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1 « Comparaisons internationales des systèmes de santé » – Présentation Power Point en français (2007) 100 « Coûts des systèmes de santé » – Article en français (2006) 106 Financing Health Care in the European Union – Etude en anglais (2009) 330 « La Participation des patients aux dépenses de ante dans 5 pays européens » – Document de Travail en français (2007) 374 Health for all ? – Ouvrage en anglais (2008) 732 Données de l’OCDE 2009 – Fiches des pays en anglais et en français (2009) 777 « Descriptions of health care systems : Germany and the Netherlands » – Etude en anglais (2007) 784 « La réforme du système de santé aux Pays-Bas » – Article en français (2007) 787 Finland – Health System Review – Ouvrage en anglais (2008) 982 The Finnish Health Care System – Ouvrage en anglais (2009) 1099 Denmark Health system Review – Ouvrage en anglais (2007) 1286 Norway and Health, An Introduction – Ouvrage en anglais (2009) 1326 Health Care in Sweden – Article en anglais (2009) 1330 infosantésuisse – dossier comparatif sur la Suisse et les Pays-Bas – Articles en français (2009 - 2010) 1336 infosantésuisse – la qualité en Europe – Article (2006) 1337 infosantésuisse consacré à l’Europe – Magazine en français (2007) 1365 liens utiles 1367 infosantésuisse consacré à l’Europe – Magazine en français (2010)

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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

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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:

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 by TJ International, Padstow, Cornwall.

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 purchaserâ&#x20AC;&#x201C;provider relations...............................60 4.4 Payment mechanisms....................................................................62 4.5 Health care expenditure................................................................64 iii

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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 systemâ&#x20AC;&#x2122;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

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 Observatoryâ&#x20AC;&#x2122;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

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

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

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

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 â&#x20AC;&#x153;value for moneyâ&#x20AC;?. 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. Doctorsâ&#x20AC;&#x2122; 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 populationâ&#x20AC;&#x2122;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

Denmark

Introduction

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

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.

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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

0.49

0.50

0.51

–

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.

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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

25.5

–

2.9

2.6

2.2

–

69.9

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 populationâ&#x20AC;&#x2122;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

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

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

79.5

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

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

–

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

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.

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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

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)

20 1953

1963

1970

1975

Source: PLS Rambøll, 2004.

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 30â&#x20AC;&#x201C;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, 1975â&#x20AC;&#x201C;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 parentsâ&#x20AC;&#x2122; 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.

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Fig. 1.7

Denmark

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

Percentage

Source: WHO Regional Office for Europe, January 2007. Notes: CIS: Commonwealth of Independent States; EU: European Union.

100

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Organizational structure

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&#x2026;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

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 â&#x20AC;&#x201C; represented by the Danish Regions and the National Association of Local Authorities â&#x20AC;&#x201C; 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

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Organizational chart of the statutory health system

State level Parliament Government Ministry of Health National Board of Health

Regions

Regional level 5 Regions Regional councils

National Association of Local Authorities

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.

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 personâ&#x20AC;&#x2122;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 SectionÂ 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 GPâ&#x20AC;&#x2122;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

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 â&#x20AC;&#x201C; but still only to a limited extent â&#x20AC;&#x201C; 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 agentâ&#x20AC;&#x2122;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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Financial resources

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: Authorsâ&#x20AC;&#x2122; compilation.

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

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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

1.3

1.2

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

% of GDP

Source: WHO Regional Office for Europe, January 2007. Notes: CIS: Commonwealth of Independent States; EU: European Union.

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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

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).

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Fig. 4.4

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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.

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Physical and human resources

5.1

Physical resources

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 1997â&#x20AC;&#x201C;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, 1990â&#x20AC;&#x201C;2005

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

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 SĂ¸rensen (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 10â&#x20AC;&#x201C;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 costâ&#x20AC;&#x201C;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 patientâ&#x20AC;&#x2122;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

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, 1990â&#x20AC;&#x201C;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, â&#x20AC;&#x201C;) 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

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

1.5

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 professionalsâ&#x20AC;&#x2122; 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, Ă&#x2026;rhus 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 physiciansâ&#x20AC;&#x2122; 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, â&#x20AC;&#x153;Tuning Educational Structures in Europeâ&#x20AC;?, 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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6.1

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 SectionÂ 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 WHOâ&#x20AC;&#x2122;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: Authorâ&#x20AC;&#x2122;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 â&#x20AC;&#x201C; mainly those specializing in dermatology, eye, and ear, nose and throat diseases â&#x20AC;&#x201C; 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 (childrenâ&#x20AC;&#x2122;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 patientâ&#x20AC;&#x2122;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 SĂ¸rensen (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 patientâ&#x20AC;&#x2122;s placement needs, and the waiting period ranges from a few weeks to six months (Payne, Wilson, Caro & Oâ&#x20AC;&#x2122;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. WHOâ&#x20AC;&#x2122;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 5â&#x20AC;&#x201C;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; StrĂśmgren 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.Â 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 14â&#x20AC;&#x201C;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, 2001â&#x20AC;&#x201C;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

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

0.30

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 systemâ&#x20AC;&#x2122;s functions, language problems, and cultural and structural barriers.

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7.1

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 (SĂ¸gĂĽrd 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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8.1

Denmark

Assessment of the health system

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 â&#x20AC;&#x153;extended free choiceâ&#x20AC;? 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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8.4

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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8.5

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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Conclusions

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 countryâ&#x20AC;&#x2122;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 â&#x20AC;&#x153;blame gameâ&#x20AC;? 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

10.1 References Aagaard J, Nielsen JA (2004). Experience from the first ACT programme in Denmark. II. Severe mental illness. A register diagnosis. Nordic Journal of Psychiatry, 58:171–174. Advisory Committee to the Minister for the Interior and Health [Indenrigsog Sundhedsministerens rådgivende udvalg] (2003). Sundhedsvæsenets organisering – sygehuse, incitamenter, amter og alternativer [The organisation of the health care sector – hospitals, incentives, counties and alternatives]. Copenhagen, Indenrigs- og Sundhedsministeriet [Ministry of the Interior and Health] (http://www.im.dk/publikationer/sundhedsvorg/rapport_jan_03.pdf, accessed 11 June 2007). Ankjær-Jensen A, Rath MB (2004). Takststyring af sygehuse. 1. delrapport: implementering af takststyringsmodeller i 4 amter [Case-based hospital financing. Report part 1: implementation of case-based financing models in 4 counties]. Copenhagen, DSI – Institut for Sundhedsvæsen [DSI – Danish Institute of Health Services Research]. Association of County Councils [Amtsrådsforeningen] (2004). Amtsråds foreningens beretning 2003 [Annual report from the Association of County Councils 2003]. Copenhagen, Amtsrådsforeningen (http://www.arf.dk/ OmForeningen/Generalforsamling2004/Beretning.htm, accessed 4 November 2005). Association of County Councils [Amtsrådsforeningen] (2005) [web site]. Copenhagen, Amtsrådsforeningen (http://www.arf.dk, accessed 4 November 2005). 143

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National Board of Health [Sundhedsstyrelsen] (2005b) [web site]. Dødsårsagsregister [Causes of Death Registry]. Copenhagen, Sundhedsstyrelsen ( h t t p : / / w w w. s s t . d k / I n f o r m a t i k _ o g _ s u n d h e d s d a t a / R e g i s t r e _ o g _ sundhedsstatistik/Beskrivelse_af_registre/Doedsaarsagsregister.aspx, accessed 4 November 2005). National Board of Health [Sundhedsstyrelsen] (2005c) [web site]. Landspatientregister [National Patient Registry]. Copenhagen, Sundhedsstyrelsen (http://www.sst.dk/Informatik_og_sundhedsdata/Registre_ og_sundhedsstatistik/Beskrivelse_af_registre/Landspatientregister.aspx?, accessed 4 November 2005). National Board of Health [Sundhedsstyrelsen] (2005d). Sygehusstatistik 2002 [Statistics of the health services]. Copenhagen, Sundhedsstyrelsen (http:// www.sst.dk/publ/publ2005/SESS/Sygehusstatistik/Sygehusstatistik_2002.pdf, accessed 12 June 2007). National Institute of Public Health [Statens Institut for Folkesundhed] (2003). Zoneterapi - den hyppigst anvendte form for alternative behandling [Zone therapy - the most frequently used type of alternative therapy]. Ugens Tal for Folkesundhed, uge 23, 2003 [Weekly Update on Public Health, Week 23, 2003]. Copenhagen , Statens Institut for Folkesundhed, Syddansk Universitet [National Institute of Public Health, University of Southern Denmark] (http:// niph.dk, accessed 12 June 2007). National Institute of Public Health [Statens Institut for Folkesundhed] (2005) [web site]. Forside [Home page]. Statens Institut for Folkesundhed, Syddansk Universitet [National Institute of Public Health, University of Southern Denmark] (www.si-folkesundhed.dk, accessed 14 June 2007). National Serum Institute [Statens Serum Institut] (2005) [web site]. Copenhagen, Statens Serum Institut (www.ssi.dk, accessed 4 November 2005). Nolte E, McKee M (2003). Measuring the health of nations: analysis of mortality amenable to health care. BMJ, 327(7424):1129. NOMESCO (2005). Health statistics in the Nordic countries 2003. Copenhagen, Nordic Medico-Statistical Committee. OECD (2004). Health data 2004 [online database]. Paris, Organisation for Economic Co-operation and Development (http://www.oecd.org, accessed 4 November 2005). OECD (2006). Health data 2006 [online database]. Paris, Organisation for Economic Co-operation and Development (http://www.oecd.org, accessed 12 June 2007).

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OECD (2007) Health data 2007 [online database]. Paris, Organisation for Economic Co-operation and Development (http://www.oecd.org, accessed 12 July 2007). Pallesen T (1997). Health care reform in Britain and Denmark: the politics of economic success and failure [PhD dissertation]. Politica, University of Århus. Patients’ Complaints Board [Sundhedsvæsenets Patientklagenævn] (2003). Afgørelser og Praksis. Årsberetning 2003 [Decisions and practice, annual report 2003]. Copenhagen, Sundhedsvæsenets Patientklagenævn (http:// patientklagenaevnet.dk/public/dokumenter/prak_03.pdf, accessed 12 June 2007). Patients’ Complaints Board [Sundhedsvæsenets Patientklagenævn] (2005) [web site]. Copenhagen, Sundhedsvæsenets Patientklagenævnet (http://www.pkn.dk, accessed 4 November 2005). Payne KA, Wilson CM, Caro JJ, O’Brien JA (1999). Resource use by dementia patients and caregivers: an international survey of medical and social services and processes of long-term care. Annals of Long-Term Care, 7[7]:263–276. Pedersen KM, Christiansen T, Bech M (2005). The Danish health care system: evolution not revolution in a decentralized system. Health Econ, 14(Suppl. 1):S41–S57. Petersen PE, Torres AM (1999). Preventive oral health care and health promotion provided for children and adolescents by the Municipal Dental Health Service in Denmark. Int J Paediatr Dent, 9(2):81–91. Peto R, Lopez AD, Boreham J, Thun M (2006). Mortality from smoking in the developed countries 1950–2000, 2nd ed. (http://www.ctsu.ox.ac.uk, accessed 11 June 2007). PLS Rambøll (2004). Monitorering af danskernes rygevaner 2004 [Monitoring the smoking habits of the Danes 2004]. Copenhagen, Sundhedsstyrelsen, Kræftens Bekæmpelse, Hjerteforeningen, Danmarks Lungeforening [National Board of Health, Danish Cancer Society, Danish Heart Foundation and Danish Lung Association]. Seemann J (2003). Sundhedsplanlægning i et interorganisatorisk perspektiv [Health planning from an interorganizational perspective]. Copenhagen, Forskningscenter for Ledelse og Organisation i Sygehusvæsenet (FLOS) [Research Centre for Management and Organisation in the Hospital Sector (FLOS)].

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Søgård J (2004). Om sundhedsvæsenet [About the health services]. In: Bakke JF, Petersen UH, eds Hvorhen Danmark? Perspektiver på kommunalreformen [Where now Denmark? Perspectives on the local government reform]. Copenhagen, Nyt fra samfundsvidenskaberne. Statistics Denmark [Danmarks Statistik] (2004) [web site]. Befolkningens brug af internet 2004 (serviceerhverv) [Internet access of the Danish population 2004 (service trade)]. Copenhagen, Danmarks Statistik (http://dst.dk/HomeUK.aspx, accessed 4 November 2005). Statistics Denmark [Danmarks Statistik] (2005) [web site]. Copenhagen, Danmarks Statistik (http://www.dst.dk, accessed 4 November 2005). Steensen J, Juel K (1990). Sygehusindlæggelser og sociale forhold [The social distribution of hospital admissions]. Copenhagen, Dansk Sygehusinstitut og Dansk Institut for Klinisk Epidemiologi [DSI – Institute of Health Services Research & Danish Institute for Clinical Epidemiology]. Strandberg-Larsen MS, Krasnik A (2006). The coordination of cancer care from the perspective of primary care providers – an assessment in a selected region of Denmark at the baseline for the second national cancer plan. Social Medicinsk Tidsskrift, 83(suppl.):125–126. Strandberg-Larsen M, Nielsen MB, Krasnik (2007). Are joint health plans effective for coordination of health services? – An analysis based on theory and Danish pre-reform results. International Journal of Integrated Care (In Press). Strandberg-Larsen M, Nielsen MB, Krasnik A, Vrangbaek K (2006). Is Denmark prepared to meet future health care demands? Eurohealth, 12(4):7–10. Strömgren AS et al. (2005). A Longitudinal study of palliative care: patientevaluated outcome and impact of attrition. Cancer, 103(8):1747–1755. The Counties, Copenhagen Hospital Co-operation (H:S), Ministry of the Interior and Health [Amterne, H:S, Indenrigs- og Sundhedsministeriet] (2005). Patienters oplevelser på landets sygehuse 2004 [The experiences of patients from hospitals in the country 2004]. Københavns Amt, Enheden for Brugerundersøgelser [Copenhagen County, Unit of Patient Evaluation] (http:// www.frederiksberghospital.dk/frederiksberg.nsf/pics/LPU2004.pdf/$FILE/ LPU2004.pdf, accessed 4 November 2005). Thomson S, Mossialos E (2004). The regulatory framework for voluntary health insurance in the European Union: implications for accession countries. In: den Exter A, ed. Health and accession. Rotterdam, Erasmus University. University College Øresund, Center for Higher Education (2005) [web site]. Copenhagen, University College Øresund (http://www.cvuoeresund.dk, accessed 4 November 2005). 156

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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.

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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7. 8.

9. 10.

• • • • •

162

Denmark

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

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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Norway and Health

IS-1730 E

an introduction

Title:

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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

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Preface

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.

BjĂ¸rn-Inge Larsen Director General BjĂ¸rn-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

International cooperation on health

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

Health: Financial and human resources 3.1 Manpower 3.2 Registration/licensing of personnel

11 12 12

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 practitionersâ&#x20AC;&#x2122; 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

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

Universal design - The Delta centre

Preparedness 9.1 Aims

34 34

Links

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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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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 employersÂ´ 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 populationâ&#x20AC;&#x2122;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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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 doctorâ&#x20AC;&#x2122;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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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 â&#x20AC;&#x153;health enterprisesâ&#x20AC;?, 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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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 practitionersâ&#x20AC;&#x2122; scheme 5.4 In 2002, the national authorities introduced a regular general practitionersâ&#x20AC;&#x2122; 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: • • •

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 • • • •

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 userâ&#x20AC;&#x2122;s involvement in the treatment process.

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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.

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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.

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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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.

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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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

Stockholm

Linköping

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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infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1330 Dossiers : comparaison entre les systèmes de santé suisse et néerlandais

Première partie : Présentation du système d’assurance néerlandais Les trois prochains numéros d’infosantésuisse consacreront une double page au système de santé néderlandais*. Le premier article le présentera, le deuxième le comparera avec celui de la Suisse et le dernier examinera les enseignements à tirer de l’expérience néerlandaise. La presse américaine tend à comparer les deux modèles. Elle y voit deux possibles sources d’inspiration pour la politique de santé du président Barack Obama. Cette mise en parallèle estelle légitime ?

Le système de santé néerlandais est essentiellement privé. Il s’organise autour de médecins libéraux (généralistes et spécialistes) et d’hôpitaux ou cliniques qui appartiennent à des organismes à but non lucratif, lointain héritage des institutions caritatives du Moyen âge. Les soins primaires sont au centre du système de santé, le médecin généraliste y a une fonction de gatekeeper. Les objectifs premiers du système sont de promouvoir la qualité des soins, l’efficience, l’accessibilité et leur économicité. Dès les 15e et 16e siècles, apparaissaient aux Pays-Bas les rudiments d’une assurance-maladie, organisée par des guildes, des groupes de citoyens partageant des intérêts communs. Malgré cette grande précocité, il a fallu attendre la Seconde Guerre Mondiale pour voir l’introduction d’un système social d’assurance-maladie étendu. L’occupant allemand a alors établi les fondements du système de santé, resté en vigueur jusqu’au 1er janvier 2006 : il initiait l’obligation d’assurance pour les deux tiers de la population en dessous d’un certain seuil de richesse, comme dans le système de santé allemand. Le tiers restant, plus fortuné, pouvait volontairement opter pour une assurance privée. Depuis le 1er janvier 2006, cette distinction est abolie. La loi sur l’assurance soins de santé (Zorgverkeringswet – ZVW) a en effet profondément modifié le système de santé néerlandais en mettant en place un système universel d’assurance-maladie.

L’obligation d’assurance

Structure du financement

Depuis le 1er janvier 2006, toute personne résidant aux Pays-Bas doit contracter une assurance auprès d’un assureur-maladie. L’affiliation d’office est remplacée par une obligation pour les résidents de prendre eux-mêmes une assurance. Dans l’ancien système, environ 2 % de la population n’était pas assurée. La nouvelle assurance prévoit aussi la prise en charge d’un catalogue de soins dits de base, fixé au préalable par l’Etat. Dans le même temps, un assureur ne pourra plus, comme c’était le cas auparavant, refuser d’admettre une personne en se basant sur les risques liés à son état de santé. Les assureurs devront accepter toute personne qui souhaite souscrire une assurance. L’assuré peut choisir parmi différents types d’assurance : la police « en nature », pour laquelle l’assureur passe directement des contrats avec les fournisseurs de soins (liberté de contracter) et paie directement les factures aux professionnels de santé (tiers payant). L’assuré, quant à lui, doit s’adresser aux professionnels de santé ayant passé un contrat avec l’assureur (restriction du choix du fournisseur de prestations). Dans la police « contre remboursement », l’assuré choisit lui-même son prestataire de soins (libre choix), paie les factures et se fait rembourser ensuite par son assureur (tiers garant). La police d’assurance peut aussi mêler les deux systèmes. En complément de l’assurance de base, il existe des assurances complémentaires prenant en charge les prestations ou les parties de prestations ne faisant pas partie du catalogue de soins.

Le système d’assurance maladie peut être divisé en trois volets couvrant chacun des prestations de soins particulières et obéissant à des modalités d’assurance spécifiques : • Le premier volet comprend les « risques extraordinaires ». Il a été défini dans la Loi sur les dépenses médicales exceptionnelles (AWBZ), qui couvre toute la population pour les frais de longs séjours. La prime est un pourcentage du revenu avec un plafond maximum. • Le deuxième volet représente le catalogue de soins de base et rassemble les soins courants comme les consultations chez les généralistes, les médicaments, les hospitalisations, etc. Chaque citoyen néerlandais est obligé de contracter cette assurance auprès de l’un des assureurs-maladie privés en concurrence. Les primes sont en partie des primes nominales et en partie des prélèvements sur le revenu. • Le troisième volet est constitué par les assurances complémentaires. Ce troisième bloc est moins régulé et les primes sont normalement liées aux risques. Il n’est pas obligatoire de souscrire à une assurance complémentaire. Un financement ayant quelques similitudes avec la Suisse

Dès 18 ans, toute personne est redevable d’une cotisation nominale pour le catalogue de soins de base. La cotisation est identique par type de police d’assurance, quel que soit l’âge, le sexe, Valeur (année)

Indicateur Dépenses publiques en % du total des dépenses de santé Dépenses publiques de santé en % du total des dépenses publiques Paiements directs en % des dépenses privées de santé

64,9 (2005) 13,2 (2005) 21,90 (2005)

Dépenses publiques de santé par habitant (au taux de change officiel de l’US $)

2311,0 (2005)

Total des dépenses de santé par habitant (au taux de change officiel de l’US $)

3560,0 (2005)

Dépenses privées en % du total des dépenses de santé

35,1 (2005)

Financement des assurances privées en % des dépenses privées de santé

55,5 (2005)

Total des dépenses de santé en % du PIB Source : Statistique de l’OMS 2006

22 | Domaine de la santé 9/09

9,2 (2005)

Foto: Keystone

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Habile mélange d’intervention de l’Etat et de loi du marché : les Pays-Bas passent aujourd’hui pour avoir le système de santé le plus satisfaisant d’Europe du point de vue des patients.

l’état de santé ou le montant de revenus. Une partie de la prime nominale peut être remboursée si l’assuré a peu ou n’a pas du tout recours aux services de santé. A côté de la prime nominale, les cotisations fixées en fonction du revenu, destinées à couvrir 50 % de la charge financière globale du régime, sont prélevés par les services fiscaux. Le plafond annuel est de 30 000 euros environ. Cet impôt est remboursé à l’assuré par son employeur et dans certains cas par l’organisme débiteur de sécurité sociale. Enfin, l’Etat prend en charge une partie des primes pour les enfants de moins de 18 ans et il peut également se substituer à une compagnie d’assurance maladie et assumer les engagements financiers que celle-ci a été dans l’impossibilité d’honorer. Les cotisations calculées en fonction du revenu et les montants versés par l’Etat financent le Fonds d’assurance maladie, administré par l’Office de l’assurancemaladie. Les ressources du fonds sont utilisées, en partie, pour compenser la pénalisation que subissent les compagnies d’assurances sur le plan financier

du fait qu’elles doivent accepter toute personne ayant l’obligation de souscrire une assurance (c’est donc l’équivalent de l’Institution commune LAMal suisse chargée de gérer la compensation des risques). Pour garantir à tous un accès à l’assurance, des allocations sont aussi prévues par le gouvernement pour aider les personnes au paiement de la prime nominale, au cas où ce montant serait disproportionnellement élevé par rapport à leurs revenus. La concurrence régulée

Le système de santé repose sur une concurrence régulée basée sur le libre choix. Les consommateurs peuvent choisir leur assureur, logiquement selon le critère du meilleur rapport qualité/ prix. La concurrence s’applique tant entre les assureurs-maladie, qu’entre les fournisseurs de prestations. Les assureurs-maladie concurrents passent en effet des contrats avec certains prestataires de soins. L’accès aux soins est assuré par des contrats annuels et l’obligation d’assurance. Ce système vou-

drait combiner ce qu’il y a de meilleur dans la loi du marché et la règlementation étatique : autrement dit, le marché pousserait le système de santé à plus de compétitivité, d’efficacité et d’adaptation à la demande, alors que le gouvernement régulerait et contrôlerait la qualité et l’équité. Bien que de nombreux changements aient déjà été introduits, beaucoup reste à faire. Mais les Pays-Bas semblent sur la bonne voie, en témoigne leur première place à l’Euro Health Consumer Index (EHCI) en 2009 et l’avis partagé par de nombreux experts faisant du système de santé néerlandais un des meilleurs du monde. maud hilaire schenker

* Les trois articles s’appuieront sur le livre de Robert E. Leu, Frans Rutten, Werner Brouwer, Christian Rütschi et Pius Matter, The Swiss and the Dutch health care systems compared, Gesundheitsökonomische Beiträge, Band 53, NOmos, 2008

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Concurrence régulée et souci de la qualité

Les systèmes néerlandais et suisse sont similaires en bien des points. Reposant sur le principe de l’obligation d’assurance, ils présentent notamment tous deux un large catalogue de prestations pour l’assurance-maladie de base. Favorables à la concurrence régulée, ils ont adopté un système de compensation des risques pour garantir une certaine égalité entre les différentes caissesmaladie. La qualité est aussi placée au centre des préoccupations de ces systèmes fondés sur le libre choix des patients. Mais comment est-elle évaluée ? Par qui ? Trouve-t-on ici les limites de ces systèmes souvent jugés comme les meilleurs du monde, notamment par les médias américains ? Découvrons les diverses ressemblances entre les deux systèmes. Obligation d’assurance…

En Suisse et aux Pays-Bas, les résidents doivent souscrire une assurancemaladie. En Suisse, bien qu’aucune donnée ou estimation n’existe, le nombre de personnes non-assurées est supposé très bas (moins de 1 %). Aux PaysBas, le pourcentage de personnes sans assurance s’élève à 1,5 % de la population. Une explication à cette différence, la Suisse mène une politique active pour identifier les personnes nonassurées. L’art.6 de la LAMal attribue cette mission aux cantons qui veillent à ce que chacun soit assuré. De plus, une fois qu’un individu est assuré, sa caisse-maladie doit le garder enregistré jusqu’à ce qu’il ait la preuve qu’il a changé d’assurance ou qu’il n’est plus obligé de s’assurer (LAMal, art. 7). Les deux pays sont cependant confrontés à un même problème, un nombre important d’individus ne paient pas leurs

primes. Ils seraient 120 000 en Suisse et 240 000 aux Pays-Bas, des chiffres comparables, si l’on sait que les Pays-Bas comptent au moins le double d’habitants. Les deux pays tentent de décourager les individus qui ne paient pas leurs primes (avec la suspension du remboursement des prestations médicales Art.64a LAMal) ou de les empêcher de passer d’un assureur à l’autre (initiative parlementaire pour une liste noire des mauvais payeurs). Ce problème n’a que récemment attiré l’attention des PaysBas, de nouvelles mesures en la matière sont donc envisageables. …et assurance de base obligatoire

Une étude détaillée soulignerait aussi probablement les nombreuses similitudes existantes entre les deux catalogues des prestations soumis à des critères de contrôles similaires : critères EAE (efficacité, adéquation et économicité) pour la Suisse, nécessité, efficacité et rapport coût/efficacité pour les PaysBas. Toutefois, dans les deux pays, il n’existe aucune procédure systématique d’évaluation au moment de la définition du panier ou de l’introduction de nouvelles prestations. Seuls les médicaments, les analyses de laboratoire et les mesures préventives sont soumis à un contrôle systématique et indiqués sur une liste positive (voir infosantésuisse 6/09 p.8). Aux Pays-Bas, cependant, l’institution qui contrôle systématiquement les médicaments est maintenant tenue de le faire pour chaque soin délivré par un spécialiste. Le catalogue des prestations comprend les soins primaires fournis par les médecins généralistes, principalement les consultations, les visites, les médicaments, l’examen par un spécialiste et les opérations mineures. Il existe aussi une liste positive pour les médicaments remboursés sans participation aux coûts. Les soins dentaires sont eux aussi couverts, à la grande différence de la Suisse. Les soins paramédicaux (comme la physiothérapie et la logopédie) sont limités. Le catalogue est plutôt décrit de manière implicite, seule une courte liste négative exclut certains services.

