 e) Azerbaijan (2004 g) Belgium (2000, 2007) Bosnia and Herzegovina (2002 g) Bulgaria (1999, 2003 b, 2007) Canada (2005) Croatia (1999, 2007) Cyprus (2004) Czech Republic (2000, 2005 g) Denmark (2001, 2007) Estonia (2000, 2004 g,j, 2008) Key Finland (2002, 2008) All HiTs are available in English. France (2004 c,g) When noted, they are also available Georgia (2002 d,g) in other languages: Germany (2000e, 2004e,g) a Albanian Hungary (1999, 2004) b Bulgarian Iceland (2003) c French Israel (2003) d Georgian Italy (2001) e German Kazakhstan (1999 g, 2007) f Romanian Kyrgyzstan (2000 g, 2005 g) g Russian Latvia (2001, 2008) h Spanish Lithuania (2000) Luxembourg (1999) i Turkish Malta (1999) j Estonian Mongolia (2007) k Polish Netherlands (2004 g) New Zealand (2001) Norway (2000, 2006) Poland (1999, 2005 k) Portugal (1999, 2004, 2007) Republic of Moldova (2002 g) Romania (2000 f, 2008) Russian Federation (2003 g) Slovakia (2000, 2004) Slovenia (2002) Spain (2000 h) Sweden (2001, 2005) Switzerland (2000) Tajikistan (2000) The former Yugoslav Republic of Macedonia (2000) Turkey (2002 g,i) Turkmenistan (2000) Ukraine (2004 g) United Kingdom of Great Britain and Northern Ireland (1999 g) Uzbekistan (2001g, 2007)
ISSN 1817-6127
HiTs are in-depth profiles of health systems and policies, produced using a standardized approach that allows comparison across countries. They provide facts, figures and analysis and highlight reform initiatives in progress.
The European Observatory on Health Systems and Policies is a partnership between the WHO Regional Office for Europe, the Governments of Belgium, Finland, Greece, Norway, Slovenia, Spain and Sweden, the Veneto Region of Italy, the European Investment Bank, the Open Society Institute, the World Bank, the London School of Economics and Political Science and the London School of Hygiene & Tropical Medicine.
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