Le marché de l’assurance de base

Concernant le marché de l’assurance de base, les deux pays se ressemblent beaucoup. Tous deux offrent un catalogue de prestations de base défini nationalement et proposé par les différents assureurs concurrents. Les assurés peuvent choisir parmi ces assureurs et en changer tous les ans, sans risquer d’être rejeté par l’assureur. Aucun des deux pays n’a récemment enregistré de nouveaux venus sur le marché de l’assurance, ce qui n’est pas surprenant : par le passé les assureurs de base ne pouvaient pas faire de profit. Cette donnée ayant maintenant changé aux Pays-Bas, il sera intéressant de voir l’évolution du marché. Une des spécificités des PaysBas est de présenter des contrats d’assurance collectifs. Aussi les employés d’une grande entreprise ou un groupe spécifique de malades peuvent-ils négocier des rabais de primes. Pour favoriser la concurrence, les Pays-Bas misent sur une plus grande liberté de contrac-

Photo: Prisma

Notre dossier sur le système de santé néerlandais se poursuit avec un zoom avant sur les éléments qui permettent de le rapprocher du système de santé suisse. Au-delà des apparences, les deux systèmes se ressemblent. Ils obéissent notamment aux mêmes règles fondamentales : obligation de s’assurer, concurrence et qualité.*

Les bons fromages ne sont pas le seul point commun entre la Suisse et les Pays-Bas. Dans le domaine de la santé aussi, les similitudes sont frappantes.

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ter (les assureurs peuvent choisir avec quels prestataires de soins ils collaborent) pour les assureurs. Aux Pays-Bas, l’obligation de contracter a été abolie, mais il existe une obligation de proposer des soins suffisants dans l’intérêt de l’assuré. La compensation des risques

La concurrence est aussi rendue possible par la compensation des risques. Dans les années nonante, les deux pays ont fondé la compensation des risques sur deux critères démographiques : l’âge et le sexe. Mais depuis, les Pays-Bas ont ajusté plusieurs fois leurs critères incluant le statut sur le marché professionnel, le domicile, vingt groupes de coûts pharmaceutiques et treize de coûts diagnostiques. La Suisse, elle, conserve son schéma démographique, mais introduira en 2012 un nouvel indicateur de « séjour dans un hôpital/EMS au cours de l’année précédente ». Aux Pays-Bas, la compensation des risques

s’effectue de manière prospective et rétrospective, ce qui incite les assureurs à adopter un comportement efficient en termes de coûts. Les modèles d’assurance alternatifs

Pour favoriser la concurrence, les assurances proposent également des modèles alternatifs appelés à se développer dans les deux pays. Cependant, la différence en la matière entre les deux pays est notoire. Alors qu’en Suisse, 12 % des assurés ont choisi un modèle d’assurance alternatif, le développement n’en est qu’à ses balbutiements aux PaysBas. Des études suisses prouvent que les modèles HMO promettent de fortes réductions de coûts, pourtant ils ne représentent que 15 % du marché des soins gérés. Une autre différence est qu’aux Pays-Bas, le médecin généraliste joue un rôle de gatekeeper. Une ordonnance médicale du médecin généraliste est en effet nécessaire pour pouvoir consulter un spécialiste. En Suisse,

Précision sur le financement (voir infosantésuisse 9/2009) Aux Pays-Bas, la part du financement assuré par les impôts est de 5 %, elle est de 30 % en Suisse. Aux Pays-Bas, 50 % du financement s’opère à la faveur de primes forfaitaires indépendantes des risques et 45 % par le biais de primes liées au revenu et prélevé sur ce dernier (7,2 % pour les salariés et 5,1 % pour les retraités et les indépendants dont le salaire ne dépasse pas 31 000 euros).

les choses sont différentes, dans la mesure où l’assurance de base permet un accès direct aux spécialistes. Aux PaysBas, les assureurs peuvent aussi acheter des pharmacies ou des hôpitaux, situation impossible en Suisse. La qualité

Les deux pays font de la qualité des soins leur but premier et considèrent les professions médicales comme centrales pour établir les critères de qualité. Aux Pays-Bas, il existe ainsi des indicateurs nationaux de plus en plus utilisés. Les contrôles de qualité sont exécutés de manière interne et externe. Les professionnels de santé en sont responsables, mais aussi les assureurs et des superviseurs gouvernementaux. En Suisse, les contrôles de qualité manquent encore. Les rapports de l’OECD et de l’OMS encouragent la Suisse à travailler dans ce sens. La Suisse n’a pas de schéma national, seulement des projets épars. De nombreux points communs rapprochent ainsi les deux systèmes, la différence fondamentale repose sur le fait qu’aux Pays-Bas la coordination des projets est nationale, alors qu’en Suisse, les spécificités cantonales dominent. Pour les experts et la presse internationale, la principale qualité de ces deux systèmes est leur juste équilibre entre concurrence régulée et intervention mesurée de l’Etat. maud hilaire schenker

* Les trois articles s’appuient sur le livre de Robert E. Leu, Frans Rutten, Werner Brouwer, Christian Rütschi et Pius Matter, The Swiss and the Dutch health care systems compared, Gesundheitsökonomische Beiträge, Band 53, Nomos, 2008

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Aux Pays-Bas, il n’y a pas que les cafés qui obéissent à la concurrence, les assurances-maladie aussi.

Dossiers : comparaison entre les systèmes de santé suisse et néerlandais. 3e partie

Troisième partie : quelles leçons pour les deux pays ? Les précédents articles ont montré les points communs et les différences des systèmes suisses et néerlandais. Le système néerlandais souvent posé comme numéro 1 des systèmes de santé a-t-il quelque chose à apprendre de l’expérience suisse ? Et le système suisse va-t-il si mal qu’il doit être remanié de fond en comble et imiter le système néerlandais ?

Le premier article de notre dossier présentait le système néerlandais (infosantésuisse 9/2009), le deuxième montrait les points communs partagés par les deux systèmes (infosantésuisse 10/2009). Ce dernier article se veut une synthèse cristallisant premièrement les différences et les ressemblances essentielles des deux systèmes et tentant finalement de voir quels enseignements peuvent être tirés des deux systèmes. Autrement dit, quels sont leurs points forts et leurs faiblesses respectives ? Comment s’améliorer, sinon en regardant ce qui se passe au-delà de nos frontières ? Une différence culturelle

La principale distinction entre les deux pays est d’ordre culturel et concerne le degré de centralisation. Le système néerlandais est très centralisé, loin de la

fragmentation du système suisse. L’Etat y joue avant tout un rôle de régulateur et ne fournit pas de prestations. Les hôpitaux sont en effet majoritairement privés, même s’ils fonctionnent comme des institutions d’utilité publique. Avec la réforme de 2006, la planification hospitalière a disparu. Les assureurs, qui comptent aussi des concurrents étrangers, sont autorisés à réaliser des bénéfices et à proposer des contrats d’assurance collectifs, choses impossibles en Suisse. Le marché de l’assurance néerlandais est aussi très concentré : cinq grandes sociétés d’assurance couvrent 82 % des 16 millions d’habitants. En Suisse, les dix plus grandes caisses maladie assurent 80 % de la population. Le système s’y caractérise par une forte décentralisation qui accorde une grande autonomie aux cantons. De fait, la Suisse connaît de grandes disparités régionales au niveau de la densité médicale et hospitalière et de larges variations de primes d’un canton à l’autre et à l’intérieur même des cantons. Une différence organisationnelle

La seconde dissemblance fondamentale concerne l’organisation des soins de premier recours. Aux Pays-Bas, tous les patients doivent s’inscrire auprès du généraliste de leur choix. Sauf en cas d’urgence, l’accès aux spécialistes ou

à l’hôpital n’est ainsi possible que par l’intermédiaire d’un médecin de famille. Les généralistes ont donc une fonction centrale de gatekeeper et se montrent restrictifs en termes de prescription de médicaments. Aussi les dépenses des soins ambulatoires sont-elles relativement basses. Des politiques, misant sur la compétitivité et l’efficience, sont également entreprises pour limiter le nombre de lits d’hôpital et de spécialistes, entraînant une faible densité de spécialistes. La Suisse, en comparaison, affiche un grand nombre de spécialistes, auxquels les assurés ont directement accès (excepté dans les soins gérés). Des points communs structurels

Par delà les distinctions, les deux pays partagent de nombreux points communs concernant notamment la structure du système fondé sur l’obligation d’assurance, une large assurance de base, offerte par des assureurs concurrents. Les deux pays autorisent aussi les assurés à changer d’assureur tous les ans en espérant qu’ils fondent leur choix sur les différences de primes et l’efficience. Les deux pays tentent aussi de développer des modèles d’assurance alternatifs et de trouver un juste équilibre entre concurrence et régulation de l’Etat. Toutefois, le degré de liberté des assureurs varient d’un pays à l’autre.

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Photo : Prisma

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sont fournis par des hôpitaux publics subventionnés par l’argent public. Seuls la liberté de contracter et un même financement moniste pour les soins stationnaires et ambulatoires insuffleraient plus de compétitivité et d’efficience. En Suisse, la concurrence sur le marché de l’assurance maladie est donc plutôt limitée, tant les assureurs manquent des outils nécessaires.

Aux Pays-Bas, les assureurs peuvent choisir avec quels fournisseurs ils veulent passer des conventions. Dans le domaine ambulatoire, la liberté contractuelle est totale, elle est en revanche partielle (environ 10 %) dans les soins stationnaires aigus. En Suisse, la liberté de contracter n’existe pas et les assureurs n’ont pas le droit de faire de bénéfices dans le cadre de l’assurance de base. Leçons de l’expérience suisse

Régulation inefficace L’exemple suisse montre ainsi qu’autoriser d’un côté la concurrence dans le marché de l’assurance-maladie et le limiter d’un autre côté par des régulations inefficientes érode une grande partie des gains potentiels apportés par la concurrence. Pour ouvrir la voie à la réalisation d’un modèle de concurrence régulée, la Suisse doit rectifier certains aspects de son système de santé. En font notamment partie l’amélioration du système de compensation des risques et la liberté de contracter (actuellement limitée aux soins gérés), qui suppose la concurrence entre les fournisseurs de prestations. Or, ce n’est actuellement pas le cas. Dans les soins ambulatoires, ce sont en effet les négociations collectives (type TARMED) qui prédominent, alors que les soins stationnaires

Managed Care En revanche, la Suisse se montre plus avancée en matière de soins gérés. Son expérience remonte au début des années 90, bien que les soins gérés ne soient admis que dans un cas particulier (tous les fournisseurs de soins gérés doivent aussi offrir une assurance de base ordinaire). Les preuves empiriques démontrent que les coûts peuvent seulement être économisés dans les organisations où les médecins partagent un risque financier (type HMO). Et pourtant ce modèle est le moins populaire de toutes les formes de soins gérés existant et représente seulement 2 % du marché. Le modèle doit donc être encouragé et plus développé. Leçons de l’expérience néerlandaise

La concurrence régulée La concurrence régulée part du principe que les choix du consommateur poussent les assureurs à plus d’efficience et d’innovation. Dans le cas où la liberté de contracter est instaurée, cette incitation à plus d’efficience se répercute sur les fournisseurs de prestations (sans perdre pour autant les aspects positifs garantis par l’intervention de l’Etat que sont l’accès à l’assurance, les soins pour tous et la qualité des soins). La Suisse possède certains éléments de la concurrence régulée comme l’obligation d’assurance avec un panier de base prédéfini, la liberté pour les assurés de choisir leur assureur sans risquer d’être refusés, la réduction des primes et la compensation des risques. Mais elle manque d’autres éléments indispensables présents aux Pays-Bas comme la liberté de contracter, une bonne compensation des risques, l’intervention à tous les étages du marché des autorités de la concurrence, l’autorisation donnée aux assureurs de réaliser des pro-

fits, le financement moniste, un moniteur de la qualité. Nécessité d’un consensus politique L’exemple des Pays-Bas montre aussi que les systèmes de santé ne peuvent se développer de manière cohérente que s’il existe un consensus politique quant à la direction à donner au système. Cet accord a ainsi permis aux Pays-Bas d’accomplir un grand pas en avant avec les réformes de 2006 vers le modèle de concurrence régulée. En suisse, le consensus est loin d’être atteint : la moitié du monde politique est en effet favorable à un système de santé plus étatique et l’autre moitié à plus de concurrence. En conséquence, les réformes restent bloquées. Monitoring de la qualité Un important élément de la concurrence est le monitoring systématique de la qualité. Aux Pays-Bas, des indicateurs de performance ont été développés en étroite collaboration avec l’Association néerlandaise des hôpitaux, la Fédération des hôpitaux universitaires , l’Association des médecins et l’Inspection de la santé. Ces indicateurs sont présentés chaque année dans les rapports annuels des hôpitaux et peuvent être comparés d’une année sur l’autre et d’un hôpital à l’autre. Ils sont loin d’être aussi élaborés qu’aux USA ou en Allemagne. Quoiqu’il en soit, c’est un premier pas important. En Suisse, malgré les actions des hôpitaux et des cantons, il n’existe pas de politique nationale en la matière. Les Pays-Bas sont certes en avance, mais les deux pays doivent encore progresser dans le domaine. La comparaison entre les deux pays indique que trop de pouvoirs délégués au niveau cantonal, combiné à un large soutien public des soins hospitaliers, n’encourage ni l’efficience, ni la stabilisation des coûts. Le message envoyé à la Suisse est donc clair : réorganiser son système pour éliminer les rôles multiples des cantons.1 maud hilaire schenker Robert E. Leu, Frans Rutten, Werner Brouwer, Christian Rütschi et Pius Matter, The Swiss and the Dutch health case systems compared, Nomos, 2008.

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SOUS LA LOUPE

infosantésuisse Nº 1–2, janvier / février 2006

A propos des expériences menées avec les systèmes de qualité en Grande-Bretagne et en Allemagne

L’Europe va de l’avant Les mesures obligatoires de la qualité sont, aujourd’hui en Suisse, une musique d’avenir. Dans d’autres pays, en revanche, elles sont en application depuis longtemps et les expériences faites sont très largement positives. Deux experts en la matière, l’un venu de Grande-Bretagne et l’autre d’Allemagne, ont présenté les systèmes de mesure de leurs pays respectifs et les résultats obtenus au cours d’un atelier de discussion organisé par santésuisse. La mesure de la qualité signifiet-elle promotion de la qualité ? Il n’y a pas, en Allemagne, d’ensemble d’indicateurs obligatoires. En revanche, les médecins sont tenus par la loi de faire mesurer périodiquement la qualité de leurs prestations, quel que soit le système dans lequel ils travaillent. La caisse-maladie AOK a élaboré dans cette perspective un ensemble d’indicateurs, et cela en collaboration avec des réseaux de médecins et d’autres experts. Cet ensemble est désormais repris dans les contrats passés entre la caisse AOK et les réseaux de médecins. Les indicateurs sont répartis par maladie, principalement les maladies chroniques, mais aussi selon les caractéristiques du cabinet. C’est ainsi que la mesure des résultats tient également compte de la structure, de la qualité et des processus. Il est à remarquer que le système de mesure de la qualité lui-même doit, en l’occurrence, lui aussi se soumettre à une mesure de la qualité. Ces démarches ont eu un résultat réjouissant : les réseaux de médecins qui prennent part au programme de l’AOK, prescrivent plus de génériques et significativement moins de médicaments dont

les principes actifs sont controversés. On constate aussi que les diabétiques sont traités plus souvent selon les dernières données de la médecine basée sur les évidences. Pour les autres points également soumis à examen, les réseaux AOK sont manifestement en avance, aussi bien sur les cabinets pris individuellement que sur les autres réseaux de médecins.

Les soins gérés : un catalyseur de la qualité L’exemple de l’Allemagne le montre clairement : les organisations de soins gérés penchent davantage que les fournisseurs individuels de prestations vers la mise en route ou le rattachement à des programmes de promotion de la qualité. C’est également cette thèse qui a été présentée récemment par le professeur Richard Grol, directeur du Centre hollandais de recherches en qualité des soins, lors d’une rencontre du « Forum Managed Care ». Bien qu’il n’y ait pas de preuve scientifique significative d’une meilleure qualité des traitements dans les systèmes de soins gérés, des indices divers laissent toutefois penser que c’est bien le cas. Peter Kraft Photo : Prisma

e Dr Robert Dobler, responsable d’un cabinet de groupe dans la localité anglaise de Cambridge, a rendu compte des résultats obtenus par l’application du système de contrôle de qualité du « National Health System (NHS) ». Alors qu’auparavant les mesures de qualité étaient appliquées sans grande coordination et que les cabinets négociaient avec le NSH leurs objectifs de qualité, c’est, depuis 2004, le « New Contract » qui a été mis en vigueur. Les indicateurs de mesure des résultats sont désormais les mêmes pour tous les cabinets et ils sont obligatoires. Les mesures sont détaillées : on trouve en effet, au total, plus de 100 indicateurs. Ce qui a le plus de poids, ce sont les mesures d’ordre clinique qui déterminent le processus de traitement en accord avec la « médecine basée sur les évidences ». Mais on tient également compte de l’organisation, de la satisfaction des patients et d’un certain nombre de prestations supplémentaires. C’est par une procédure spécifique et adaptée que les processus suivis au cabinet sont transmis au NHS ; a cela s’ajoute une visite d’audit des autorités sanitaires. La satisfaction des patients est très conventionnellement mesurée à l’aide d’un questionnaire. Le NHS élabore pour chaque cabinet un bilan par points, bilan qui a des répercussions directes sur la rémunération. La part du revenu dépendant de la qualité des prestations peut aller jusqu’à 21 %. Robert Dobler a toutefois souligné l’existence d’un certain nombre de problèmes. C’est ainsi que le système de mesure peut faire en sorte que les cabinets se concentrent d’abord sur les affections pour lesquelles un nombre maximal de points de qualité est en jeu. Cette dérive possible est contrée par une révision et une extension permanentes du catalogue des indicateurs.

Pour les questions de qualité, l’AOK travaille en lien étroit avec les réseaux de médecins allemands.

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infosantésuisse Magazine des assureurs-maladie suisses N° 4, avril 2007

Le rapport Cox : indicateur de direction à double face pour la politique de santé de l’UE page 14

Nello Castelli nous parle de la campagne pour la votation du 11 mars en Suisse romande page 18

SOUS LA LOUPE :

Les systèmes de santé dans les pays voisins

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1338

SOMMAIRE

infosantésuisse No 4, avril 2007

SOUS LA LOUPE 4 6 8 10 12 14

Allemagne : lourde ponction sur les salaires France : un système étatique bon mais coûteux Le système de santé italien s’enfonce dans la crise Autriche : sur les plus hautes marches du podium. Est-ce vrai aussi pour la santé ? Scandinavie : payer peu mais attendre longtemps ? Le rapport Cox : indicateur de direction à double face pour la politique de santé de l’UE

ASSURANCE-MALADIE 6 1 18 19

Allemagne : lourde ponction sur les salaires

page 4

France : un système étatique bon mais coûteux

page 6

Le système de santé italien s’enfonce dans la crise

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Trois questions à Nello Castelli, délégué aux relations publiques en Suisse romande de santésuisse Claude Longchamp commente la votation sur la caisse unique Le RCConv facilite le contrôle des factures et les négociations

DOMAINE DE LA SANTÉ 0 Graphique du mois 2 21 De la maladie des chemins de fer au coup du lapin 22 Livre à lire : comprendre les données relatives à la santé

SERVICE 3 2 23 23 24 24 25 25

Nouvelles du monde Cours pour les enfants en surcharge pondérale et pour leur famille Testez vos connaissances sur l’assurance-maladie Prévention du cancer de la peau et de l’intestin Chaire suisse de chiropratique à partir de 2008 Manifestations

No 4, avril 2007, paraît dix fois par an

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ÉDITORIAL

infosantésuisse No 4, avril 2007

Pour une compétition saine et dynamique

L Pierre-Marcel Revaz Vice-président de santésuisse

’année 2006 a été marquée par une surprise inattendue. Pour la première fois depuis que l’assurancemaladie alimente le débat national – plus de 50 ans – la croissance des coûts de la santé a enregistré une cassure très nette. Ce sont plusieurs mesures peu spectaculaires qui, ajoutées les unes aux autres, sont à l’origine de ce résultat. Elles concernent le prix des médicaments et les génériques, le contrôle des factures opéré par les assureurs et la volonté d’obtenir, lors de chaque négociation tarifaire, la meilleure prestation au meilleur prix, sans oublier la bonne santé financière des assureurs. Des décisions et des mesures dont les effets sont clairement mesurables. Il est bien sûr trop tôt pour crier victoire car l’environnement législatif n’a pas changé. De lourdes incertitudes demeurent, surtout en ce qui concerne le financement des hôpitaux et celui des soins dus à l’âge. Mais cette éclaircie légère qui se répand sur l’enjeu de la maîtrise des coûts doit nous renforcer dans la voie que nous avons choisie : celle d’un système de santé où les tâches des uns et des autres doivent être clairement définies. Aux professionnels de la santé revient la charge de dispenser des soins de qualité et de manière efficiente. Aux pouvoirs publics celle de garantir l’équité sociale et des conditions cadres cohérentes, en veillant à ce que les plus démunis d’entre nous ne soient pas privés, pour des motifs économiques, des soins que leur état requiert. Aux assureurs, enfin, la responsabilité de faire jouer la solidarité entre malades et bien portants et de prendre garde, avec les professionnels de la santé, à une répartition judicieuse des ressources disponibles, au meilleur rapport qualité-prix. Des tensions entre partenaires, il y en aura encore. Elles sont même saines, à condition que chacun joue la partition qui lui revient. Nous connaissons les qualités de notre système, nous en savons aussi les lacunes. Les négociations entre partenaires, les appels d’offres, les comparaisons de prix et de qualité doivent être au

cœur de notre démarche : cela se nomme concurrence. Sur le plan des coûts, les gains de productivité sont un objectif ambitieux mais réaliste. Il est également urgent de repenser le pacte de solidarité entre jeunes et aînés, en allégeant notamment le fardeau pesant sur les jeunes de 20 à 35 ans, devenus, aujourd’hui, la catégorie d’assurés la plus subventionnée par les pouvoirs publics. infosantésuisse consacre cette édition aux systèmes de santé étrangers. Une comparaison utile où l’on constate que chaque système, dans les pays développés du moins, est confronté aux mêmes défis : la maîtrise des coûts et l’enjeu démographique. Incriminer, dès lors, le seul système d’assurance, comme le font chez nous certains milieux dont l’action est mue par l’idéologie plutôt que par la vérité des faits, c’est tromper les gens. Le projet d’une caisse unique allait dans ce sens. Le bon sens populaire a opposé un refus cinglant à cette aberrante aventure. A nous maintenant de nous engager pour corriger les défauts du système. Il faut éviter, notamment, que les défaits du 11 mars ne propagent des mesures qui leur permettent d’atteindre leur objectif par une voie détournée. C’est clairement la compétition entre les acteurs qui doit être soutenue et rien d’autre. Elle seule est capable d’établir le meilleur rapport qualité-prix.

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Le système d’assurance-maladie allemand en voie de réforme

Allemagne : lourde ponction sur les salaires Le système d’assurance-maladie allemand se caractérise, comme en Suisse, par un grand nombre de caissesmaladie que l’assuré peut choisir librement. Le catalogue des prestations de base est également comparable au nôtre. Ce qui est différent, c’est qu’en Allemagne il est possible de s’assurer auprès d’une caisse-maladie publique ou privée et que l’assurance-maladie publique est financée par des contributions prélevées sur les salaires bruts.

st assuré automatiquement à une caisse-maladie publique celui qui perçoit un salaire annuel inférieur à la limite de revenu fixée pour l’assurance obligatoire, soit 47 700 euros (76 800 francs). Celui qui jouit d’un revenu plus élevé ou qui exerce une activité indépendante peut, mais ne doit pas, s’assurer auprès d’une caisse-maladie publique. La personne qui a conclu une assurance-maladie privée (AMPr) paie des contributions qui dépendent des prestations convenues, de l’âge d’entrée dans la caisse et de l’état de santé du preneur d’assurance. De plus, dans l’AMPr, les assurés constituent des réserves de vieillesse pour atténuer le poids des primes qui augmentent avec l’âge. Les assurés en AMPr ne peuvent passer dans l’assurance-maladie publique que s’ils sont âgés de moins de 55 ans et que leur revenu tombe en dessous de la limite fixée pour l’assurance obligatoire. 88 % environ des habitants d’Allemagne sont assurés auto-

matiquement à une caisse-maladie publique contre seulement un faible 10 % en privé. Sur à peu près 72 millions d’assurés auprès des caisses publiques, 31 millions sont des salariés obligatoirement assurés, 20 millions sont assurés gratuitement en qualité de membres de la famille, 17 millions sont des retraités et 4 millions des assurés facultatifs. Nous nous limitons ci-après à présenter l’assurance-maladie publique.

Financement de l’assurancemaladie publique A première vue, en Allemagne le financement de l’assurance-maladie semble être plus social qu’en Suisse, les contributions se calculant en fonction de la capacité financière des assurés. De plus, les membres de la famille sans revenu sont assurés gratuitement. Mais ce constat est remis en question parce que les bénéficiaires de salaires plus élevés peuvent se soustraire à la

solidarité en concluant une assurance privée et que les revenus sur lesquels il faut payer des contributions sont plafonnés. Or la limite maximale est basse et correspond à un revenu annuel de 42 750 euros (68 900 francs). Les caisses-maladie publiques sont financées principalement par des contributions des assurés et des employeurs. Jusqu’à maintenant, les différentes caisses ont fixé leur taux de prélèvement de manière autonome. Cette ponction représente actuellement quelque 12 à 16 % du revenu soumis à contributions. Cela va changer à partir de 2009 (voir encadré). Jusqu’à mi-2005, salariés et employeurs ont supporté des taux de prélèvement à parts égales. A partir de cette date, les salariés paient 0,9 % de plus que les employeurs. Les personnes retraitées paient la même contribution sur leurs rentes. En principe, les indépendants se voient appliquer le taux complet (part de l’employeur et de l’employé). Les chômeurs s’acquittent d’une contribution minimale de 116 euros par mois.

Réforme du système de santé en 2007 Contre la volonté des assureurs-maladie, des médecins, des hôpitaux et de l’industrie pharmaceutique, la réforme du système de santé a été adoptée en février 2007 par le Bundestag et le Bundesrat (la Chambre des Länder). Les points principaux de cette réforme sont les suivants : • Un fonds de santé est créé, alimenté dès 2009 par toutes les contributions des employeurs et salariés ainsi que par des impôts. Chaque caisse reçoit un forfait par personne assurée puisé dans le pot commun. Les caisses dont la structure des risques est mauvaise reçoivent en supplément des contributions versées par la compensation de la structure des risques. • A partir de 2009, un taux de prélèvement unique, fixé par l’Etat, est instauré. • Les caisses qui n’arrivent pas à s’en sortir avec les fonds octroyés peuvent exiger des primes supplémentaires de leurs assurés (au maximum 1 % du revenu soumis à contribution). • Les caisses peuvent offrir des options en ce qui concerne les quotes-parts et remboursements. • Les nouvelles prestations suivantes sont remboursées : cures parents-enfants et mesures de réadaptation. De plus, les assurés doivent participer régulièrement à des contrôles préventifs, se comporter en satisfaisant aux exigences de la thérapie et collaborer à des programmes de traitement. (En cas de refus, la part qu’ils doivent payer de leur propre poche augmente.) • L’assurance est obligatoire pour tous (actuellement, environ 300 000 personnes ne sont pas assurées).

Prestations et dépenses Le catalogue des prestations, qui est défini par le législateur, est au moins aussi généreux qu’en Suisse. Il comprend non seulement tous les traitements ambulatoires et stationnaires qui sont médicalement indiqués mais aussi, en plus, les traitements dentaires. Dans une mesure restreinte, les différents assureurs peuvent compléter le catalogue des prestations fixé dans la loi par leurs propres prestations (prévues par leur règlement). Ces dernières ne représentent cependant que 5 % du volume total des prestations. Les assurés disposent du libre choix du médecin. Mais ils s’acquittent, lors de la première consultation auprès d’un médecin de famille, de 10 euros par trimestre. En cas de consultation d’un médecin spé-

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les risques. Elles se démarquent les unes des autres avant tout par rapport à leur taux de prélèvement et aux prestations supplémentaires qu’elles offrent. Au milieu des années nonante, le libre choix des caisses a été introduit pour toutes les personnes obligatoirement assurées ; la compensation de la structure des risques entre caisses est également entrée en vigueur à cette date. En plus des critères de l’âge et du sexe que le système suisse de compensation des risques a retenus, les revenus soumis à contribution, les taux de contribution et le nombre des assurés bénéficiant d’une rente d’incapacité de travail et de gain jouent également un rôle dans le système allemand de compensation des risques.

Lourde charge grevant les salaires

paient chacun 0,85 % du revenu soumis à cotisation.

136 caisses-maladie Il existe actuellement en Allemagne 136 caisses-maladie. Les principaux t ypes de caisses sont les suivants : les Ortskrankenkassen (caisses locales d’assurancemaladie), les Betriebskrankenkassen (caisses-maladie d’entreprises), les Innungskrankenkassen (caisses-maladie des corps de métiers) et les Ersatzkassen (caisses d’assurance-maladie des ouvriers salariés). Les caisses sont des corporations de droit public mais elles se gèrent elles-mêmes. Les conseils d’administration sont composés paritairement de représentants des assurés et des employeurs. Les assurés peuvent choisir librement leur assureur et les caisses sont tenues d’assurer toutes les personnes, et par là même, tous

Le problème majeur du système d’assurance-maladie allemand se résume ainsi : les coûts croissants doivent être financés par des prélèvements plus lourds sur les salaires. Ainsi, au début de 2007, il a fallu augmenter le taux de prélèvement qui a passé en moyenne de 14,26 % à 14,82 %. De telles charges ont des répercussions néfastes sur la compétitivité de l’économie allemande, ce qui est d’ailleurs l’une des raisons ayant conduit à l’actuelle réforme du système de santé. Toutefois, les sceptiques craignent que cette réforme aggravera encore les problèmes financiers de l’assurance-maladie publique en raison de l’extension prévue du catalogue des prestations. Walter Frei

ALLEMAGNE (Entre parenthèses les valeurs relatives à la Suisse) :

Part des coûts de santé au PIB : 10,9 % (11,6 %) Dépenses de santé par personne : 3005 dollars US (4077 dollars US) Médecins pour 1000 habitants : 3,4 (3,9) Lits d’hôpital pour 1000 habitants : 6,6 (3,9)

Source : OCDE, 2004

cialiste sans avoir été adressé par le médecin de famille, ils paient une nouvelle taxe de 10 euros. Si l’assuré choisit un modèle de médecin de famille, ces taxes sont supprimées. Les assurés doivent de surcroît payer un montant supplémentaire lorsqu’ils se procurent des médicaments (5 à 10 euros par emballage) ou en cas de traitements stationnaires (10 euros par jour durant 28 jours au maximum). Le paiement des fournisseurs de prestations s’effectue toujours par l’intermédiaire de la caisse-maladie (tiers payant). Toutefois, les décomptes avec les médecins se font au travers de l’Union fédérale des médecins de caisse conventionnés. Cette dernière reçoit des caisses-maladie la totalité des justificatifs et des versements et honore les factures des différents médecins dans le cadre d’une procédure de compensation complexe. En 2006, l’assurance-maladie publique a encaissé 149,5 milliards d’euros et a dépensé 147,6 milliards. Avec 50 milliards d’euros (34 %), les traitements hospitaliers représentent le plus gros poste de dépenses des caisses. Viennent ensuite les médicaments, avec presque 26 milliards d’euros (17,6 %). Les traitements médicaux occupent la troisième place avec 22,24 milliards d’euros (15 %). Les dépenses pour les traitements dentaires se sont élevées à 10,4 milliards d’euros (7 %) et des indemnités journalières ont été versées pour un montant de 5,7 milliards d’euros (4 %). Comme en Suisse, les frais administratifs des caisses atteignent à peine 5,5 % des dépenses. Les dépenses de soins dans les homes et à domicile n’entrent pas en ligne de compte puisqu’en Allemagne il existe une assurance spéciale pour ces prestations, l’assurance sociale des soins. Au niveau organisationnel, elle est incorporée dans l’assurance-maladie étant donné qu’une caisse de soins est rattachée à chaque caissemaladie. Le financement est réglé de manière analogue à celui de l’assurance-maladie publique : les employés et employeurs

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L’énorme endettement de l’assurance-maladie étatique pèsera encore longtemps sur les réformes

France : un système étatique bon mais coûteux Le système de santé français est le plus centralisé d’Europe. Les soins de santé sont de qualité, le système jouit d’une bonne réputation et pendant longtemps l’évolution des coûts a été raisonnable. Mais, depuis quelques années, le financement de la santé – qui dépend de la conjoncture – provoque des déficits énormes. Paris réagit à cette situation déplorable en édictant des nouvelles mesures d’étatisation dont le succès est assez improbable.

Source : OCDE, 2004

n l’an 2000, l’OMS a qualifié le système de santé français comme étant le meilleur au monde. Selon elle, la qualité et l’accès équitable aux soins étaient en France plus élevés que partout ailleurs. Trois ans plus tard, le système subissait une débâcle incroyable : 15 000 personnes décédées en été 2003 suite à une vague de chaleur qui a duré plusieurs semaines. Les homes pour personnes âgées et les hôpitaux ont été totalement dépassés par la situation – tout comme le gouvernement français d’ailleurs. Ni le président Chirac, ni les ministres compétents n’ont pris position, car on n’aime guère se faire déranger quand on est en vacances. Deux semaines après la crise, le gouvernement a rendu la population responsable du désastre : à ses yeux, l’absence de solidarité et l’indifférence face aux personnes âgées ont conduit à ce nombre élevé de décès. Il s’en est suivi des protestations véhémentes si bien que le gouvernement s’est vu contraint d’agir : il a déclaré que le lundi de Pentecôte était un jour de travail non payé et que les ressources supplémentaires dégagées en faveur des assurances sociales seraient investies dans

FR ANCE (Entre parenthèses les valeurs relatives à la Suisse) :

Part des coûts de santé au PIB : 10,5 % (11,6 %) Dépenses de santé par personne : 3159 dollars US (4077 dollars US) Médecins pour 1000 habitants : 3,4 (3,9) Lits d’hôpital pour 1000 habitants : 3,8 (3,9)

les domaines de la santé qui posent problème. Depuis cette date, le lundi de Pentecôte est régulièrement marqué par des grèves de grande ampleur. On ne sait pas encore jusqu’à quand la France maintiendra cette mesure. Le cas est exemplaire : même si le système étatique français est souvent présenté comme un modèle pour d’autres pays, il doit faire face à des difficultés considérables.

Paris dirige – avec de gros déficits à la clé En France, l’Etat a plus de compétences en matière de santé que tous les autres Etats européens : des assureurs-maladie, aux budgets globaux, jusqu’aux agences régionales d’hospitalisation, tout est sous le contrôle de Paris. La France dispose pratiquement d’une caisse-maladie publique unique : la plupart des personnes actives et des bénéficiaires de rentes, ainsi que les membres de leur famille sont assurés dans le cadre du « Régime général d’assurance maladie ». Quelques groupes professionnels particuliers n’en font pas partie, tels les agriculteurs, mineurs ou marins, parce qu’ils ont leur caisse spécifique. En France, l’assurance-maladie est financée par un prélèvement en pour-cent sur les salaires – mais depuis longtemps ces prélèvements ne suffisent plus. C’est pourquoi des ressources fiscales supplémentaires alimentent le système. Pourtant, cela n’empêche pas que depuis un certain temps l’assurance-maladie publique affiche d’énormes déficits – 8 milliards d’euros en 2005 – ce qui porte le montant total des dettes à 41 milliards. Le système de santé étant financé par des

prélèvements sur les salaires et par des impôts, les moyens à disposition de l’assurance-maladie publique sont donc très largement dépendants de la conjoncture. Lorsque la croissance économique ne progresse pas au même rythme que l’augmentation des coûts de santé, les déficits se creusent automatiquement. En revanche, un autre grand problème posé par le système est résolu depuis l’an 2000 : les chômeurs et les étudiants sont désormais assurés auprès de l’institution « Couverture maladie universelle » nouvellement créée et financée par les impôts.

Ponction importante dans le porte-monnaie des gens On peut tout à fait comparer le catalogue des prestations de l’assurance-maladie française à celui de la Suisse. Mais la population doit prendre en charge une forte participation aux coûts : en moyenne, les prestations sont remboursées à hauteur de 70 %. La participation aux coûts est particulièrement élevée pour les médicaments (30 à 65 %) et pour les soins ambulatoires (35 %). En conséquence, presque 90 % des Françaises et Français ont conclu des assurances complémentaires qui couvrent les coûts restant à leur charge. L’objectif initial visé par des participations élevées, à savoir de freiner les coûts, a donc été détourné. Il est étonnant que le système de santé français, si fortement centralisé, soit par ailleurs très libéral à l’égard de ses fournisseurs de prestations. Les médecins ayant terminé leur formation peuvent s’établir

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saux de ces dernières années ont mis en évidence qu’il ne suffisait plus de boucher les trous et de serrer les boulons ici et là. Il y a une année, le gouvernement a donc initié un ensemble de mesures visant à maîtriser les coûts. Des investissements importants dans la chirurgie ambulatoire sont censés faire baisser les coûts des traitements stationnaires. Il existe des plans visant à regrouper tous les niveaux de traitement dans un réseau de santé public. Enfin, les moyens financiers consacrés à la promotion de la santé et à la prévention, domaines qui n’avaient jusqu’à ce jour que peu d’importance, doivent augmenter drastiquement. En ce qui concerne les prix des médicaments, la France s’est déjà fait connaître pour son attitude ferme à l’égard de l’industrie pharmaceutique. Il s’agit, par des incitations ciblées, d’encourager encore plus fortement la consommation des génériques. En outre, le prix des médicaments dont l’utilité additionnelle est faible par rapport aux préparations moins coûteuses doit être radicalement abaissé. Parallèlement aux mesures destinées à freiner les coûts, des mesures visant à augmenter les recettes sont également entrées en vigueur : les pourcentages perçus sur les salaires et les impôts servant au financement du système de santé ont été considérablement augmentés, surtout les contributions des employeurs.

Succès incertain

librement partout où ils l’entendent et la population a le libre choix du médecin. Les cliniques privées sont nombreuses en France – même si la plupart du temps elles se sont spécialisées dans certains créneaux. Elles peuvent facturer à charge de l’assurance-maladie aussi bien que les grands hôpitaux publics. Depuis quelques années, le personnel des hôpitaux applique strictement la semaine de 35 heures. Outre des coûts supplémentaires, cet horaire a avant tout provoqué une pénurie de personnel : les postes supplémentaires

qu’entraîne la semaine de 35 heures ne sont de loin pas encore tous occupés.

Plus d’Etat pour des coûts moindres ? La règle du lundi de Pentecôte n’est que la plus insolite parmi les nombreuses mesures de réforme auxquelles le système de santé français est constamment soumis. Durant les 25 dernières années, il y a eu 20 réformes – mais elles n’ont jamais été substantielles et n’ont touché que des domaines partiels. Les déficits abys-

Les incitations à adhérer à un modèle de médecin de famille sont déjà en place : celui qui s’engage à ne consulter qu’un généraliste au début d’un traitement bénéficie d’une réduction sensible de sa participation aux coûts. Mais le succès du modèle du médecin de famille est moindre que prévu parce que les assurances complémentaires sont très largement répandues et que les Français atténuent ainsi le choc des quotes-parts élevées : même pas la moitié de la population recourt à cette possibilité de faire des économies. D’une manière générale, les économistes spécialistes de la santé en France sont sceptiques face à la réforme : elle cimente les structures existantes du système de santé étatique et, si tant est qu’il se produise, le succès sera plus lent qu’espéré. Les experts estiment qu’il faudra au moins vingt ans pour arriver à résorber l’endettement colossal de l’assurancemaladie. Peter Kraft

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Des coûts croissants, une qualité en baisse et un fossé entre le Nord et le Sud

Le système de santé italien s’enfonce dans la crise Jusqu’en 1987, le système de santé italien a été caractérisé par la diversité des caisses. Puis suivit sa transformation en système étatique, encore en vigueur actuellement. Le but de la transformation était de combler le fossé existant entre le Nord et le Sud et de maîtriser les coûts. Jusqu’ici, l’objectif n’a pas été atteint par le Servizio Sanitario Nazionale (SSN). Au contraire : des messages alarmants à propos de la santé inquiètent régulièrement la population, principalement dans le sud du pays.

Des autorités de santé locales Le système italien est organisé sur trois niveaux. Depuis la dernière réforme, l’Etat n’est plus compétent que pour les normes légales. Rome exerce en outre un contrôle relativement strict sur le marché des médicaments et la recherche. L’Italie dispose de 16 cliniques dans lesquelles, sur mandat de l’Etat, des recherches pharmaceutiques sont menées. Les régions sont responsables de la planification de la desserte. Elles distribuent les crédits aux établissements et surveillent, au moins sur le papier, leur qualité et leur efficacité.

La desserte de santé est menée au niveau local et même communal. En moyenne, 100 000 habitants forment une « unité sanitaire locale (USL) ». Les autorités locales de santé exploitent les hôpitaux, mettent en place les médecins et gèrent les données d’assurance des habitants concernés. Avec cette structure, l’Italie a une forte densité d’hôpitaux car toutes les USL ont au moins une clinique. En revanche, il y a peu de centres offrant des techniques de pointe. Ceux-ci passent des contrats avec leur USL mais travaillent néanmoins très librement.

revenus supplémentaires proviennent des prestations hors catalogue payées directement par le patient. Les spécialistes ne peuvent être consultés qu’avec indication du médecin de famille. Les spécialistes eux aussi sont en grande partie employés de l’USL. On trouve par ailleurs des spécialistes indépendants, hors du système étatique, qui traitent principalement des assurés privés.

Qui le peut s’assure en privé

Part des coûts de santé au PIB : 8,4 % (11,6 %)

Le catalogue des prestations est, en Italie, moins large qu’en Suisse et, pour une part, les participations personnelles sont élevées. Les visites chez le médecin de famille et les examens hospitaliers sont pris en charge en totalité. Mais pour les médicaments, les traitements ambulatoires chez les spécialistes, les analyses de laboratoire et la réadaptation, les patients doivent assumer des parts importantes des frais. Ceci fait que ceux qui peuvent se le permettre s’assurent de manière privée et près de 30 % de la population s’offre ainsi un accès à des soins de santé non étatiques. Comme le système italien est étroitement étatisé, il n’y a pratiquement aucune collaboration entre les secteurs public et privé. Les prestations des assureurs privés ne complètent pas celles du secteur public mais, le plus souvent, les remplacent. L’Italie a ainsi, à l’état pur, une médecine à deux vitesses.

Dépenses de santé par personne : 2392 dollars US (4077 dollars US)

Le problème des coûts résolu ?

Modèle strict de médecin de famille Les prestations de santé, en Italie, hormis les cas d’urgence, passent toutes par le médecin de famille. Toutes les Italiennes et tous les Italiens s’inscrivent auprès d’un médecin. Les médecins de famille sont soit employés directement par l’USL ou liés à elle par contrat. Un médecin de famille se voit attribuer environ 1500 patients et il touche pour chacun un forfait qui représente une grande part de son revenu. Les

Source : OCDE, 2004

e fait que le SSN ne parvient pas à atteindre ses objectifs a été constaté rapidement et a été jusqu’ici une constante de la politique de santé en Italie. C’est pourquoi le service étatique est un candidat permanent à la réforme : par quatre fois déjà il a été complètement remanié. La dernière en date est celle de 2001 : les 21 régions d’Italie ont obtenu de larges compétences pour la desserte médicale et elles touchent une contribution fixe du gouvernement central. D’ici 2013, elle devrait être supprimée par étapes de telle sorte que les régions portent l’entière responsabilité du financement. Parallèlement, un fonds national de solidarité doit être mis sur pied qui devrait combler en partie l’énorme fossé de la desserte entre les régions. Le système italien de santé est financé depuis 1978 par divers impôts. Par le biais de la régionalisation, l’IRAP (Imposta regionale sulle attività produttive) – un impôt régional sur les gains des entreprises et les salaires – est devenu la principale source de financement.

ITALIE (Entre parenthèses les valeurs relatives à la Suisse) :

Médecins pour 1000 habitants : 4,1 (3,9) Lits d’hôpital pour 1000 habitants : 3,9 (3,9)

Le SSN a eu dès ses débuts pour but de maîtriser les coûts en hausse. Trente ans plus tard, on en est plus éloigné que jamais puisque les coûts augmentent deux fois

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romaine, des faits effrayants ont été mis à jour : des laboratoires ouverts avec des contaminants dangereux et des matières radioactives, des crottes de chien et des seringues dans les couloirs, du personnel fumant lors des soins et même des prélèvement illégaux d’organes ont été rapportés par le journaliste. Le gouvernement italien a réagi avec une large enquête. Cette dernière a permis de confirmer une partie des révélations et de constater que la situation en matière d’hygiène devenait plus mauvaise au fur et à mesure que l’on descendait vers le Sud. La densité hospitalière est plus faible dans le Sud que dans le Nord et l’âge des installations est plus élevé. Les deux tiers des hôpitaux du Sud datent d’avant la Deuxième Guerre mondiale. Comme les dépenses de santé sont maintenant dépendantes des impôts sur le

plus vite que les revenus. Alors qu’en 1997, les dépenses représentaient 7,6 % du PIB, elles en sont aujourd’hui à près de 9 % et cette évolution ne semble pas devoir s’arrêter. Le gouvernement Berlusconi a mis en route quelques réformes sérieuses et le nombre des lits d’hôpital a été réduit de quelque 10 %, l’utilisation des génériques a été soutenue et le catalogue des prestations a été réduit. Le système italien de santé ne parvient toutefois pas à obtenir une réduction des coûts par ces mesures. La régionalisation de la desserte sanitaire n’a pas eu non plus d’effet sur les coûts.

Un fossé dramatique entre Nord et Sud Le deuxième problème qui doit être résolu par le système étatique de santé est celui de l’énorme fossé entre le Nord et le Sud. Il n’y est jusqu’ici pas parvenu. Lorsque, au début de l’année, un journaliste s’est fait engager comme nettoyeur dans une policlinique

revenu, rien ne va changer avant longtemps à la situation peu enviable du Sud – au contraire. Les difficultés proviennent également, surtout en Sicile, de la Mafia dont l’argent permet à des médecins de construire des cliniques privées. Elles facturent alors à l’Etat des tarifs très élevés et livrent les bénéfices à la Mafia. En conséquence, l’argent manque alors pour la desserte médicale publique. Les retombées de cette situation sont décrites par une étudiante en médecine allemande, après un stage en Sicile, dans la revue « viamedici » : « Les traitements médicaux et l’hygiène des hôpitaux correspondent à un pays du tiers monde. Le respect des patients par les médecins est inexistant. Pratiquement aucun des patients n’obtenait le diagnostic le concernant. La salle d’opération était une attraction pour ellemême. Seuls un bonnet, un masque et une paire de gants nous étaient remis ; le masque était de toute manière enlevé lorsqu’il fallait recoudre en raison de la chaleur régnant dans la salle. »

Objectif manqué Le problème de la qualité n’est pas limité aux régions du sud du pays. Selon une étude de l’Association italienne des oncologues, il y a chaque jour près de 90 cas de décès évitables dans les hôpitaux. On rencontre partout des listes d’attente, y compris pour les opérations vitales. L’hygiène, au Nord, n’est pas aussi catastrophique qu’au Sud mais elle est nettement insuffisante. Dans toutes les régions, les médecins sont mal payés et peu motivés. Le site de conseils pour immigrants « justlandet.com » conteste la rumeur selon laquelle les patients n’ont rien à manger dans les hôpitaux, mais de manière peu convaincante : « Il y a à manger tous les jours sans frais, mais il faut tenir compte du fait que c’est peut-être immangeable. Il faudra peut-être que le repas vous soit amené de l’extérieur pour survivre à un séjour dans un hôpital public. » Suite logique, les paiements supplémentaires augmentent dans le « Triangle d’or » entre Milan, Gênes et Turin et une bonne desserte en soins devient ainsi une question de revenus. C’est exactement le contraire de ce que la médecine étatisée était censée atteindre. Peter Kraft

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Problèmes de financement et pratiquement pas de libre choix dans la république de l’arc alpin

Autriche : sur les plus hautes marches du podium. Est-ce vrai aussi pour la santé ?

Source : OCDE, 2004

La Suisse est en compétition avec l’Autriche au niveau sportif et trop souvent nous ne sommes pas les vainqueurs. Mais les rivalités ne se limitent pas au seul domaine du sport ; nos voisins d’outre-Rhin jouent aussi un rôle politique important. Dans les discussions au sujet de la caisse unique, on a beaucoup parlé du système de santé autrichien et de ses avantages. L’Autriche prend-elle effectivement aussi la première place sur le podium, devant la Suisse, en ce qui concerne son système de santé ?

AUTRICHE (Entre parenthèses les valeurs relatives à la Suisse) :

Part des coûts de santé au PIB : 9,6 % (11,6 %) Dépenses de santé par personne : 3124 dollars US (4077 dollars US) Médecins pour 1000 habitants : 3,4 (3,9) Lits d’hôpital pour 1000 habitants : 6 (3,9)

ors de la dernière Coupe du monde de ski, la Suisse n’a pas caché sa joie de voir à nouveau quelques-uns de ses athlètes se classer devant les concurrents autrichiens. Pour autant, la position dominante de l’Autriche n’est de loin pas compromise et même en ce qui concerne le football, les Autrichiens nous battent plus souvent qu’à notre tour. Nous sommes derrière l’Autriche non seulement dans le domaine du sport mais aussi en matière de politique de la santé. C’est du moins ce que prétendaient les partisans de l’initiative pour une caisse unique, laquelle a été mise en échec par le peuple. Est-ce vraiment le cas ? Quel est le coût du système de santé autrichien ? Comment estil organisé ?

Dépenses totales moindres ? Selon les statistiques de l’OCDE, les dépenses totales de santé en Autriche représentent 9,6 % du produit national brut (PNB), contre 11,6 % en Suisse. Le système de santé autrichien est donc moins coûteux que le nôtre – cela pour une espérance de vie légèrement moindre et un catalogue comparable des prestations. Il convient néanmoins de noter que les dé-

penses totales du système de santé autrichien ne comprennent pas toutes les dépenses qui sont habituellement prises en compte par les statistiques officielles. Ainsi, il manque les salaires des médecins des hôpitaux universitaires, certains frais généraux hospitaliers, les investissements des hôpitaux pénitentiaires et de l’armée, les dépenses de soins aux malades et aux malades à domicile ainsi que les dépenses de formation dans le domaine de la santé. Ces dépenses sont enregistrées sous d’autres rubriques. On estime ainsi que la part des dépenses de santé par rapport au PNB est sous-évaluée jusqu’à hauteur de 3 points de pourcentage. Il en résulte que les coûts totaux autrichiens correspondent donc aux « conditions suisses »1.

Organisation décentralisée Avec ses 9 Länder, l’Autriche est comme la Suisse un Etat fédéraliste. Cela se traduit par une administration décentralisée de la santé. L’Etat assume la responsabilité au niveau législatif. L’autorité suprême pour la politique de la santé est le ministère de la santé et des femmes. Lui incombe notamment la surveillance des caisses responsables de l’assurance-maladie sociale. Il n’existe pas d’autres autorités nationales inférieures puisque l’administration est assumée par les Länder et les communes. Ainsi, les services de santé publics sont dans les mains des 9 Länder qui disposent aussi de larges compétences en matière de financement et de réglementation de la prise en charge stationnaire.

Pas de libre choix dans l’assurance de base L’assurance-maladie légale, le pendant de l’assurance obligatoire des soins (AOS) en

Suisse, est également organisée de manière décentralisée. L’assurance-maladie obligatoire couvre la maladie, l’incapacité de travail par suite de maladie et la maternité. Elle assurait en 2005 environ 8 millions de personnes, soit 97,8 % de la population. Il existe en Autriche 19 assureurs-maladie qui sont regroupés dans leur Association faîtière, la Hauptverband der Sozialversicherungsträger. Il n’y a pas de concurrence, car l’affiliation est obligatoire et s’effectue selon l’appartenance à un groupe professionnel ou en fonction du lieu de travail ou de domicile. Une caisse régionale (Gebietskrankenkasse GKK) existe dans chacun des 9 Länder. De plus, il existe 6 caisses professionnelles ainsi que 4 autres caisses d’assurances sociales qui gèrent de manière séparée l’assurance-maladie. Les caisses régionales sont obligatoirement l’organe d’exécution de l’assurance-maladie dans les cas où il n’y a pas d’autre caisse d’assurance-maladie.

Médecins conventionnés et médecins au libre choix En Autriche, la plupart des prestations médicales sont fournies par des partenaires conventionnés de la caisse-maladie, qu’il s’agisse de médecins ou d’hôpitaux. Ces partenaires facturent leurs prestations aux patients directement à l’assurance-maladie. Tous les partenaires conventionnés sont liés aux tarifs contractuels convenus et au système de décompte direct entre caisse et fournisseur conventionné. Le patient ne doit effectuer aucun paiement qui va au-delà des quotes-parts fixées par la loi. En Autriche, seuls 64 % des médecins

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ont signé une convention avec les caissesmaladie. Si un patient veut consulter un médecin qui n’est pas conventionné (à choisir librement), la caisse ne rembourse que 80 % des coûts qu’elle aurait dû normalement supporter. Dans ce sens, on peut donc admettre que le libre choix du médecin n’existe pas en Autriche, pas plus que l’obligation de contracter.

Financement déficitaire, dépendant du revenu Les pouvoirs publics financent environ 70 % de la totalité des coûts de la santé en Autriche mais les assureurs-maladie supportent à eux seuls près de 50 % de ceux-ci. Les 30 % restants sont à charge des ménages privés ainsi que des assurances-maladie privées. Les recettes de l’assurance-maladie obligatoire proviennent de contributions paritaires proportionnelles au revenu, payées par l’employeur et l’employé. Les indépendants et les paysans s’acquittent de leurs contributions auprès de l’assureur compétent. Au total, les Autrichiens paient 7,5 % de leur salaire à l’assurance-maladie obligatoire, et cela jusqu’à un revenu plafonné à environ 6000 francs par mois. Ce plafonnement peu élevé évite que les primes deviennent un impôt sur la richesse mais elles pèsent lourdement sur la classe moyenne. A l’inverse de l’assurance obligatoire des soins en Suisse, l’assurance-maladie autrichienne souffre d’un endettement chronique. Ainsi, pour la huitième année consécutive, les caisses régionales affichent en 2006 des chiffres rouges. Depuis 1998, les caisses enregistrent au total un découvert de 2,7 milliards de francs.2

Réforme du système de santé en 2005 Afin d’assurer à terme le financement du système de santé autrichien en dépit d’exigences qui vont croissant, le gouvernement a mis en route en 2005 une réforme de la santé dont les objectifs sont les suivants : • Assouplissement de la séparation stricte des différents secteurs de la santé en vue d’atteindre une meilleure harmonisation de la planification, de la gestion et du financement. • Garantie à long terme que le système de santé reste finançable en prenant des mesures de maîtrise des coûts, de gain d’efficience et de pilotage. • Soutien de mesures de prévention et de garantie et d’amélioration de la qualité au niveau national.

Sur le podium ? Il est reconnu que l’Autriche offre une bonne qualité des soins. Toutefois, elle doit faire face à des déficits financiers et ne connaît que des libertés de choix restreintes. Le système présente des avantages par rapport à la Suisse, non pas au niveau du prélèvement des primes ou de l’organisation de l’assurance-maladie mais plutôt par rapport aux points suivants : • L’Autriche dispose clairement avec Vienne d’un centre d’économie, de recherche et de médecine de pointe. En Suisse, il existe au moins cinq centres potentiels, comme le montre la

lutte entre différents cantons pour jouer un rôle d’avant-garde en médecine de transplantation. • Le système de santé autrichien ne connaît que 9 régions et non pas 26 régions comme c’est le cas en Suisse. • En Autriche, les assureurs-maladie peuvent avoir une influence sur le nombre des médecins qui pratiquent à charge de l’assurance-maladie dans le domaine ambulatoire. L’Autriche a sans aucun doute un système de santé de qualité élevée et d’égale valeur à celui de la Suisse. Même si, en comparaison internationale, les deux pays sont classés parmi les bons élèves, il n’est pas possible de dire lequel est le meilleur et se place devant l’autre sur le podium. Mais une chose est sûre : les deux pays doivent faire face à des coûts croissants, les obligeant à entreprendre des réformes fondamentales s’ils veulent à l’avenir garantir le financement de leur système sans avoir à prendre en compte des pertes de qualité. Matthias Schenker

Source : www.sozialversicherung.at Source : Fritz Beske, Leistungskatalog des Gesundheitswesens im internationalen Vergleich, Band I, Kiel, août 2005, p. 163/164 (Catalogue des prestations du système de santé en comparaison internationale, volume 1)

Source : Pressearchiv WGKK (2006), expertise indépendante confirmant qu’une crise financière menace le système de santé, www.wgkk.at

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Les rêves de santé du Nord s’évanouissent devant les listes d’attente

Scandinavie : payer peu mais attendre longtemps ? Les systèmes de santé, dans toute la Scandinavie, sont partie intégrante d’un Etat social généreux. Les coûts sont toutefois maintenus étonnamment bas. Comment cela est-il possible ? Travaillent-ils plus efficacement que les autres systèmes ou sont-ils obligés, faute de recettes fiscales supplémentaires, de réduire les prestations ?

es pays scandinaves sont connus pour leurs systèmes sociaux très développés. Alors que les uns les considèrent comme des exemples à suivre, d’autres ont en revanche peur du pouvoir attribué aux autorités. De fait, les pays scandinaves interviennent fortement dans la vie quotidienne de leurs citoyens – aussi bien pour les protéger que pour les régir. Ceux qui veulent acheter une bouteille de vin en Norvège, par exemple, doivent le faire avant 16 heures parce que les magasins, monopole d’Etat, sont ensuite fermés. Dans le Nord du pays, peu peuplé, il faut parfois faire une longue course en voiture pour disposer d’une bonne bouteille pour le dîner. Les taxes particulièrement élevées sur l’alcool poussent d’ailleurs tout un chacun à réfléchir deux fois pour savoir s’il a vraiment besoin de vin. Tout cela nous paraît un peu rebutant mais semble raisonnable dans la mesure où les Etats scandinaves sont parvenus, par ce biais, à maîtriser les importants problèmes posés par l’alcoolisme dans la population. Peutêtre l’habitat dispersé, les grandes distances et les conditions climatiques extrêmes sont-ils à la base du rôle fortement régulateur de l’Etat. Il tente de rééquilibrer des conditions très diverses. Les solutions étatiques imprègnent dès lors le système de santé. Même dans un pays fortement peuplé comme la Suisse, les régions rurales ont de la peine à conserver une desserte médicale suffisante. Dès lors, comment faire pour qu’un médecin s’établisse en Laponie si l’on ne laisse jouer que les lois du marché ?

La Finlande : le seul pays de l’OCDE avec des coûts en baisse Le système de santé finnois est le plus fortement étatisé de toute la Scandinave.

Le gouvernement central établit les conditions cadres légales ; pour la desserte médicale proprement dite, ce sont les communes qui sont compétentes. Selon leur grandeur, elles exploitent seules ou en commun des centres de santé dans lesquels des soins généraux, mais aussi de la gynécologie et de la physiothérapie, sont fournis. De nombreux centres ont des divisions de soins stationnaires pour des maladies courantes et, dans les régions éloignées, ces centres servent d’hôpitaux. Les traitements de spécialistes ne peuvent être obtenus que sur prescription d’un généraliste et sont donnés dans les hôpitaux. Ces derniers sont la propriété d’associations de communes, dénommées district hospitalier. Chaque commune doit être membre d’un district. Les prestations des centres de santé et des hôpitaux sont principalement financées par les recettes fiscales de la commune et le taux fiscal moyen des communes finlandaises s’élève à 18 %. Il existe en outre une assurance-maladie d’Etat qui est alimentée par les cotisations des salariés et des employeurs. Elle verse des indemnités pour perte de gain en cas de maladie, paie environ la moitié des coûts des médicaments ainsi que les transports par ambulance. Les dépenses finlandaises pour la santé se montent à 7,4 % du PIB et sont donc relativement basses. La Finlande est le seul pays de l’OCDE qui est parvenu à réduire légèrement ses dépenses par rapport à 1990. Les capacités hospitalières, pour ce faire, ont été fortement réduites. La conséquence en est l’existence de listes d’attente, principalement pour les opérations et les examens spéciaux. Le secteur privé de la santé est, en Finlande, pratiquement inexistant. Il com-

prend principalement des médecins qui fournissent des prestations qui ne sont pas prises en charge par l’Etat.

Suède : des participations personnelles élevées et des listes d’attente Tout comme l’Etat finlandais, l’Etat suédois n’est compétent que pour les conditions cadres et pour la surveillance du système de santé. Ce sont les 21 provinces qui sont responsables de la desserte médicale. Les communes s’occupent des soins à domicile et des EMS. Les régions sont relativement libres dans l’organisation de cette desserte. La plupart travaillent pourtant avec des centres de santé, comme en Finlande. Il existe des différences : les soins stationnaires ne sont fournis que dans les hôpitaux et les médecins des centres de santé n’ont pas de fonction de premier recours. Les patients suédois sont donc libres d’aller consulter les spécialistes dans les hôpitaux. Comme le système suédois n’est pas non plus strictement réglementé, le secteur privé est relativement important : environ un quart des prestations est fourni par des cabinets privés qui ont obtenu un contrat avec les autorités locales. Le système de santé suédois est financé par les impôts des provinces et des suppléments de l’Etat central. Les participations personnelles sont relativement élevées. Selon les provinces, il faut compter environ 30 francs par visite chez le médecin. Les journées d’hospitalisation entraînent également des frais. Les médicaments ne sont pris en charge qu’à partir d’un montant annuel d’environ 350 francs – et cela seulement en partie. Il y a encore un problème en Suède ; ce sont les listes d’attente, aussi bien pour les traitements ambulatoires que stationnaires. La

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loi prescrit seulement que les patients doivent obtenir un rendez-vous dans un délai d’une semaine chez un généraliste et dans les trois mois chez un spécialiste ou dans un hôpital. Les coûts de la santé restent relativement stables en Suède avec près de 9,4 % du PIB. Comme en Finlande, cette situation est obtenue par une réduction du secteur stationnaire et l’existence de temps d’attente.

Norvège : le plus libéral de tous les systèmes scandinaves Le système norvégien est, lui aussi, fortement régionalisé. Les communes sont compétentes pour la desserte de base et les soins. Le financement est principalement assuré par les impôts communaux et des suppléments venus de l’Etat. Les communes décident librement de leur organisation de fourniture de soins. Il n’y a pas de centres de santé en Suède et la plupart des médecins travaillent librement mais touchent un traitement de base des communes ainsi qu’un forfait par personne. Il en va de même pour les physiothérapeutes et les sages-femmes. Les traitements par les spécialistes sont fournis dans les hôpitaux et ce sont les 19 régions qui en sont responsables. Les hôpitaux d’Etat sont plus autonomes que dans le reste de la Scandinavie. Ils fonctionnent comme des entreprises axées sur les résultats et ne reçoivent des autorités qu’un mandat de prestation. Les spécialistes et les hôpitaux ne peuvent être consultés que sur avis d’un médecin de famille. Lorsqu’ils ne sont pas couverts par les communes, les frais de prestations médicales sont pris en charge par un fonds d’assurances sociales. Il est financé pour trois quarts par les salariés et un quart par les impôts. En Norvège également, les patients paient des participations personnelles élevées : le montant est de 25 francs par visite chez le médecin et les médicaments ne sont remboursés que pour les maladies chroniques. Les dépenses de santé des Norvégiens ont atteint au cours des dernières années 10,3 % du PIB, ce qui est relativement élevé. La faiblesse des ressources dans le domaine hospitalier est nettement moins marquée que dans le reste de la Scandinavie. La Norvège connaît aussi le problème des listes d’attente mais, selon le Ministère de la santé, cela ne touche que les traite-

ments simples. Les opérations importantes sont en général rapidement effectuées.

Danemark : un exemple qui n’est pas le bon Le système de santé danois est, comme dans tous les autres Etats scandinaves, décentralisé : l’Etat ne définit que les conditions cadres. Les régions sont responsables des hôpitaux, des EMS et de la desserte médicale de base. Les communes s’occupent de la prévention et des soins à domicile. Le Danemark, comme la Norvège, ne connaît pas de centres de santé, mais se repose sur les médecins établis. Le système du médecin de famille est le plus strict de toute la Scandinavie : chaque Danois doit s’annoncer chez un généraliste dans un rayon de 10 km. Un changement de médecin, si tant est qu’il soit possible dans un périmètre si petit, est soumis à des frais. L’assurance-maladie danoise est financée par les impôts. Des participations importantes sont par ailleurs demandées aux patients : les prestations des physiothérapeutes, des chiropraticiens et des psychothérapeutes ne sont que partiellement payées. La participation aux coûts des médicaments peut atteindre 85 %. L’amplitude de la participation personnelle est fonction de la consommation de médicaments au cours des années passées. C’est une charge importante pour les malades chroniques. Le système de santé danois maîtrise les coûts : ils sont de l’ordre de 9 % du PIB de-

puis des années. Ce but a été atteint par une réduction dans le secteur stationnaire ; des listes d’attente en sont la conséquence. Depuis 2002, les patients qui doivent attendre plus de deux mois une opération peuvent se faire opérer à l’étranger. Le Danemark n’assure donc plus de manière autonome la desserte de santé de sa population et ne mérite donc pas le titre d’exemple que les partisans d’une caisse unique en Suisse lui ont souvent attribué.

Généralités Les systèmes de santé scandinaves se différencient par des nuances mais sont fondamentalement semblables. La voie scandinave vers la fourniture de soins suit dans tous les Etats les règles suivantes : • C’est l’Etat, en Scandinavie, qui planifie, exploite et finance le système de santé. • Le système est fortement régionalisé, parfois jusqu’au niveau de la commune. • Les fournisseurs de soins sont des employés d’Etat ou doivent passer un contrat avec les autorités. • Les coûts, dans les quatre pays, sont maintenus à bas niveau. • Le moyen d’y parvenir est une réduction des prestations dans le domaine stationnaire, ce qui a pour conséquence de longues listes d’attente. • Les participations personnelles des patients sont, dans tous les pays, importantes. Peter Kraft

Desserte hospitalière aux îles Lofoten Les Lofoten sont un groupe d’îles norvégiennes qui sont situées au-delà du cercle polaire, en pleine mer. Alors que les îles principales sont relativement peuplées, il existe des îles secondaires qui ne sont atteignables que par bateau, qui n’ont pratiquement aucune infrastructure et dont les habitants vivent principalement de la pêche au cabillaud. Pourtant, ces régions reculées bénéficient d’une desserte hospitalière de première qualité. Les 24 000 habitants de ce groupe d’îles disposent d’un hôpital qui, compte tenu de sa grandeur et de son offre, équivaudrait tout à fait en Suisse à un hôpital central. On trouve notamment aux Lofoten toutes les disciplines chirurgicales importantes, la radiologie, l’oncologie, la psychiatrie pour enfants et adultes et une maternité. Les patients des îles de pêcheurs, comme celle de Røst, sont transportés sur l’île principale par deux avions prévus spécialement à cet effet. Cet exemple montre pourquoi les pays scandinaves réglementent si fortement leur système de santé : l’hôpital des îles Lofoten ne pourrait guère satisfaire aux exigences de la concurrence et travailler efficacement au niveau des coûts en comparaison d’autres hôpitaux.

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SOUS LA LOUPE infosantésuisse No 4, avril 2007

Le rapport Cox à la Commission de l’UE : réjouissant ou alarmant ?

Indicateur de direction à double face pour la politique de santé de l’UE Le rapport Cox est une étude sur l’avenir de la politique de la santé dans l’UE à laquelle de nombreux experts de renom ont collaboré. Les auteurs recommandent aux Etats de l’UE d’introduire plus de concurrence et de transparence dans leurs systèmes de santé. Günter Verheugen, vice-président de la Commission de l’UE, a accepté formellement le rapport. Jusque-là, rien à redire ? Pas tout à fait car l’étude pose des exigences qui pourraient se transformer en dangereuses mesures boomerang.

’est une équipe choisie de représentants de la Banque mondiale, de la Banque européenne d’investissements, d’économistes de la santé venus de diverses écoles européennes réputées, de représentants de l’industrie et des gouvernements qui a signé l’étude mentionnée. Elle porte le nom du directeur de l’équipe, Pat Cox, ancien président du Parlement européen. Les chapitres principaux de l’étude sont la justice et l’efficacité, le retour sur investissement dans le système de santé, l’information des patients ainsi que le financement des systèmes de santé dans les nouveaux Etats membres de l’UE.

conclure, l’étude demande davantage de concurrence dans les domaines centraux : les participations des patients doivent être étendues pour que les prestations inutiles soient supprimées et que celles qui sont indispensables soient assurées. Les fournisseurs de soins doivent soumettre des offres à ceux qui paient les coûts de manière à ce que ces derniers puissent choisir les plus efficaces. Les soins gérés doivent être promus par des incitations à la concurrence. Le rapport Cox demande également pour l’UE la concurrence entre les assureurs. Les auteurs estiment que les assureurs devraient traiter avec de grands collectifs d’assurés et non pas avec des particuliers.

Des exigences raisonnables, mais… Le rapport Cox constate qu’il est difficile, dans les systèmes européens de santé, de savoir où va réellement l’argent. Une transparence et une meilleure ouverture du financement sont dès lors indispensables si l’on tient à désormais mieux cibler les investissements. L’utilisation plus large des DRG en Europe est expressément saluée. Le rapport qualifie de mythe l’idée selon laquelle les coûts croissants de la santé sont avant tout la conséquence du vieillissement de la population. Les dépenses plus élevées sont dues en premier lieu aux progrès de la médecine. C’est pourquoi il faut accorder une attention particulière aux investissements dans les nouvelles technologies et les nouveaux médicaments. Il faut, selon le rapport Cox, de meilleures procédures d’évaluation afin de mesurer plus précisément l’utilité des nouvelles technologies. Il est trop fréquent aujourd’hui que les innovations soient introduites trop tard et que d’inutiles nouveautés soient introduites trop tôt. Pour

… avec un arrière-goût Manifestement, le rapport de l’UE n’est pas qu’une simple étude de plus. Günter Verheugen, vice-président de la Commission de l’UE, a déclaré ceci lors de la réception formelle de l’étude: « Cette nouvelle étude est une contribution importante pour assurer que la qualité de nos systèmes de santé corresponde aux capacités concurrentielles de notre économie. » Hannu Hanhijärvi, responsable du domaine de la santé auprès du fonds finnois pour l’innovation Sitra, a reçu un mandat de grande envergure : il doit diriger une série de programmes afin d’ancrer les recommandations du rapport Cox dans les systèmes de santé européens. Tout cela résonne comme une politique de réforme. Un certain nombre de déclarations qui ne sont pas mentionnées dans le résumé ne laissent pas d’étonner. C’est ainsi qu’un lien particulier est tracé entre la force économique d’un pays et l’état de santé de la population :

plus la population est en bonne santé et plus l’économie est florissante, affirme le rapport. La cause et la conséquence semblent ici avoir été confondues. Mais l’argumentation ne s’arrête pas là : une augmentation des dépenses augmenterait la qualité générale. Le Portugal a augmenté de près de 300 % ses dépenses de santé depuis 1970 mesurées au PIB, de sorte que le nombre des décès médicalement évitables a reculé significativement. Les Pays-Bas, en revanche,

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n’investissent que 30 % de plus depuis 1970 et l’on voit également que le nombre des décès médicalement évitables a nettement moins régressé. Cette argumentation laisse toutefois de côté le fait que le Portugal, en 1970, partait de situations complètement différentes, tout autant pour ce qui est des dépenses que pour le nombre des décès évitables. Au Portugal, les investissements ont été utiles, alors qu’aux Pays-Bas une pareille augmentation des dépenses n’aurait eu qu’une utilité nettement moindre. Le rapport Cox appelle ainsi, de manière générale, à une augmentation des dépenses sans tenir compte de la qualité déjà offerte par le système. Le fait que les nouveaux investissements ont, précisément dans le domaine de la santé, une utilité qui devient décroissante à un moment donné ne semble pas avoir été pris en compte par les auteurs.

La signature de Pfizer

bles à ces produits qui ne sont pas encore sur le marché ? Le rapport Cox propose de tester les produits sur le marché avant qu’ils ne soient autorisés. Voilà qui est inquiétant : il y a en effet des dangers à tester un nouveau médicament sur la population. De plus, il sera difficile de retirer une nouveauté du marché même si elle a été introduite seulement à des fins de test. La procédure d’évaluation que propose le rapport Cox pourrait en effet créer un état de fait avant que l’utilité d’une nouveauté soit démontrée. A plusieurs reprises, le rapport Cox souligne que les innovations médicales arrivent aujourd’hui trop lentement sur le marché. De nouvelles méthodes d’évaluation devraient permettre aux responsables étatiques « de surmonter leurs incertitudes et de reconnaître la valeur de l’innovation ».

L’industrie plutôt que la politique de la santé ?

Photo : Prisma

Fait étonnant : alors que la plupart des systèmes de santé en Europe tentent de réduire leurs coûts par l’abandon des investissements inutiles, le rapport Cox se fo-

calise sur les nouveaux investissements. Il est aussi étonnant qu’outre des économistes indépendants et des institutions avec mandats publics, le géant pharmaceutique Pfizer ait participé à cette étude. L’entreprise est la seule organisation à siéger au comité directeur avec deux représentants. C’est pourquoi près de la moitié du rapport Cox est consacrée à l’évaluation des innovations dans le secteur de la santé. Les propositions paraissent au premier abord raisonnables : le rapport Cox demande plus de transparence dans l’autorisation de nouveaux médicaments et de nouvelles technologies. Une fois autorisés, l’efficacité des nouveautés doit être régulièrement vérifiée. Les innovations intéressantes devraient être activement recherchées par l’Etat et rémunérées par des taxes. C’est là qu’on voit déjà la marque de l’entreprise pharmaceutique. L’influence est encore plus marquée avec d’autres exigences. L’évaluation de nouvelles technologies devrait moins prendre en compte le rapport coûts/efficacité que la « préférence des patients » et « l’acceptation des produits ». Mais comment doivent être vérifiés les critères applica-

Le Bureau européen des unions de consommateurs a critiqué le fait que le rapport Cox suive essentiellement des critères industriels. C’est ainsi que le rapport n’a pas été remis au commissaire européen en charge de la santé mais bien au viceprésident « Entreprises et industrie » Ver heugen. Pascal Garel, président de l’Association européenne des hôpitaux, critique le rapport pour son manque de nuances et se demande comment les auteurs sont parvenus à leurs recommandations.

Modération venue d’Helsinki ?

Plus d’argent pour la fourniture de soins signifie-t-il nécessairement plus d’efficacité ?

Hannu Hanhijärvi, du fonds finlandais pour l’innovation, qui doit mettre en œuvre les exigences du rapport Cox dans les pays européens, relativise : il conduit actuellement des discussions avec plusieurs Etats qui entendent jouer un rôle de précurseur dans le domaine de la e-Health. Il souhaite mettre sur pied avec eux des projets pilotes pour promouvoir la médecine basée sur des preuves et les directives cliniques. La commission de l’UE pourrait ultérieurement prendre en charge la coordination et le financement de ces projets. Hanhijärvi doute toutefois qu’il en sorte des directives obligatoires pour les Etats de l’UE. Le comité directeur du rapport Cox est moins loquace : il a refusé de prendre position sur les questions relatives à l’influence de Pfizer et à la suite des événements. Peter Kraft

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ASSURANCE-MALADIE infosantésuisse No 4, avril 2007

Trois questions à Nello Castelli, délégué aux relations publiques pour la Suisse romande de santésuisse

« Nous avons à peine discuté des faits »

Photos : Peter Kraft

Nello Castelli, en tant que délégué aux relations publiques en Suisse romande, a eu une tâche difficile avant la votation sur la caisse unique : tenter de convaincre les Romands, critiques envers les caisses, que l’initiative était une fausse solution. Il y est parvenu et peut maintenant se retourner calmement sur les événements. Il souligne toutefois, après le « non » des urnes, que beaucoup de travail attend encore santésuisse et les assureurs.

« Nous devons maintenant nous efforcer d’éliminer les faiblesses de notre système. »

Comment avez-vous vécu la campagne précédant la votation ? L’image des assureurs-maladie n’est pas aussi bonne en Romandie qu’en Suisse alémanique. Depuis plusieurs années, les milieux qui sont opposés au système actuel répandent des allégations fausses. Ces dernières ont été adoptées par la population. Les assureurs-maladie feraient ainsi des bénéfices grâce à l’assurance de base, ils auraient des conseils d’administration coûtant des millions et engloutiraient l’argent des primes dans la gestion. Les partisans de l’initiative ont utilisé cette situation en leur faveur et ont mené, particulièrement en Romandie, une campagne très émotionnelle. Contrairement à ce qui s’est passé en Suisse alémanique, on a très peu parlé des faits. Pour moi, cela a été difficile car santésuisse voulait mener une campagne factuelle. Je me suis donc tenu en retrait lorsque les débats devenaient très émotionnels. Contrer ces arguments est l’affaire des politiciens et non pas de l’association de branche. Peut-on voir le résultat de la Romandie comme une victoire des faits ? Je ne peux pas dire cela car les analyses à ce propos ne sont pas encore disponibles. Il serait un peu audacieux de croire que seule notre information factuelle a conduit à la victoire. Nos chiffres ont été accusés jusque dans les médias, d’être manipulés, alors même que nos modèles avaient été calqués aussi bien que possible sur les déclarations des initiants. Quelles sont les raisons du résultat réjouissant de la Romandie ? L’argument principal des promoteurs tenait aux primes – sans pourtant qu’ils aient fourni quelque chose de concret aux votants. Les opposants, en revanche, pou-

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Des surprises Nello Castelli, dans l’après-midi du 11 mars, a été très surpris du résultat positif de la Romandie. Il n’avait pas compté, dit-il, avec un « non » à Genève et au Tessin. Souvent, lors des débats publics, il s’est senti dans la cage aux lions. Lors des débats sur la caisse unique, le plus souvent organisés par les partisans, l’ambiance a été extrêmement critique à l’endroit des assureurs-maladie. Nello Castelli donne un exemple : à la gare de Lausanne, une dame le reconnaît suite à une émission de télévision diffusée la

vaient désigner ce qui allait être perdu avec l’initiative, par exemple la liberté de choix. Une vague promesse faisait donc face à une perte certaine. Il est possible, outre toutes les questions de système, que la satisfaction des gens dans le rapport personnel avec leur caissemaladie ait eu son importance. Une autre explication encore : beaucoup de gens ne considèrent pas le système comme parfait mais ils ne souhaitent pourtant pas

veille. Au premier abord, il n’est pas mécontent : ce n’est pas tous les jours que l’on est abordé après un passage à la TV. La surprise a suivi – et a été plutôt négative : en termes hauts et clairs, la dame lui a déclaré qu’elle ne partageait nullement son opinion et qu’elle allait voter en faveur de la caisse unique. Peut-être Nello Castelli a-t-il pu convaincre d’autres gens par ses interventions ? Bon nombre de Romands et de Tessinois ont manifestement suivi ses vues.

qu’il soit bouleversé. Ils n’étaient pas non plus au clair avec ce qu’aurait impliqué pour eux, personnellement, un changement de système. Il ne faut surtout pas considérer le vote comme une autorisation à ne rien faire. Nous devons maintenant nous efforcer d’éliminer les faiblesses de notre système. En outre, il est important de convaincre les gens, surtout en Romandie, que les problèmes ne résident pas dans les frais

de gestion et le nombre de caisses, mais bien dans les coûts. La conscience du fait que les primes reflètent les coûts est plus nette en Suisse alémanique. En Romandie, en revanche, l’idée est répandue que les primes servent surtout à constituer des réserves, faire des bénéfices, faire de la publicité et entretenir une administration inutile. Nous devons corriger cette image déformée. Interview : Peter Kraft

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ASSURANCE-MALADIE infosantésuisse No 4, avril 2007

Entretien avec Claude Longchamp, directeur de l’Institut de recherches « gfs.bern »

« Les initiatives populaires sur la santé sont de mauvaises conseillères pour la politique » Claude Longchamp constate, après la votation populaire sur l’initiative pour une caisse unique, que les propositions de la gauche en matière de politique de santé polarisent trop fortement pour pouvoir attirer, au centre, les nombreux partisans potentiels. Il conseille aux milieux politiques de poursuivre sur le chemin des réformes, sans s’arrêter sur les exigences les plus radicales, c’est-à-dire en direction de plus de concurrence, selon les vœux de la population.

La caisse unique ou les primes liées au revenu : quel est l’élément qui a rencontré le scepticisme le plus marqué de la population ? Nous ne le saurons qu’avec les analyses VOX. Sur la base des enquêtes préalables, il semble toutefois que le refus s’est plutôt porté sur l’unification des caisses. Il y a davantage de soutien sur le changement de système pour les primes.

Les premières analyses montrent un lien clair : le montant des primes que paie une famille pour l’assurance de base est le meilleur indicateur d’une approbation. Plus les primes sont élevées en comparaison intercantonale, plus la tendance au oui s’accentue. En Suisse alémanique, cet effet est repris par la mesure dans laquelle la population touche des réductions de primes. Plus le pourcentage d’aide est élevé, plus l’opposition au statu quo a été faible. Nous ne pouvons pas montrer un pareil effet en Romandie. Là, le mécontentement augmente avec le niveau moyen des primes. Souvent évoquée, la « barrière de rösti » n’a pas été aussi évidente que l’on pouvait le craindre. Qu’est-ce qui a poussé la Suisse latine à voter majoritairement contre l’initiative ? Photo : màd.

infosantésuisse : L’initiative pour une caisse unique a été rejetée clairement avec plus de 70 % des voix, ce qui a été une surprise. Comment expliquez-vous ce verdict ? Claude Longchamp : Si l’on s’en tient aux faits, cette initiative est celle qui a le mieux réussi des trois initiatives de la gauche, surtout en Romandie. Mais ni le PS ni les Verts ne sont parvenus à percer en matière de politique de santé. La polarisation qui est induite par leurs propositions est trop forte. Elle ne sépare pas seulement, comme on le voit, la gauche et la droite. Le centre bourgeois prend le plus souvent une position claire de refus.

L’initiative aurait-elle mieux réussi si elle avait été formulée plus clairement ? Non, le résultat n’a pas été une conséquence du texte de l’initiative. Dans la dynamique de la formation de l’opinion, le fait que le financement n’ait pas été précisé dans sa conception a toutefois joué un rôle. Cela a permis aux assureurs-maladie d’occuper en premier ce terrain important aux yeux de la population. Est-ce que le puissant « non » des urnes est simplement un refus de l’initiative ou est-ce un plébiscite pour le système en place ?

« Le montant des primes est le meilleur indicateur d’une approbation. »

Les tendances vont dans la direction inverse. Aucun canton romand n’a eu jusqu’ici des taux d’acceptation aussi élevés pour une initiative de gauche sur la santé. Cela vaut également pour le Tessin. Les régions avec des primes élevées – Genève et Bâle-Ville – ont également refusé l’initiative. Est-ce que l’idée s’est imposée qu’une caisse unique n’amène pas des primes moins lourdes ? A Bâle et à Zurich, il y a des indices d’une telle tendance mais pas à Berne ni à Genève. Quel chemin la politique doit-elle suivre après les résultats de ce vote ? Les initiatives en matière de politique de santé sont de mauvaises conseillères pour la politique. Il importe peu qu’elles soient de droite ou de gauche : elles ont toutes été refusées depuis la mise en vigueur de la LAMal. Le conseil adressé à la politique pourrait être le suivant : ne pas se laisser arrêter dans le processus de réforme par les exigences de changement les plus radicales présentées par les initiatives. Quelles conséquences les acteurs du système de santé doivent-ils en tirer ? Les grandes tendances dans la population sont devenues claires depuis trois ans : pas de baisse de la qualité et de la quantité dans la fourniture des soins médicaux, même avec une augmentation de la participation personnelle, fourniture liée de manière générale avec plus, et non pas moins de concurrence entre les prestataires de soins afin de maîtriser la hausse des coûts. Interview : Peter Kraft

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RVK et santésuisse s’allient pour mettre en place un registre central des conventions (RCConv)

Le RCConv facilite le contrôle des factures et les négociations En raison de l’utilisation croissante des moyens de communication électroniques, santésuisse a créé en 2001 pour ses membres et ses services internes la banque de données des conventions (BDConv) : elle contient toutes les conventions en vigueur dans le domaine de l’assurance obligatoire des soins. La RVK (association des petits et moyens assureurs-maladie) a pour sa part développé, en priorité pour les assureurs qui lui sont affiliés, une application similaire sous le nom de « banque de données sur les conventions et tarifs ». Ces deux outils sont maintenant réunis en un seul.

es deux banques de données garantissent à leurs membres la diffusion électronique d’informations écrites relatives aux conventions. Elles facilitent ainsi principalement le contrôle manuel des factures et la tâche des personnes chargées de négocier des conventions. Les deux banques de données existent en parallèle depuis des années et se sont développées de manière différente bien qu’elles contiennent les mêmes conventions. Chaque application dispose d’informations et de fonctions supplémentaires afin que les clients puissent bénéficier d’un ouvrage de référence pertinent en matière d’informations sur les prestations.

Nouvelles exigences – solution commune L’idée d’une solution commune est née des discussions qui ont eu lieu entre santésuisse et la RVK en novembre 2005. En faisant l’inventaire de ces outils, il s’est avéré que tous deux étaient très utilisés par les clients et qu’ils avaient des caractéristiques différentes. Les deux banques de données existantes doivent désormais répondre à de nouvelles exigences, notamment fournir une vue d’ensemble du nombre croissant des conventions, faciliter la préparation d’une éventuelle levée de l’obligation de contracter et inclure le contrôle électronique des factures. C’est pourquoi la mise sur pied d’un projet commun a été décidée, lequel doit éliminer les faiblesses des applications actuelles ainsi que les doublons coûteux au niveau de la gestion de deux systèmes. Après des négociations minutieuses, la RVK et santésuisse ont signé en date du 20 décembre 2006 des contrats de collaboration dont l’objec-

tif est la mise en place d’un registre central des conventions (RCConv). Les buts visés sont les suivants : • Application web • Interface standard (analogue au rcc), y compris tous les liens • Interface avec le DFI, servant de catalogue électronique des conventions • Faculté d’octroyer des mandats de négociation des conventions. Pour les clients, il en résultera une utilité accrue considérable à différents niveaux.

De gauche à droite : Matthias Wechsler, Franz Wolfisberg, Ruedi Bucher.

Plans concrets Le RCConv est intégré au ressort du Registre des codes créanciers (rcc) à Lucerne et c’est là qu’il sera mis en service et exploité. Les tâches qu’implique le RCConv présentent une grande analogie avec celles du rcc. Il sera ainsi possible de tenir compte des expériences réalisées au moyen du projet de révision du rcc de 2004. De même, les outils et méthodes du rcc sont applicables par analogie. De plus, les processus de production et de distribution prévus pour le RCConv sont identiques à ceux du rcc. Dans une première phase, les assureurs ont été contactés et invités à signer le contrat de licence en vue de la création du nouveau Registre central des conventions. Cette étape n’est pas encore terminée parce que chaque assureur doit analyser à l’interne les différentes propositions de solution et prendre les décisions

stratégiques correspondantes. Pour l’instant, nous recueillons les souhaits et demandes supplémentaires des assureurs et les intégrons au projet dans la mesure du possible. Dans une phase ultérieure, nous réaliserons la mise en exploitation et la diffusion de la nouvelle banque de données. Puis débutera la gestion pilote. Les premières corrections une fois effectuées, les données seront ensuite reprises par le nouvel instrument. Cette opération prendra beaucoup de temps car chaque convention doit être analysée et intégrée dans les nouvelles structures. La gestion des caractéristiques des conventions constitue en tout cas un facteur essentiel de réussite du projet et c’est pourquoi nous accordons une importance particulière à ce point. Il est prévu d’introduire le Registre central des conventions au 1er janvier 2008. Franz Wolfisberg

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DOMAINE DE LA SANTÉ infosantésuisse No 4, avril 2007

Graphique du mois

Les coûts des soins et les autres dépenses divergent vers l’âge de 80 ans A partir de ce numéro, nous présenterons régulièrement dans infosantésuisse le « graphique du mois ». Pour commencer, voyons une comparaison entre les coûts des soins et les autres dépenses de santé selon les classes d’âge.

• C’est à partir de 80 ans environ que les autres coûts de santé par assuré baissent. • C’est avant la 90e année que les coûts des soins par assuré deviennent plus importants que toutes les autres prestations de santé mise ensemble. • La forte hausse des coûts des soins à partir de l’âge de 80 ans est avant tout due aux coûts des EMS. • Les soins à domicile jouent un rôle nettement moindre. Leur coût par assuré est bas en comparaison à celui des EMS. Ils

augmentent nettement moins vite avec l’âge. Notre graphique confirme deux choses : d’une part que les coûts des soins sont un domaine sur lequel il est possible d’agir et, d’autre part, qu’il faut promouvoir les soins à domicile et non pas les soins stationnaires – non pas seulement pour des raisons de coûts mais encore parce qu’ils procurent une plus grande indépendance et une meilleure qualité de vie aux personnes concernées. Matthias Schenker

Explosion des coûts des soins avec l'âge Prestations brutes par personne assurée et par tranche d'âge en 2005 Prestations brutes par assuré en CHF

Source : pool de données santésuisse, données annuelles 2005

e graphique du mois d’avril montre comment se répartissent les coûts des soins à domicile, des EMS et des autres prestations de la LAMal selon les diverses classes d’âge, à partir des valeurs du Pool de données de santésuisse. On peut en tirer d’intéressantes conclusions : • Ce n’est qu’à partir de l’âge de 70 ans environ que les coûts des soins des assurés prennent des valeurs notables. • C’est à partir de 80 ans environ que les coûts des soins commencent à augmenter fortement.

25000

20000

Spitex / assurés EMS / assurés Autres / assurés

15000

10000

5000

0 s

1 6-

1 1-

1 6-

2 9-

2 1-

3 6-

3 1-

4 6-

4 1-

5 6-

5 1-

6 6-

6 1-

7 6-

7 1-

8 6-

8 1-

9 6-

9 1-

0 -1

Tranches d'âge

C’est à partir de 80 ans environ que les coûts des soins commencent à augmenter fortement, tandis que les dépenses de santé baissent.

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DOMAINE DE LA SANTÉ

infosantésuisse N 4, avril 2007 o

Les discussions sur les traumatismes par coup du lapin tournent en rond depuis des décennies

De la maladie des chemins de fer au coup du lapin Les traumatismes d’accélération crânio-cervicaux conduisent-ils fréquemment à l’invalidité ? Quelles sont les causes réelles des douleurs qui surviennent, le plus souvent à la suite d’un accident ? Quand les rentes ou les indemnités sontelles la meilleure façon d’aider les victimes ? Ces questions sont d’actualité et pourtant aussi vieilles que les plus vieilles pièces exposées dans le secteur des chemins de fer du Musée des transports de Lucerne.

e chirurgien anglais John Eric Erichsen a établi en 1866 une hypothèse qui, à son avis, expliquait les conséquences lourdes d’accidents de train pourtant sans gravité. La secousse survenant à la suite d’un changement brusque de vitesse agit sur la colonne vertébrale et provoque des changements de structure qui induisent à leur tour des perturbations des sens, des douleurs dans les membres et la tête et des pertes de concentration. Vingt ans plus tard, le médecin allemand Hermann Oppenheim avançait la théorie selon laquelle les violentes douleurs faisant suite à des accidents de train avaient pour cause des « neuroses traumatiques ». Ce n’est pas une modification dans la colonne vertébrale mais bien une expérience choquante, liée à une technologie nouvelle et encore mystérieuse, qui provoquait les douleurs, selon Oppenheim.

Un phénomène culturel ? Comme c’est à cette époque qu’étaient mis en place les premiers systèmes d’assurance, la discussion sur les causes de la « maladie des chemins de fer » a été vive à cette époque-là déjà. Les accidents de trains conduisent-ils vraiment souvent à des dommages irréversibles ou ne provoquent-ils que des traumatismes qui peuvent être surmontés ? Deux siècles plus tard, le même débat est toujours en cours mais on parle aujourd’hui de coup du lapin ou de traumatisme du rachis crânio-cervical. Au cours des dernières années, la discussion a pris un tour des plus vifs parce que les coûts d’assurance (principalement pour l’invalidité, l’assurance-accident et la responsabilité civile) ont fortement augmenté : 33 % de tous les paiements pour dommages corporels en Suisse relèvent du coup du lapin alors qu’il n’y en a que 3 % en

France. Environ un demi-milliard de francs va chaque année aux victimes du coup du lapin. En Romandie, les coûts ont doublé depuis 1990 et sextuplé en Suisse alémanique. La question est ainsi posée : les traumatismes par accélération sont-ils principalement la conséquence d’accidents avec choc ou les facteurs culturels jouent-ils un rôle, de même que le niveau de connaissance du sujet ? Les compagnies d’assurance parlent d’une « hypersensibilité », en particulier en Suisse alémanique, alors que les associations de victimes se plaignent que la maladie ne soit guère reconnue en Suisse romande – notamment parce que la population est moins informée de la question. Selon le psychiatre allemand Andréas Stevens, de nombreuses victimes s’attendent justement à un traumatisme par accélération lors d’un accident de la circulation. Il s’agit d’un « rituel appris et culturel » avec lequel l’attente d’un dédommagement joue un rôle important.

Le Tribunal fédéral va-t-il modifier sa pratique ? Quoi qu’il en soit, il est frappant de constater que la forte augmentation des traumatismes par coup du lapin a commencé avec une décision du Tribunal fédéral de 1991. Il a en effet reconnu les prétentions d’un patient à une rente AI alors même qu’il n’y avait pas d’explication médicale à ses douleurs. Ce jugement a été le fondement de l’allocation généreuse de rentes. Le spécialiste fribourgeois du droit des assurances, Erwin Murer, escompte toutefois un changement de cap. Les fortes dépenses pour les cas d’assurance sans cause connue ont souvent conduit les juges fédéraux à des jugements prudents. Les traumatismes par coup du lapin pourraient ainsi perdre le statut juridique de douleurs induites. Se-

lon Murer, les véritables causes des traumatismes pourraient ainsi être mises en relief : stress professionnel, tensions familiales ou autres difficultés personnelles. Plusieurs études, notamment des professeurs Bogdan Radanov et Thomas Ettlin, recommandent également le recours à la psychothérapie dans le traitement du coup du lapin. Les assurances également sont invitées à agir. L’association suisse d’assurances recommande à ses membres, en cas de traumatisme par coup du lapin, de tirer aussi vite que possible au clair les risques qu’a la douleur de devenir chronique. Ce n’est que de cette façon que les démarches nécessaires peuvent être entreprises et que l’on peut éviter la survenue d’une invalidité permanente. Peter Kraft

Il y a quatre ans, les assureurs, de concert avec les fournisseurs de soins, ont élaboré un questionnaire qui doit être rempli lorsqu’un traumatisme par coup du lapin s’est produit. Le questionnaire vise à établir le déroulement de l’accident et rend possible un premier compte-rendu des constats médicaux tels qu’ils se présentent aux urgences ou dans le cabinet de premiers recours. Le questionnaire peut être facturé selon TARMED et peut être téléchargé avec les instructions en allant sur le site internet de l’ASA, rubrique Médecine, Formulaires. On préserve ainsi des données importantes qui peuvent être précieuses pour la compréhension de la suite des événements. Les assureurs-maladie et accidents ont chaque année à traiter un nombre à peu près semblable de cas et ils demandent à tous les médecins d’utiliser cette fiche documentaire pour le premier examen médical.

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DOMAINE DE LA SANTÉ infosantésuisse No 4, avril 2007

Livre à lire : comprendre les données relatives à la santé

Les données relatives à la santé doivent aussi être fiables « Les statistiques sont trompeuses » – un jugement que l’on entend souvent mais qui n’est certainement pas juste en étant proféré de manière aussi abrupte. Les statistiques peuvent tout à fait être pertinentes pour autant qu’elles aient été établies selon des méthodes scientifiques – pourtant, elles ne sont pas toujours dépourvues de pièges. C’est ce que démontre au moyen d’exemples concrets le livre « Comprendre les données relatives à la santé ».

dies cardio-vasculaires ? Parce qu’il s’agit d’une maladie « typique de la vieillesse ». Parmi les causes de décès, ce sont ces maladies qui dominent : cela tient au fait qu’aujourd’hui les gens deviennent plus âgés et meurent moins d’autres maladies. Autrement dit, par rapport à l’espérance de vie qui augmente, le taux de mortalité imputable aux maladies cardio-vasculaires régresse alors que ces maladies et les cas de séjour à l’hôpital croissent.

Un point essentiel : la fiabilité

Josef Kuhn, Manfred Wildner « Gesundheitsdaten verstehen », 100 pages. Verlag Hans Huber, Berne.

’ouvrage se focalise sur le système de santé allemand mais les analyses présentées par les auteurs, Josef Kuhn et Manfred Wildner, et les conclusions qu’ils en tirent ont une portée générale. Nous sommes quotidiennement interpellés par les données relevant du domaine de la santé, que ce soit en matière de coûts et de fréquence des maladies ou de chiffres clés sur l’efficacité des traitements médicaux. Parfois, on ne peut pas sans autre consulter les statistiques et savoir ce qu’elles signifient : pour être comprises, elles doivent être interprétées. Afin d’en faciliter la compréhension, le livre explique dans l’introduction des notions qui sont importantes en matière d’épidémiologie*, telles que la mortalité, la prévalence ou le risque relatif.

Nécessité d’interpréter… Beaucoup de données statistiques doivent être interprétées. Un exemple : pourquoi autant de personnes meurent de mala-

Dans la mesure où elles existent, les statistiques sur les accidents ne sont pas forcément fiables. Ainsi, en Allemagne, la statistique annuelle des accidents établie ne recense que les accidents enregistrés par la police. Les accidents frappant des piétons sans que d’autres acteurs participant au trafic ne soient concernés ne sont pas considérés comme des accidents imputables au trafic routier. Les statistiques sont muettes sur le nombre de ceux qui glissent en hiver sur des routes et sur des trottoirs verglacés et qui se blessent. De même, ne sont pas pris en compte en tant qu’accidents du trafic routier les accidents sur une propriété privée. Alors que les accidents graves et notamment ceux dont l’issue est mortelle sont recensés de manière très fiable, il n’en va pas de même pour les accidents bénins. La question de la fiabilité se pose en particulier aussi lorsque des résultats statistiques doivent prouver un lien de cause à effet. Ainsi, il n’est nullement prouvé qu’un risque d’accident statistiquement plus élevé chez les jeunes ait dans tous les cas quelque chose à voir avec le fait que la personne est « jeune ». Le livre mentionne comme exemple célèbre le recul de la population des cigognes et le recul des naissances !

S’interroger sur les valeurs moyennes Les auteurs jettent aussi un regard critique sur l’utilisation fréquente de valeurs moyennes. Lorsque l’on réduit une grande quantité de données à quelques chiffres clés, la présentation d’un état de fait est certes simplifiée mais comporte le risque de masquer des différenciations importantes. Tout comme une note moyenne ne permet pas de discerner les bonnes et les mauvaises prestations, un recensement général des malades ne permet pas de faire des distinctions selon l’âge, le sexe, le statut professionnel ou la grandeur de l’entreprise. Ce n’est pas pour rien que les statisticiens affirment que les moyennes ne sont pas pertinentes et qu’elles ne disent rien. Même si la profondeur d’un fleuve n’est en moyenne que de 50 centimètres, ce dernier peut être suffisamment profond à certains endroits pour qu’une vache puisse se noyer ! Le présent ouvrage contribue donc grandement à une meilleure compréhension des statistiques. Il les examine de manière critique, passe également en revue les sources de ces données et montre comment on peut présenter des statistiques en les manipulant. Ce livre de 100 pages en petit format n’est pas un ouvrage académique mais un guide compréhensible permettant d’y voir clair dans le flot d’informations sur la santé. Il serait souhaitable que la prochaine édition tienne également compte de statistiques suisses. Josef Ziegler

* Etude de la fréquence et de la distribution des facteurs de risque, maladies et troubles psychiques dans la population.

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1359

service

Pour cent culturel de la Migros : nouvelle initiative

Cours pour les enfants en surcharge pondérale et pour leur famille

Vers l’Allemagne : La clinique universitaire du SchleswigHolstein a signé un accord de coopération avec les six plus grands hôpitaux danois. L’objectif est de faire traiter chaque année en Allemagne voisine quelque 150 patients atteints du cancer. La raison de cette démarche tient au fait que les temps d’attente dans le système de santé danois ne permettent pas de traiter tous les cancéreux dans des délais adéquats.

En mai prochain, le Pour cent culturel de la Migros lance un nouveau cours du club minu, portant sur le comportement et destiné aux enfants et adolescents qui souffrent de surcharge pondérale. Le programme inclut toute la famille et motive les jeunes de onze à seize ans qui sont en excès de poids à manger sainement

et à faire plus d’exercice physique. Le cours dure neuf mois et comprend 13 rencontres qui ont lieu en groupes séparés pour enfants et parents ainsi que deux entretiens avec la famille. Un camp d’été de deux semaines est organisé à l’intention des enfants, suivi en automne d’une journée pour les familles. Avant l’inscrip-

tion définitive, chaque famille est soumise à un entretien d’admission. Le club minu est dirigé par une équipe spécialisée composée d’un psychologue en alimentation, d’une conseillère en nutrition, d’une enseignante en économie ménagère et d’un maître de sport. Les intéressés peuvent s’inscrire sous www.minuweb.ch.

Photo : Prisma

Nouvelles du monde

Pression sur les prix : Les autorités anglaises de régulation de la concurrence entendent modifier complètement la procédure de détermination des prix des médicaments, malgré les menaces de retraits de l’industrie. Le potentiel d’économie serait de l’ordre de 1,5 milliard de francs. Actuellement, les entreprises pharmaceutiques sont libres de déterminer leurs prix. Il n’existe que des limites supérieures aux gains des entreprises. Etats-Unis I : Selon des rapports de la police de Los Angeles, il arrive de plus en plus souvent que des cliniques mettent à la rue des patients déments ou SDF avant la fin de leur traitement. Motif : ces patients sont incapables de payer les soins fournis. Etats-Unis II : Les trois candidats démocrates à la présidence ont désormais inscrit à leur programme électoral l’introduction d’une assurance-maladie obligatoire. Une candidate, Hillary Clinton, avait déjà tenté, mais en vain, d’introduire cette assurance pendant le mandat présidentiel de son mari.

Connaissez-vous les détails ?

Testez vos connaissances sur l’assurance-maladie Vous avez la possibilité de tester vos connaissances en matière d’assurance-maladie en vous rendant sur le site www.santesuisse.ch. Vous répondez aux 20 questions posées présentant un degré de difficulté variable et, pour terminer, vous recevez une

évaluation de vos connaissances. Le test vous rendra peut-être attentif à d’autres questions dont vous ne connaissez actuellement pas les réponses. La main sur le cœur : pouvez-vous dire spontanément si les médicaments de l’assurance de base sont aussi remboursés lorsqu’ils sont pres-

crits par le dentiste ? Ou dans quel délai vous devez recourir si vous n’êtes par d’accord avec une décision de votre assureur ?

Vous trouvez le test sous www.santesuisse.ch – Formation – e-learning

SANTÉSUISSE – SERVICE

infosantésuisse No 4, avril 2007

Photo : Prisma

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1360

La Ligue suisse contre le cancer lance deux campagnes

Prévention du cancer de la peau et de l’intestin La Ligue suisse contre le cancer fait actuellement campagne contre deux types de cancer les plus fréquents – et donc les plus dangereux. En collaboration avec la Société suisse de dermatologie, l’Office fédéral de la santé publique et pharmaSuisse, la Société Suisse des Pharmaciens, la Ligue organise le 7 mai la journée nationale du cancer de la peau. Ce jourlà, les dermatologues de toute la Suisse offrent le premier examen gratuit d’une tache pigmentée suspecte. Une action similaire avait déjà eu lieu il y a une année, avec le résultat que l’on sait : grâce à ces examens gratuits, 177 mélanomes (cancer malin de la peau) ont été découverts. S’agissant du cancer de la peau, le dépistage précoce joue un rôle décisif quant aux chances de guérison. Outre des examens réguliers à faire soi-même, la Ligue conseille d’éviter les coups de soleil et de fréquenter les solariums. Ce sont avant tout les personnes dont la peau est claire qui devraient suivre strictement ces mesures de précaution. La Suisse occupe le deuxième rang derrière la Norvège en ce qui concerne

la fréquence des cancers de la peau. Celle-ci a augmenté fortement dans notre pays durant ces vingt dernières années (voir graphique). La campagne « Non au cancer de l’intestin ? » est rééditée. La Ligue suisse contre le cancer met à disposition une brochure donnant des informations de base sur la maladie : qu’est-ce que le cancer de l’intestin, quels sont les facteurs de risque, quels en sont les symptômes et comment ce cancer est-il traité ? Naturellement, la brochure explique aussi ce que chacun peut faire pour réduire ses propres risques. Les mesures de précaution les plus importantes sont les suivantes : alimentation équilibrée, activité physique suffisante, consommation d’alcool mesure et renonciation au tabac. Un guide spécial est consacré à une alimentation saine, laquelle ne fait « que » réduire le risque de cancer. La Ligue organise en outre le 13 septembre un symposium sur le thème du dépistage du cancer de l’intestin. Vous pouvez commander des documents sur les deux campagnes sous shop@swisscancer.ch ou au numéro 0844 85 00 00.

Largement financée par des fonds privés

Chaire suisse de chiropratique à partir de 2008

NOMBRE DE NOUVEAU CAS / 100000

CANCER DE LA PEAU: NOMBRE DE NOUVEAUX CAS 1985 – 2003 22 20 18 16 14 12 10 1985–88

1989–92 HOMMES

1993–96

1997–00

2001–03

FEMMES

La fréquence des cancers de la peau a augmentée fortement durant ces dernières années.

Les futurs chiropraticiens doivent faire leurs études au Canada ou aux USA parce qu’il n’existe pas de chaire de chiropratique en Suisse alémanique. Ces études étant très coûteuses, de nombreuses personnes douées ne peuvent pas s’offrir cette formation. A partir de l’automne 2008, cette situation va changer : dès cette date, l’Université de Zurich aura une chaire de chiropra-

tique. Celle-ci sera financée par ChiroSuisse, l’Association Suisse des Chiropraticiens, et grâce à l’initiative privée de chiropraticiens suisses. En 2005, ceux-ci avaient par exemple renoncé à percevoir un jour d’honoraires afin de récolter des fonds pour la chaire. En outre, ChiroSuisse a créé la « Fondation pour la formation de chiropraticiens », une institution privée.

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SANTÉSUISSE – SERVICE

infosantésuisse N 4, avril 2007 o

Manifestations Organisateur

Fait particulier

Date/lieu

Renseignements

12 avril 2007 Berne

www.snf.ch

Avec notamment Peter Indra, vice-directeur de l’OFSP

3 mai 2007 Hôtel Berne, Berne

www.sggp.ch

Thème : l’avenir de la télémédecine

8 mai 2007 Hôtel Hilton, Bâle

www.medgate.ch

77 manifestations et expositions

9-11 mai 2007 Music & Convention Centre, Montreux

www.sbk.ch

10 mai 2007 Kongresshaus Zürich, Zurich

www.rvk.ch.ch

PNR 49, Résistance aux antibiotiques Fonds national de la recherche

Présentation des conclusions

Médecines complémentaires : besoin ou luxe ? SGGP

4 e Medgate-Symposium Medgate

Congrès 07 Association suisse des infirmières et infirmiers ASI

RVK

Le patient, centre des préoccupations – avec Thierry Carrel et Peter Indra

Dessin : Marc Roulin

Neuvième Forum suisse de l’assurance maladie sociale

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1362 9. Schweizerisches Forum der sozialen Krankenversicherung: Donnerstag, 10. Mai 2007, 9.30 bis 16.00 Uhr im Kongresshaus Zürich

Der Patient im Mittelpunkt Der Patient als Mittel. Punkt Es sind viele Parteien, die im schweizerischen Gesundheitswesen mitspielen: Ärzte, Spitäler, Krankenkassen, Versicherte, Patienten, Politiker. Und es sind ebenso viele, die mit einem Stück des 50 Milliarden grossen Kuchen liebäugeln. Manchmal so intensiv, dass Ziel und Zweck aus den Augen verloren gehen. Das diesjährige Schweizerische Forum der sozialen Krankenversicherung lässt alle Parteien zu Wort kommen. Damit der Patient und seine Gesundheit wieder in den Mittelpunkt rücken. Informationen und Anmeldung: www.rvk.ch

Daniela Lager Moderatorin «10 vor 10», SF DRS

Ben L. Pfeifer Aeskulap-Klinik

Volker Amelung Medizinische Hochschule Hannover

Antoine Chaix Médecins Sans Frontières Schweiz

Weitere Informationen und Online-Anmeldung im Internet: www.rvk.ch

Frank Mathwig Schweiz. Evang. Kirchenbund

Peter R. Müller Krebsliga Schweiz

RVK Haldenstrasse 25, 6006 Luzern Telefon +41 (0) 41 417 05 00

Peter Indra Bundesamt für Gesundheit

Thierry Carrel Inselspital Bern

RVK – Verband der kleinen und mittleren Krankenversicherer

Annuaire de l’assurance-maladie suisse 2007 L’annuaire de l’assurance-maladie suisse vient de paraître. Grâce à cette indispensable source de renseignements actualisés, vous disposez d‘une mise à jour complète de vos connaissances pour la pratique de l‘assurance-maladie et accidents. Le livre est disponible en français et en allemand au prix de Fr. 35.– par exemplaire, TVA, frais de port et d’emballage en sus.

Je commande _____ exemplaire(s) de l’Annuaire de l’assurance-maladie suisse 2007, édition française _____ ex. Handbuch der Schweizerischen Krankenversicherung 2007, deutsche Ausgabe

Nom/ Prénom • Fax 032 625 41 51 • shop@santesuisse.ch • www.santesuisse.ch

Rue / No NPA / Localité

Charles Giroud Präsident RVK

Infosantesuisse 91x270 C

18:17 Uhr Seite 1 infosantésuisse : dossier 6.8.2006 Comparaisons internationales (4e partie) 1/2010 1363

– Institute of Health Economics and Management

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03/10

info santésuisse

Les différents systèmes de santé en Europe

Le magazine des assureurs-maladie suisses

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1366

Page 4

Page 10

Page 11

Les systèmes de santé en Europe : critères de définition

Quels sont les « meilleurs » systèmes de santé ?

Trois questions à Willy Oggier, expert en économie de la santé

Sommaire Sous la loupe 4 Les systèmes de santé en Europe : critères de définition 5 Les modèles de Bismarck et de Beveridge 6 Les sources de financement 8 Les systèmes de santé s’orientent vers la décentralisation 10 Quels sont les « meilleurs » systèmes de santé ? 11 Trois questions à Willy Oggier, expert en économie de la santé 12 Vers une harmonisation européenne ? Domaine de la santé 14 Les dix caractéristiques d’un système de soins chroniques performant 15 Graphique du mois 16 A lire. Pénurie croissante de personnel soignant 17 Registre des codes créanciers de santésuisse : les nouveautés 18 La nouvelle carte d’assuré a fait son entrée à l’hôpital Service 19 Image du mois 20 Physiothérapie en cabinet médical 20 Nouvelles du monde 21 Manifestations 21 Monsieur Raoul

No 3, avril 2010 Paraît dix fois par an prix de l’abonnement 69 fr. par an, 10 fr. le numéro Éditeur et administration santésuisse, Les assureurs-maladie suisses, Römerstrasse 20, case postale, 4502 Soleure Responsable de la rédaction Maud Hilaire Schenker, Département Politique et Communication, Case postale, 4502 Soleure Téléphone : 032 625 41 27, Fax : 032 625 41 51, Courriel : redaction@santesuisse.ch production : Rub Graf-Lehmann AG, Murtenstrasse 40, 3001 Berne Conception de la mise en page Pomcany’s mise en page Henriette Lux administration des annonces Toutes les annonces – les offres d’emploi y compris – sont à adresser à : « infosantésuisse », Römerstrasse 20, case postale, 4502 Soleure courriel : redaction@santesuisse.ch Administration des abonnements Téléphone : 032 625 42 74, Fax : 032 625 41 51 Portail : www.santesuisse.ch Page de titre : Keystone, Zurich ISSN 1660-7236

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1367

Développons nos points forts et évitons de nous lancer dans le flou expérimental ! La présente édition est consacrée à la comparaison des différents systèmes de santé européens. En Suisse, la question de la santé est revenue sur le devant de la scène politique depuis l’annonce d’une augmentation des primes supérieure à la moyenne pour l’année 2010. Toutefois, le parlement semble peu disposé à lancer des réformes pragmatiques qui permettraient une véritable avancée. Il s’embourbe dans une lutte superficielle contre les symptômes, comme dans le cas du paquet de mesures destiné à juguler l’augmentation des coûts. Parallèlement, l’idée d’une caisse unique attire de nouveau plus de partisans ; or, celle-ci ne ferait également que lutter contre les symptômes. Elle n’agirait pas là où le bât blesse, au niveau du coût des prestations. Il est vrai que l’augmentation des primes est fâcheuse, notamment pour les ménages modestes. Nous ne devons néanmoins pas oublier les avantages du système de santé suisse. D’autres pays nous envient les grands principes de la loi fédérale sur l’assurance-maladie (LAMal), entrée en vigueur en 1996, comme l’obligation de s’assurer, la prime unitaire avec compensation des risques (toutefois insuffisante), la réduction des primes et le catalogue de prestations complet. L’introduction d’une obligation de s’assurer aux Etats-Unis, la réforme planifiée du gouvernement de coalition allemand visant à séparer les coûts de la santé de ceux du travail et la discussion sur la rationalisation en Grande-Bretagne en lien avec le National Health Service, système de santé centralisé et public, montrent clairement que la Suisse a une longueur d’avance sur ces pays. Soignons donc plutôt nos acquis, qui sont incontestables, et réglons les problèmes actuels en nous appuyant sur nos points forts et en lançant les réformes nécessaires. Au lieu de nous rapprocher du modèle anglais, à savoir d’un système étatique, avec l’introduction d’une caisse unique, nous devons encore améliorer la compensation des risques. La concurrence réglementée que nous avons en Suisse, qui permet à la population de profiter d’une offre en soins médicaux de grande qualité, surpasse aussi bien l’approche libérale américaine que le modèle de planification britannique. En outre, la comparaison montre que ces systèmes ne sont pas plus avantageux que le nôtre. En ce qui concerne la discussion actuelle portant sur le modèle des soins gérés, il faut éviter qu’une surrégulation nuise au potentiel d’économies. Les fournisseurs de prestations et les assureursmaladie ont besoin d’une certaine marge de manœuvre, afin que les soins gérés puissent contribuer à l’augmentation de la valeur ajoutée. Il serait de loin préférable d’introduire enfin la liberté de contracter. L’exemple des Pays-Bas montre que les craintes sont injustifiées aussi bien du côté des médecins que des patientes et des patients. Evitons donc les erreurs de nos voisins et inspirons-nous plutôt des modèles qui ont fait leurs preuves.

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Peter Fischer Membre du Conseil d’administration de santésuisse

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1368 Un triangle pour décrire les systèmes de santé

Critères de définition des systèmes de santé Les systèmes de santé sont des constructions complexes et polymorphes. Quelles sont alors les questions essentielles et les critères pour définir un système de santé de qualité ?

Pour décrire les systèmes de santé, le Professeur Reinhard Busse1 utilise l’image d’un triangle (voir schéma). A sa base figurent les deux principaux acteurs : la population et les fournisseurs de prestations. A son sommet sont représentés les « tiers payants », soit les encaisseurs de primes et les agents payeurs (assureurs-maladie, Etat) qui assurent une grande partie du financement. En son centre, sont rassemblés les régulateurs du système (Etat, cantons). Le professeur Busse recourt à ce même triangle pour classifier les questions essentielles et les critères de définition des systèmes de santé. A la base du triangle : les questions de protection et d’approvisionnement

A la base du triangle se trouvent ainsi les questions relatives à la protection de l’assurance. Qui est assuré ? Existe-il comme en Suisse une obligation d’assurance maladie pour tous les résidents ? La population a-t-elle une couverture universelle ou partielle ? Qu’est-ce qui est assuré ? Existe-il un catalogue des prestations (Suisse, Pays-Bas) ? La population a-t-elle facilement accès aux soins ? L’approvisionnement sanitaire est-il satisfaisant et également réparti sur le territoire ? Existe-il des listes d’attente (Grande-Bretagne) ? La population a-t-elle directement accès aux spécialistes (Suisse) ou existe-il des gatekeepers (France, Pays-Bas) ?

cières. Les soins sont-ils financés par des primes (Suisse) ou par les impôts (Grande-Bretagne) ? Sont-ils prélevés sur le salaire (France) ? Sont-ce des primes par tête (Suisse) ou une contribution proportionnelle aux revenus (France) ? Estce un système solidaire reposant sur un fonds commun national alimenté par l’ensemble de la population (GrandeBretagne) ? Ou est-ce un système comptant sur la responsabilité individuelle, comme à Singapour où chaque citoyen dispose de son propre compte d’épargne-santé qu’il utilisera pour financer les soins nécessaires. Au sommet du triangle : la mise en commun des ressources et leur réallocation

La question de la (ré-)allocation aux agents payeurs, donc de la compensation des risques, est aussi primordiale. La compensation des risques a lieu entre les assureurs en concurrence (Suisse). Mais elle a aussi cours dans les systèmes qui ne sont pas axés sur la compétitivité pour savoir comment le fonds national doit être réparti entre les régions. Le montant adéquat doit-il être fixé antérieurement (Pays-Bas) ou postérieurement (Suisse) ? Outre les variables démographiques générales (âge, sexe), doit-on l’affiner et prendre en compte des indicateurs de morbidité (Pays-Bas) ou d’hospitalisation (Suisse) ? La troisième arête du triangle : les achats de prestations

Les agents payeurs achètent des prestations et les rétribuent. Existent-ils des conventions tarifaires ? Les contrats sont-ils sélectifs (Pays-Bas) ou obligatoires (Suisse) ? Les achats sontils soumis à la concurrence ou sont-ils planifiés par l’Etat ? Le système doit-il être structuré par l’Etat (France) ou doit-il La deuxième arête du triangle : la mobilisation et la obéir à la concurrence régulée (Pays-Bas), où l’Etat n’interprovenance des ressources vient que pour garantir la qualité et un approvisionnement S’y ajoutent des questions touchant à la mobilisation, à la sanitaire suffisant ? En Suisse, la question fait débat. provenance, à l’ampleur et à la nature des ressources finan- La qualité des soins et les coûts sont aussi fondamentaux : fournir des soins de qualité à tous au meilleur coût dans un système durablement viable étant un but commun. MISE EN COMMUN DES RESSOURCES ET (RE-)ALLOCATION maud hilaire schenker ENCAISSEURS DE PRIMES

MOBILISATION / PROVENANCE DES RESSOURCES

AGENTS PAYEURS («TIERS PAYANTS»)

«STEWARD» REGULATEUR

ACHATS DE PRESTATIONS / CONTRATS / RETRIBUTION

FOURNISSEUR DE PRESTATIONS

POPULATION ASSURANCE QUI? QUOI? (CATALOGUE D'APPROVISIONNEMENT EN PRESTATIONS)?

ACCES ET APPROVISIONNEMENT

SOURCE: BUSSE / LA VIE ECONOMIQUE

REGULATION

Selon le Professeur Reinhard Busse, tout système de santé peut se schématiser par un triangle.

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1 Reinhard Busse, « Les Systèmes de santé en Europe : données fondamentales et comparaison », publié dans La Vie économique, Revue de politique économique 12-2006, pp10-13

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1369 Photo: Keystone

Les modèles de Bismarck et de Beveridge

En Europe, deux types de systèmes de santé prédominent L’Europe connaît essentiellement deux types de systèmes de santé : le modèle bismarckien et le modèle beveridgien. Système reposant sur le travail et système financé par les impôts se font face, même si les frontières tendent à s’estomper.

Le modèle de Beveridge, financé principalement par l’impôt, a été adopté par les pays nordiques, l’Irlande et le RoyaumeUni. Mais depuis les années 80, il est aussi présent en Espagne, au Portugal et en Grèce. Le système de Bismarck repose sur l’assurance-maladie obligatoire. Il est répandu dans la quasi-totalité des pays d’Europe centrale et, depuis une dizaine d’années, en Europe orientale.

Essentiellement deux types de système de santé se font face en Europe : les modèles de Bismarck et de Beveridge.

Le modèle bismarckien

Les assurances sociales sont nées en Allemagne à la fin du 19e siècle, à l’époque du Chancelier Bismarck. Sa politique, guidée par un double souci de lutte contre les syndicats et contre la montée du parti socialiste, s’est traduite par la dissolution de ces organisations. En contrepartie, l’Etat a pris la responsabilité d’institutionnaliser la protection sociale, dispensée auparavant par de nombreuses « caisses de secours ». Les assurances sociales obligatoires sont apparues dans ce pays à partir de 1883. Quatre principes fondamentaux définissent le système bismarckien : • une protection exclusivement fondée sur le travail et, de ce fait, limitée à ceux qui ont su s’ouvrir des droits à protection par leur travail ; • une protection obligatoire pour les seuls salariés dont le salaire est inférieur à un certain montant, donc pour ceux qui ne peuvent recourir à la prévoyance individuelle ; • une protection fondée sur la technique de l’assurance, qui instaure une proportionnalité des cotisations par rapport aux salaires, et une proportionnalité des prestations aux cotisations ; • une protection gérée par les employeurs et les salariés eux-mêmes. L’assurance se distingue donc nettement de l’assistance sociale : la protection sociale est en effet accordée en contrepartie d’une activité professionnelle. Pour sa part, l’Etat a pour tâche d’assurer le bien-être des citoyens. Il doit fixer le cadre de l’action des caisses et redresser la situation en cas de déséquilibre financier. Depuis les années 70, la majorité des pays, inspirés par ce modèle (France, Luxembourg, Pays-Bas, Autriche), ont pris des mesures pour rendre l’accès aux soins plus universel.

ladie obligatoire, le considérant comme « trop limité avec le système du plafond d’affiliation, trop complexe avec la multitude des caisses et mal coordonné ». Aussi propose-t-il une réforme fondée sur la socialisation des coûts à l’échelle nationale. Les principes suivants définissent le système : • l’universalité : tout citoyen est protégé contre tous les risques sociaux quelle que soit sa situation professionnelle ; • l’uniformité des prestations en espèces : chaque individu bénéficie des services selon ses besoins, indépendamment de ses revenus ; • le financement par l’impôt ; • l’unicité : avec la gestion étatique de l’ensemble de la protection sociale. Evolution de ces modèles

Il n’est toutefois pas toujours aisé de différencier empiriquement un système financé par l’impôt d’un système bismarckien. Ainsi, en Belgique et en Suisse, le financement par l’impôt constitue une partie non négligeable, mais l’existence des caisses-maladie les placent plutôt dans la catégorie bismarckienne. Actuellement, les différences entre les pays d’inspiration bismarckienne ou beveridgienne ont tendance à s’atténuer. Ils sont en effet tous soumis aux mêmes contraintes sociales (garantir l’accès aux soins à tous), organisationnelles (améliorer l’efficience du système en place) et économiques (limiter l’inflation des dépenses de santé). maud hilaire schenker

Le modèle beveridgien

Le Royaume-Uni constitue le berceau du second modèle, dont les principes furent énoncés en 1942 par Lord Beveridge. Celui-ci critique alors le régime britannique d’assurance ma-

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infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1370 Systèmes de santé nationaux fiscalisés et systèmes d’assurance maladie obligatoire

Deux systèmes, une même orientation : la concurrence régulée Les systèmes de santé bismarckiens et beveridgiens se distinguent notamment par leurs sources de financement. Le premier est essentiellement financé par les cotisations sociales et les impôts, le second est majoritairement fiscalisé. En dépit de cette différence, les réformes récentes convergent toutes vers plus de concurrence.

Dans les systèmes bismarckiens et beveridgiens, la part publique est la principale source de financement. En moyenne, dans tous les pays de l’OCDE, excepté au Mexique et aux Etats-Unis, la part du secteur public dans les dépenses de santé était de 73 %, en 2007. Dans les pays nordiques (à l’exception de la Finlande), au Royaume-Uni et en Irlande, pays beveridgiens, le financement public atteignait même plus de 80 % du total des dépenses de santé. Mais qu’entend-on par financement public ? Le financement public peut se limiter aux recettes publiques dans les pays où le gouvernement central et / ou les administrations locales (Espagne, Norvège) sont responsables du financement. Mais il peut aussi regrouper les recettes publiques générales et les cotisations sociales dans les pays où le financement repose sur un système d’assurance sociale (France, Allemagne). Le financement privé, lui, englobe les paiements à la charge des ménages, l’assurance maladie privée, les services de santé directement financés par l’employeur (médecine du travail) etc. L’ampleur et la composition du financement privé diffèrent considérablement d’un pays à l’autre, indépendamment de leur modèle de référence.1 La nature du financement façonne toutefois la structure même du système de santé. Les systèmes nationaux de santé

Le modèle beveridgien repose sur le principe de la gratuité des soins pour garantir une couverture universelle. De cette protection universelle découle un financement assuré par l’impôt et une forte prédominance du secteur public, souvent nationalisé. Les hôpitaux appartiennent aux collectivités publiques et les médecins hospitaliers ont un statut de salariés. Quant aux médecins généralistes, ils sont soit sous contrat avec le National Health Service britannique, soit employés directement par les centres de santé locaux comme en Suède et en Finlande. Le financement public implique une régulation étatique du système de santé. Si, dans ces pays, la définition a priori du budget de santé a permis de limiter les dépenses publiques, elle a pour corollaire le ra-

tionnement quantitatif des soins. Le manque d’investissement et la lourdeur de l’organisation du système entraînent donc de longues listes d’attente. Pour pallier ces difficultés, les réformes des années 1990 ont introduit des mécanismes de marché : mise en concurrence entre les acteurs de santé, recours à des modes de rémunération plus incitatifs des médecins ou responsabilisation des gestionnaires de santé. Le Cas de la Suède

En Suède, la responsabilité des prestations incombe aux vingt conseils généraux et, dans certains cas, aux communes. Aussi existe-il une inégalité régionale dans l’accès aux soins et de longues listes d’attente dans les hôpitaux. Les dépenses de santé représentent quelque 9 % du PIB, un pourcentage resté assez stable depuis le début des années 1980. Les prestations fournies par les conseils généraux, y compris les subventions aux médicaments, représentaient en 2005 un coût de 175 milliards de couronnes suédoises, SEK (25,7 milliards de CHF). Les dépenses de santé sont financées à 71 % par les impôts locaux, les conseils généraux ayant droit de prélever un impôt sur le revenu dont le taux moyen est de 11 %. Les dotations de l’État sont une autre source de financement qui couvre 16 % des dépenses, alors que la part versée par les patients ne constitue que 3 % des recettes. Les 10 % restants proviennent d’autres contributions. Les patients hospitalisés versent un forfait journalier de 80 SEK (11,7 CHF). Pour les soins non hospitaliers, chaque conseil général fixe les redevances à verser par les patients. Dans le secteur des soins primaires, le prix d’une consultation médicale peut aller de 100 à 150 SEK (14,7 à 22 CHF). Chez un spécialiste, le tarif est plus élevé. Les frais médicaux des patients sont plafonnés à 900 SEK (environ 132 CHF) pour une période de douze mois à compter de la première consultation et à 1800 SEK (264 CHF) pour les médicaments délivrés sur ordonnance.

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Photo: Keystone

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1371

Les différents systèmes de santé mettent tous le cap vers un même objectif : la concurrence régulée.

Les systèmes d’assurance maladie obligatoire

Le trait essentiel du système bismarckien réside dans le caractère obligatoire et national de ces assurances et de leur gestion par les partenaires sociaux. Les frais de soins sont généralement pris en charge par les caisses d’assurancemaladie dont la gestion est tantôt centralisée (France), tantôt régionalisée (Allemagne). L’offre de soins est en général mixte, à la fois publique et privée. Ce modèle peine à maîtriser les dépenses de santé, entraînant le déficit persistant des caisses d’assurance maladie. L’augmentation des cotisations et de la contribution des malades aux frais des soins ne suffit plus à enrayer les dérives des dépenses de santé. La régulation de l’offre des soins, l’introduction des méthodes de gestion privée et la liberté de contracter constituent le cœur des réformes dans ces pays. Le cas de l’Allemagne

En Allemagne, environ 85 % de la population est couverte par l’assurance obligatoire. Les personnes ayant un revenu supérieur à une certaine limite peuvent s’assurer de manière privée. Les quelque 170 caisses-maladie regroupées en sept associations pouvaient encore jouir d’une certaine autonomie jusqu’en 2009. Mais elles ont ensuite considérablement perdu de leur indépendance financière avec la création d’un Fonds de santé commun. En revanche, elles ont conservé leur autonomie en termes de négociations contractuelles avec les fournisseurs de prestations. Aujourd’hui, les caisses sont financées par les allocations du Fonds national, principalement alimenté par les cotisations des employeurs et des salariés. Le taux de cotisation représente au niveau national 14,3 % du salaire (14,9 % avec les indemnités journalières). Il est prélevé jusqu’à une certaine limite de revenu (2010 : 45 000 euros). Les retraités paient la moitié du taux de cotisation prélevée sur leur rente. Les caisses peuvent en outre

prélever chez leurs membres une cotisation supplémentaire se chiffrant à 1 % maximum des revenus assujettis aux cotisations. L’Etat apporte une contribution supplémentaire au financement via les impôts. Pour finir, les patients doivent participer aux coûts pour toujours plus de prestations. En Allemagne, les dépenses totales de santé représentaient, en 2007, 10,4 % du PIB, soit 1,5 % au-dessus de la moyenne des pays de l’OCDE. Face à l’augmentation rapide des coûts, il n’est pas étonnant que le nouveau gouvernement fédéral prépare une nouvelle réforme de la santé. Les discussions portent sur un sytème, qui serait financé pour un tiers par les entreprises, un tiers par les impôts et un tiers par les cotisations des citoyens. En outre, la concurrence doit être relancée. La réforme des systèmes financés par l’impôt

Ces dernières années, les systèmes financés par la fiscalité (modèle Beveridge) se sont nettement diversifiés. Parmi eux, il y a encore 15 ans, le citoyen n’avait affaire qu’à une seule et même organisation, l’État, à laquelle il payait ses impôts et qui, en retour, lui assurait un accès – souvent limité – aux prestations de santé. La première réforme importante introduite dans les pays de type Beveridge a été celle de la séparation entre acheteur et fournisseur. Tout demeurait certes aux mains de l’État, mais l’organisation se scindait désormais en deux moitiés, l’une achetant les prestations, l’autre les fournissant. Certains éléments de cette seconde moitié – hôpitaux, services de secours, etc. – sont devenus autonomes ; tout en restant aux mains de l’État, ils sont financièrement indépendants et gérés comme tels. La deuxième réforme, liée à la première, a été d’accorder à la population une plus grande liberté dans le choix du fournisseur de prestations. La troisième réforme a été de décentraliser. Grâce à une quatrième réforme, il est, enfin, possible de conclure des contrats avec des prestataires privés ou libéraux d’utilité publique et pas seulement étatiques.2 Il semblerait donc que les deux systèmes beveridgiens et bismarckiens s’orientent vers la concurrence. La question de l’étatisation se poserait alors seulement en Suisse, pourtant sur la bonne voie avec son système concurrentiel, qui pourrait certes encore être amélioré. maud hilaire schenker

1 2

OCDE, Panorama de la Santé 2009, Paris, 2009, p170 Pr Reinhard BUSSE, « Les systèmes de santé en Europe : données fondamentales et comparaison », dans La Vie économique Revue de politique économique 12–2006, pp 10–13

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infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1372 Décentralisation : un éclairage international

Les systèmes de santé s’orientent vers la décentralisation La décentralisation était – avec la concurrence – une idée-phare des réformes de santé menées dans les années 90. Certains pays délèguent la gestion du système et son financement à des collectivités locales. D’autres délèguent des responsabilités à des acteurs locaux (institutions, groupes de professionnels). Comment se répartissent les compétences ? Quel est l’impact de la décentralisation sur les systèmes de santé ?

En sciences sociales, la décentralisation renvoie à l’idée d’un accroissement des responsabilités et de l’autonomie d’acteurs périphériques par rapport au niveau central. Il existe quatre formes de décentralisation1 : • La déconcentration recouvre la notion de transfert de responsabilités à des niveaux territoriaux plus bas au sein des gouvernements centraux et des agences centrales. • La délégation transfère des responsabilités de gestion étendues, dans un domaine et pour des fonctions spécifiques, à des organisations (souvent qualifiées de « paraétatiques ») qui agissent en marge de la structure administrative centrale. • La dévolution consiste à confier des pouvoirs à des gouvernements territoriaux autonomes. • La privatisation est un transfert de responsabilités à des organisations privées, lucratives ou non, à qui sont déléguées certaines fonctions antérieurement assumées par les gouvernements. Aussi la décentralisation revêt-elle diverses formes selon les pays. Une dévolution très poussée : les pays Scandinaves

Les systèmes de santé scandinaves sont des services nationaux, présidés par les principes d’universalité et de gratuité des soins. L’offre de soins y est presque exclusivement publique, mais le financement et la gestion du système de santé sont décentralisés au niveau des régions, voire des municipalités, en Finlande notamment. Ainsi, au Danemark, les cinq régions possèdent et gèrent les hôpitaux et les centres de soins primaires et rémunèrent les professionnels de santé qui sont salariés ou sous contrat. Les 160 municipalités élargies s’occupent de la prévention et de la promotion de la santé, mais aussi des soins de longue durée et des services d’aide à domicile pour les personnes âgées, les handicapés et les malades mentaux. Le rôle de l’Etat y est limité. Il définit les cadres et les grandes orientations, redistribue ses dotations entre les régions et alloue des enveloppes fléchées, c’est-àdire des fonds utilisés pour des objectifs précis.

Le « fédéralisme asymétrique » espagnol

En Espagne, le processus de décentralisation a été progressif. L’Espagne est passée dès 1978 d’un système d’assurances sociales assez centralisé dans sa gestion à un système national de santé géré par des communautés autonomes. De 1981 à 1994, sept communautés autonomes ont obtenu l’une après l’autre la responsabilité de la gestion des services de santé, la première étant la Catalogne. Dans les dix autres régions, les services de santé étaient gérés de manière centralisée par une structure nationale, l’INSALUD. Depuis 2002, le processus de dévolution est étendu à toutes les régions espagnoles. Mais la décentralisation vers les sept communautés ne s’est pas accompagnée d’une décentralisation du financement. Jusqu’en 2002, l’essentiel des dépenses publiques de santé était couvert par des dotations allouées aux régions à partir d’un budget national. L’Espagne a alors rencontré trois difficultés : trouver un consensus sur les règles de péréquation financière, coordonner les régions et découpler la responsabilité de la gestion du système et la responsabilité du financement. Les modèles de décentralisation vers les producteurs de soins ou des acteurs collectifs : la Grande Bretagne et l’Allemagne

Au début des années 90, la politique de Thatcher a augmenté la responsabilisation et les marges d’autonomie et de négociation des acteurs locaux (autorités sanitaires, généralistes et hôpitaux). La réforme de 1997 confère aussi une autonomie professionnelle et économique à des réseaux de professionnels locaux, les « groupes de soins primaires (primary care trusts). Ces réseaux regroupent des généralistes et des équipes de soins primaires intervenant sur une zone géographique définie, couvrant environ 150 000 personnes. Leur responsabilité inclut les soins, la gestion des ressources financières et la gestion de la qualité. Ils se voient attribuer un budget global couvrant leurs prescriptions de médicaments, de consultations de spécialistes et d’hospitalisations non urgentes, pour lesquelles ils deviennent des « acheteurs de soins ». En Allemagne, la décentralisation prend encore un autre visage. Elle passe par une négociation locale et collective décentralisée des soins ambulatoires entre les associations de caisse-maladie et les associations de médecins. Quels sont les avantages et les inconvénients de la décentralisation ?

Les processus de décentralisation sont souvent présentés comme des facteurs visant à améliorer l’efficience et la réactivité du système, à rapprocher les décisions des populations et à favoriser l’implication et la participation des citoyens. Ils garantiraient aussi une meilleure efficience dans l’allocation des ressources, mieux adaptée aux préférences et aux besoins locaux. La capacité de se comparer avec les autres régions inciterait à l’émulation et accroîtrait donc l’efficience et la capacité d’innovation. Sous un autre éclairage, les mêmes arguments peuvent être perçus comme des incon-

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infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1373

vénients. La diversité peut être vue comme un signe positif de l’adaptation aux besoins locaux ou comme un élément négatif, favorisant l’iniquité. De même, la compétition entre les territoires peut être considérée comme stimulant l’efficience ou comme porteuse de surenchères électorales génératrices de déficits publics. Les désavantages se résument donc à l’iniquité des prestations, l’absence de maîtrise des coûts, l’influence des groupes d’intérêts, l’absence d’information et d’évaluation et le blocage potentiel des réformes. Impact de la décentralisation

Peu de travaux scientifiques sont cependant disponibles pour évaluer l’impact de la décentralisation sur les systèmes de santé. La maîtrise des coûts semble plus tenir des caractéristiques organisationnelles d’un système qu’à son degré de décentralisation. Si certains pays comme le Royaume-Uni ou les pays nordiques ont réussi à contenir leurs dépenses de santé, d’autres comme l’Espagne ont connu plus de difficultés. De même, il est difficile de juger de l’efficience de la décentralisation. La plupart des systèmes nationaux ont choisi dans les années 90, à l’échelle nationale, des orientations concurrentielles et managériales, qu’ils soient centralisés comme le Royaume-Uni ou décentralisés comme les pays scandinaves ou l’Espagne. En termes d’équité du financement, la décentralisation se solde toujours par des variations territoriales : ainsi, au Danemark, le taux d’imposition varie de 29 % à 34 %, ce qui entraîne des problèmes de péréquation financière. On observe aussi des inégalités au niveau de la répartition des soins spécialisés sur le territoire dans les pays scandinaves par exemple (au Danemark, les consultations de spécialistes varient dans une proportion de 1 à 2,2 ). Mais ces mêmes disparités se retrouvent en France, pays centralisé par excellence. Les différences des dépenses de médecins spécialistes entre les départements varient de 1 à 2,3. Si les pays décentralisés sont inégalitaires dans leur distribution de l’offre, la centralisation n’empêche pas les fortes disparités géographiques de l’offre. La question de la décentralisation laisse toutefois en suspens de nombreux problèmes : le type de régulation de l’offre (planifiée ou contractuelle), les modes de rémunération des professionnels et des structures de soins ainsi que les instruments de répartition de l’offre et de péréquation financière2. maud hilaire schenker

Rondinelli D. A., Nellis J. R., Cheema S. (1983), Decentralization in developing countries : a review of recent experiences, World Bank Staff working paper, n° 581, World Bank. 2 Polton Dominique, « Décentralisation des systèmes de santé : un éclairage international », dans RFAS, no4-2004, pp267-299 1

Un système de santé, des organisations locales : avec la décentralisation, les systèmes de santé prennent des allures de mosaïques colorées.

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infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1374 Quels sont les « meilleurs » systèmes de santé ?

Une bonne place pour la Suisse Quels sont les « meilleurs » systèmes de santé ? Pourquoi ? Nombre de décideurs politiques souhaiteraient connaître la clef du succès. Les comparatifs de l’OCDE1, de l’OMS2 ou de l’Euro Health Consumer Index (EHCI)3 tentent de donner des éléments de réponse.

En quoi les bons systèmes de santé se distinguent-ils ? Pour y répondre, il faut d’abord analyser les objectifs et les critères qui caractérisent un bon système de santé. Les buts les plus souvent cités au plan international sont la qualité, l’accès, l’égalité de traitement, la limitation des coûts et un rapport coûts/efficacité optimum. Divers classements, divers objectifs

Il est cependant difficile d’établir des classements internationaux, tant les méthodes de collecte des données divergent selon les pays. Aussi l’OMS a-t-elle rapidement abandonné le projet. L’OCDE en revanche se livre régulièrement à l’exercice et relève les objectifs suivants : la santé, l’accès aux technologies médicales et à des fournitures de soins adaptés aux besoins, la sensibilité aux attentes de la population et des patients, l’équité et la durabilité du financement. L’EHCI, lui, est établi en fonction de la satisfaction des patients issus de trente-trois pays. Parmi les critères retenus figurent : les droits et l’information des patients, l’e-health, les délais d’attente pour des traitements, les résultats, l’étendue et la portée des services fournis et les produits pharmaceutiques.

Top 10 Euro Health Consumer Index 2009 Rang 1

PAYS pays-bas

EVOLUTION -

danemark

IslandE

AUTRICHE

-1

SUISSE

ALLEMAGNE

1ère participation

FRANCE

SUEDE

-3

LuxembOurg

-5

NORVEGE

-2

SOURCE : health consumer powerhouse ab, 2009

Aux Pays-Bas, les assurés peuvent choisir librement parmi les différents assureurs-maladie en concurrence.

Les meilleurs systèmes de santé allient concurrence et efficacité

Les pays qui ont privatisé ou favorisé la concurrence sont aussi ceux qui présentent l’indice le plus élevé de satisfaction des patients. Premiers dans le classement de l’EHCI, les Pays-Bas ont un système qui permet de choisir librement parmi les assureurs concurrents. Ils ont aussi mis en place une organisation particulière dans laquelle les patients sont associés aux décisions concernant le système de santé. Les politiques et les fonctionnaires sont exclus des équipes décisionnaires, et les réformes sont faites uniquement par les professionnels de la santé après consultation des principaux intéressés, les patients. Deuxième du classement, le Danemark a adopté un système de libre choix pour les individus pour se faire soigner ainsi qu’une publication en ligne des hôpitaux qui prodiguent les meilleurs soins. La concurrence est donc une règle mise au service des patients. En Suisse : un bon système et des patients satisfaits

La Suisse figure parmi les trois pays ayant les dépenses de santé totales (publiques et privées) par habitant les plus élevées avec 4417 dollars, derrière les USA (7290 dollars) et la Norvège (4763 dollars).5 Aux Pay-Bas, elles s’élèvent à 3837 dollars et au Danemark à 3362 dollars, ce qui les situe aussi au-dessus de la moyenne de l’OCDE (2894 dollars)4. En revanche, la Suisse caracole en tête en ce qui concerne la santé de la population et la qualité des soins. Avec une espérance de vie à la naissance de 81,9 ans, elle se positionne ainsi à la deuxième place, derrière le Japon6. Les calculs portant sur les causes de mortalité évitables sont certes plus significatifs, mais là aussi, la Suisse cumule de bons résultats, notamment au niveau des maladies respiratoires, des insuffisances cardiaques et de l’hypertension. Dans l’EHCI 2009, la Suisse occupe la cinquième marche. Ses points forts sont les délais d’attente, l’accès aux médicaments et les résultats des traitements. Ses faiblesses sont les statistiques et l’information des patients. Si la Suisse doit encore améliorer certains éléments, dans l’ensemble, son système est très bon. maud hilaire schenker

Organisation de coopération et de développement économiques Organisation Mondiale de la Santé 3 L’Indice européen des consommateurs de soins de santé est élaboré à partir de statistiques publiques, d’enquêtes et de recherches produites par la compagnie d’analyse et d’information Health Consumer Powerhouse de Bruxelles. 4 OCDE, Panorama de la Santé 2009. Chiffres de 2007 5 OCDE, Panorama de la Santé 2009. Chiffres de 2007 6 OCDE, Panorama de la Santé 2009. Chiffres de 2007 1 2

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infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1375 Trois questions à Willy Oggier, expert en économie de la santé

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« La caisse unique serait un pas dans la mauvaise direction »

Willy Oggier : « Le risque est grand qu’avec une caisse unique les personnes ayant le plus besoin de prestations soient finalement celles qui en sont privées. »

Selon l’économiste de la santé Willy Oggier, trois éléments sont nécessaires pour obtenir en comparaison internationale un bon modèle en matière de système de santé : une meilleure compensation des risques entre assureurs, un financement hospitalier moniste et un choix plus vaste grâce à une plus grande liberté de contracter. La caisse unique, à l’heure actuelle, résolument prônée par divers milieux politiques, ne résout en revanche aucun problème et porte un coup fatal au modèle de la concurrence régulée.

Du point de vue économique, quel est le meilleur système de santé en Europe et pourquoi ?

Il est impossible de répondre clairement à cette question tant que les critères du concept « meilleur système de santé » n’auront pas été préalablement définis. Dans une optique focalisée sur les coûts par exemple, les systèmes étatiques s’en sortent généralement mieux. Mais dans le domaine de la santé, la maîtrise des coûts ne peut en aucun cas être le seul critère déterminant. D’autres sont tout aussi importants comme la prise en compte appropriée des besoins, l’accès au système des personnes socialement faibles, âgées et des patients occasionnant des coûts élevés ou encore l’efficacité d’un système à s’adapter aux nouvelles pathologies par exemple. Les modèles étatiques connaissant souvent une forme pure et dure de rationnement obtiennent en l’occurrence de mauvais résultats dans ces domaines.

Qu’est-ce que la Suisse pourrait apprendre de cette comparaison ? Quelles idées pourrait-elle reprendre à son compte ?

Au niveau international, les systèmes s’orientent assez clairement vers un modèle de concurrence régulée. Il peut se résumer ainsi : « Autant d’Etat que nécessaire, autant de concurrence que possible. » Pour que ce modèle devienne la règle, les éléments suivants sont fondamentaux. Tout d’abord, la compensation des risques entre assureurs-maladie doit tenir compte de l’état de santé des assurés (morbidité). Ainsi, l’intérêt des caisses à disposer de bons modèles de prise en charge s’accroît et les assureurs sont moins enclins à pratiquer la chasse aux bons risques. Ensuite, le financement des hôpitaux doit être moniste (de source unique) afin d’éliminer les distorsions financières entre les secteurs stationnaires et ambulatoires et de mieux exploiter les possibilités de substitution, l’un des organismes payeurs n’étant plus avantagé au détriment de l’autre. Enfin, les assurés doivent bénéficier d’un choix plus vaste grâce aux possibilités plus nombreuses offertes par la liberté de contracter. En d’autres termes, ils doivent avoir le libre choix de l’assureur. Quant aux assureurs-maladie et aux fournisseurs de prestations, ils doivent être en mesure de proposer d’autres formes novatrices d’assurance-maladie en plus du modèle ordinaire. Concernant le premier et le troisième élément notamment, on constate une évolution positive aussi bien en Allemagne qu’aux Pays-Bas. Sur la base de cette comparaison européenne des systèmes, que faut-il penser de la « solution miracle » de la caisse unique prônée ces derniers temps en Suisse par certains milieux ?

Les éléments essentiels d’une concurrence régulée énumérés ci-dessus permettent d’affirmer sans ambiguïté que la caisse unique représente un pas dans la mauvaise direction. Elle ne change rien aux incitations financières néfastes que nous déplorons aujourd’hui. Dans un système de monopole, les assurés n’ont plus le droit de changer de caisse en cas d’insatisfaction. Il en va de même pour les personnes malades. Le risque est donc grand qu’avec une caisse unique – comme dans les systèmes purement étatiques – les personnes ayant le plus besoin de prestations soient finalement celles qui en sont privées. En fait, elles sont pieds et poings liés à la caisse unique et n’ont en règle générale pas les moyens d’acheter ces prestations sur le marché libre et de les financer à titre privé. Il n’est donc pas étonnant que dans d’autres Etats, les experts du domaine de la santé membres des partis situés à gauche de l’échiquier politique se prononcent clairement contre une caisse unique. C’est le cas notamment du professeur allemand Karl W. Lauterbach, expert en épidémiologie, économiste de la santé et député social-démocrate au Bundestag. Interview : Gregor Patorski

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Les systèmes de santé européens connaissent de profondes réformes depuis plusieurs années. A terme, assistera-t-on à une harmonisation des politiques de santé ?

Convergences des réformes des systèmes de santé européens

Vers une harmonisation européenne ? Les systèmes d’assurance maladie ne représentent plus une frontière invisible entre les Etats membres. Tous doivent en outre relever les mêmes défis au regard des nécessités de financement et d’élévation de la qualité des soins. Aussi mènent-ils des réformes analogues.

Le système d’assurance maladie est profondément ancré dans les traditions nationales. Il existe ainsi une pluralité de modèles d’assurance-maladie à travers l’Union européenne. Le modèle beveridgien s’oppose au modèle bismarckien et le modèle socialiste a profondément marqué, après-guerre, les nouveaux Etats membres. Chaque modèle a ses failles : soit la maîtrise des coûts est assurée au détriment de la qualité des soins, soit à l’inverse la qualité des soins s’impose au détriment de l’équilibre budgétaire. Néanmoins, tous les pays se heurtent aux mêmes défis : vieillissement de la population, augmentation des coûts liés à une qualité des soins élevés et nécessité de maintenir les charges sociales ou la part des finances publiques à un niveau compatible avec une ouverture du marché domestique à la concurrence internationale. Tous sont confrontés à une croissance accélérée des dépenses de santé. C’est pourquoi, malgré les différences initiales, les réformes préconisent toutes l’ouverture à la concurrence, la pression sur le prix des médicaments et la responsabilisation des acteurs. L’Union européenne favorise un tel rapprochement. Des réformes convergentes

Trois types de réforme se déclinent sur l’ensemble du continent : le premier se concentre sur la limitation des prestations et la responsabilité individuelle, l’exemple type est l’Allemagne ; le deuxième se focalise sur la décentralisation et l’introduction de la concurrence comme c’est le cas en Grande-Bretagne et le troisième établit un nouveau système d’assurance comme en Pologne.

La réforme allemande La réforme allemande vise principalement la stabilisation des taux de cotisation en limitant les prestations et en élevant les versements supplémentaires. La réforme, entrée en vigueur le 1er janvier 2004, a réduit le champ des prestations prises en charge, comme les médicaments non soumis à l’obligation de prescription, les lunettes et les lentilles de contact et les frais de transport, etc. De plus, ont été créés un ticket modérateur de 10 euros par trimestre pour la consultation médicale ambulatoire, un ticket modérateur forfaitaire lors de l’achat de médicaments et une augmentation du forfait hospitalier (10 euros par jour). De nouvelles sources de financement ont été également prévues : l’industrie pharmaceutique verse une contribution de solidarité et les cotisations maladies des retraités augmentent. En outre, la concurrence est renforcée avec l’introduction du libre choix de la caisse. La réforme de 2007, elle, uniformise le taux de cotisation et (à partir du 1.1.2009) crée un Fonds de santé commun. Les caisses-maladie, jusqu’ici financièrement indépendantes, y puisent les ressources nécessaires. Dans la mesure où les recettes du Fonds ne suffisent pas, les caisses peuvent prélever une cotisation supplémentaire se chiffrant à 1% maximum du revenu assujetti à la cotisation. En revanche, les caisses bien gérées peuvent proposer des remboursements de primes. Aussi la réforme a-t-elle accordé une plus grande liberté aux partenaires contractuels pour établir les contrats. Elle a aussi introduit une évaluation coûts-bénéfice pour les médicaments. Actuellement, une nouvelle réforme est en discussion. Le nouveau gouvernement veut renforcer la concurrence. La transition graduelle vers une prime indépendante du revenu, prévue par le Ministre, est très controversée. La réforme britannique La réforme du système d’assurance maladie de 1991 a conduit à une décentralisation de la gestion et à une mise en concurrence des acteurs de santé. Elle a ainsi introduit des méca-

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infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1377

nismes de marché au sein du très bureaucratique NHS. Le but était de mieux réguler les dépenses de santé. Devenus des « NHS trusts » autonomes et responsables financièrement, les hôpitaux mis en concurrence, fournissent, quant à eux, des soins aux patients, couvrant ainsi leurs dépenses. Les travaillistes ont poursuivi cette réforme en créant des réseaux de soins, les groupements de soins primaires (Primary Care Trusts ou PCT), nouvel échelon régional du NHS. Ils associent des médecins généralistes, des infirmières, des représentants des services sociaux et des patients et desservent une population de 150 000 personnes. Au niveau budgétaire, le NHS, par l’intermédiaire des autorités sanitaires régionales, attribue une enveloppe financière, indexée sur la situation économique générale à chaque PCT pour négocier les contrats de soins avec les hôpitaux. Dans le cadre de la réforme des hôpitaux de 2003, les hôpitaux jugés performants ont obtenu le statut de « fondations hospitalières ». Ces hôpitaux, gérés soit par les autorités publiques, soit par des entreprises privées, peuvent investir, emprunter, gérer leur patrimoine et payer les salariés à leur guise. Un partenariat public-privé a aussi été créé entre le NHS et le secteur privé. Ainsi, les hôpitaux du NHS et les PCT peuvent signer avec les cliniques et les centres de soins privés des contrats pour réduire les délais d’attente des malades. Pour éviter que l’ouverture à la concurrence ne soit perçue comme une dégradation du service public de santé, 572 forums locaux ont été créés. Ces commissions locales indépendantes représentant les patients et les habitants sont investies de pouvoirs d’enquête et de visite. Une commission nationale indépendante soumet des recommandations au Ministre de la santé à partir des informations recueillies auprès des forums locaux. La réforme en Pologne La réforme en Pologne montre le développement des systèmes de santé en Europe de l’Est après l’effondrement du communisme. En 1999, le gouvernement a créé une assurance maladie obligatoire s’inspirant du modèle bismarckien. Les caisses maladies régionales y sont autonomes et financées via les cotisations des salariés (les cotisations patronales n’existent pas en Pologne). Le modèle montrant de grosses défaillances, une seconde réforme est mise en place en 2003. Le système de santé est à nouveau homogénéisé et le Fonds de santé national (NFZ) couvre les obligations des caisses-maladie. Il se divise en seize unités régionales, subordonnées à un centre. Le NFZ dépend lui-même du Ministère de la Santé, qui dispose de vastes compétences. Il décide notamment du budget et de l’offre de prestations du NFZ. Toutes les personnes actives en Pologne sont obligées de s’assurer (les familles sont aussi couvertes). Le taux de cotisation avoisine aujourd’hui les 9 %. S’y ajoutent les nombreux paiements supplémentaires versés par les patients pour de nombreuses prestations. Les patients peuvent choisir leur médecin de famille parmi un réseau de médecins conventionnés et en changer gratuitement deux fois par an. Le nombre

insuffisant de médecin de famille fait que des spécialistes font aussi office de médecin de premier recours. Aussi l’attente est-elle souvent longue chez les médecins conventionnés. Les services publics de santé jouent un rôle important dans le système de santé en Pologne (installations stationnaires, ambulances et crèches). Devant le manque d’argent du Fonds de santé national, les dettes s’accumulent dans ces services, qui ne peuvent pas toujours garantir des soins suffisants. Pour nombre de Polonais, le secteur privé est trop cher. Une troisième réforme serait donc urgente. Elle est annoncée depuis longtemps, mais elle n’est pas encore passée à l’offensive. La détermination d’une politique de santé européenne

Le Conseil européen de Lisbonne a posé un premier jalon vers la modernisation du modèle social européen, en précisant que les régimes de protection sociale doivent « fournir des services de santé de qualité ». La promotion d’une collaboration plus étroite entre les Etats membres en matière de modernisation des systèmes de protection sociale à travers l’UE a été lancée. Le but était de faire en sorte que les citoyens puissent se faire soigner dans d’autres Etats membres, s’ils le souhaitaient, et que la coopération européenne puisse aider les systèmes à fonctionner de concert. Le principe de libre circulation a donc été étendu aussi bien aux personnes (patients, professionnels) qu’aux produits de santé et aux soins. La décision de créer la carte européenne d’assurance maladie est le résultat de l’évolution de la jurisprudence dans ce domaine. La commission européenne œuvre aussi pour l’émergence d’une politique communautaire du médicament favorisant les génériques et les importations parallèles au sein de l’Union européenne. Vers l’harmonisation ?

La similarité des objectifs et des défis à relever conduit les Etats membres à mener des réformes analogues. Le Centre français d’analyse stratégique a indiqué la nécessité d’inscrire toute réforme nationale dans une dynamique européenne. Il a aussi souligné deux axes majeurs de réformes : le transfert des cotisations sociales vers la fiscalité directe et la responsabilisation des acteurs du système de santé. Toutefois, il est peu probable que l’harmonisation communautaire intervienne à moyenne échéance dans ce domaine, tant il est inhérent à la culture des Etats.1 maud hilaire schenker

* Philippe Garabiol, « L’assurance-maladie en Europe », dans Questions d’Europe n°37, Fondation Robert Schuman, 4 septembre 2006

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infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1378 Le système de soins chroniques : comment l’améliorer ?

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Les dix caractéristiques d’un système de soins chroniques performant

Les maladies chroniques sont la première cause de mortalité dans le monde. Les prendre en charge et les soigner dans un système de soins performant devient donc une priorité. Une étude britannique1 propose une série de mesures pour un système de soins des maladies chroniques de qualité.

Le « Chronic Care Model » (modèle des soins chroniques) vise à fournir des soins de haute qualité aux patients souffrants de maladies chroniques. Les éléments clés de ce modèle sont l’implication directe du patient dans son traitement, le système d’informations médicales, la sécurité du patient, la coordination des soins et le Case Management. Ce système est fondé sur l’Evidence-based medecine et est centré sur le patient. Son efficacité repose sur la combinaison de tous ces éléments, et non sur un élément particulier. L’OMS et le NHS (National Health Service) britannique ont notamment mis en place de tels modèles. Un fossé sépare les différents systèmes

En 2006, le Fond du Commonwealth a comparé les soins reçus par les patients atteints de maladie chronique dans six pays. Des différences flagrantes appa-

raissent notamment au niveau du suivi du traitement par les patients et du contrôle de la médication par le médecin. L’implication directe du patient dans son traitement n’est pas non plus systématique. Le rôle des infirmières varie aussi fortement : en Australie, 16 % des malades chroniques rapportent l’implication d’une infirmière dans le traitement contre 52 % en GrandeBretagne. La communication entre le patient et le médecin, la coordination des soins et l’accès aux soins dans un temps donné sont d’autres problèmes récurrents. Aussi les investissements devraient-ils davantage porter sur les soins primaires (que sur les hôpitaux de soins aigus), qui favorisent plus le Disease Management, et l’accent être posé sur la coordination des soins et le rôle des patients. Les dix caractéristiques d’un système de soins chroniques performants

Les dix caractéristiques d’un système de soins chroniques performants sont : 1 Garantir la couverture universelle 2 Eviter que la population n’ait à avancer le coût des soins (système du tiers payant par exemple) pour ne pas léser les populations les plus pauvres 3 Mettre l’accent sur la prévention et non pas seulement sur le traitement

4 Impliquer le patient assisté des soignants et de la famille 5 Donner la priorité aux soins primaires et favoriser la collaboration pluridisciplinaire 6 Stratifier la population souffrant de maladies chroniques en fonction de ses risques et lui offrir l’aide adaptée à ce risque 7 Mettre en place un système de soins gérés pour coordonner et faciliter l’accès aux soins spécialisés en cas de nécessité. 8 Améliorer les technologies de l’information (télémédecine etc.) pour soutenir la participation active du patient 9 Développer la coordination des soins 10 Allier les neufs caractéristiques précédentes dans un ensemble cohérent et stratégique Stratégies

Mettre en place ces dix caractéristiques suppose des actions à différents niveaux : • Impliquer les médecins pour jouer un rôle critique dans la réorientation des services de santé. • Mesurer l’impact et les résultats de ces programmes pour continuer de les améliorer. • Multiplier les incitations pour favoriser ces stratégies, soit en récompensant les bons résultats, soit en développant les soins primaires. • Engager la participation d’organisations comme les groupes de patients etc. Un premier pas semble être fait pour refondre les systèmes de santé à la faveur des soins des maladies chroniques. Toutefois, la route reste longue avant la mise en place d’un système hautement compétitif et de qualité homogène. maud hilaire schenker

Chris Ham, “The ten characteristics of the high-performing chronic care system”, publié dans Health Economics, Policy and Law (2010), Cambridge University Press 2009, pp71-90

14 | Domaine de la santé 3/10

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1379 Graphique du mois

Une réputation d’îlot de cherté à reconsidérer Le système de santé suisse est réputé pour être l’un des plus coûteux du monde. Pourtant, une analyse approfondie des chiffres de l’OCDE révèle un résultat étonnant : en comparaison internationale, la Suisse se situe dans la moyenne si l’on tient compte des dépenses de santé publiques, en excluant les coûts assumés à titre privé.

Le système de santé américain est de loin, avec 7290 dollars par tête et par an, le plus coûteux au monde. La Suisse suit en troisième position, avec 4417 dollars US. En mesurant les dépenses de santé par rapport au PIB, on obtient un cliché similaire : les Etats-Unis viennent en tête avec 16 % et la Suisse occupe le 3e rang avec 10,8 % (la moyenne des pays de l’OCDE étant de 2984 dollars américains ou 8,9 %). Part des dépenses publiques : pas plus coûteuse qu’ailleurs

En revanche, la situation est très différente si l’on ne tient compte que des dépenses publiques de santé (à savoir toutes les prestations payées par les assurances sociales) et que l’on comptabilise séparément les dépenses privées de santé. Sans ces coûts directement assumés à titre privé et facultatif (que ce soit les coûts « out of the pocket », les assurances complémentaires ou les autres coûts non couverts par

l’assurance de base), la Suisse se situe dans la moyenne des pays de l’OCDE. En fait, les dépenses publiques de santé représentent exactement 6,4 % du PIB, soit la moyenne des pays de l’OCDE. Les chiffres absolus le prouvent aussi. La Suisse, avec 2618 dollars américains par tête et par an, atteint un montant légèrement supérieur à la moyenne de 2193 dollars US affichée par les pays de l’OCDE. Le système de santé suisse est donc seulement plus cher, du fait que le citoyen moyen consent, à titre privé, à dépenser beaucoup d’argent pour sa santé. Bien que l’assurance de base couvre de nombreuses prestations, Monsieur et Madame tout le monde en veulent plus : ils paient de leur propre poche 40,7 % (1799 dollars US) de l’ensemble des coûts de santé. En Suisse, le système de santé public est bien moins coûteux qu’on ne le prétend communément. Gregor Patorski

DEPENSES DE SANTE TOTALES PAR HABITANT 2007 (PUBLIQUES ET PRIVEES) DEPENSES DE SANTE PUBLIQUES 7290

7000

DEPENSES DE SANTE PRIVEES

823 MEXIQUE

TURQUIE (2005)

POLOGNE

COREE

HONGRIE

PORTUGAL (2006)

NOUVELLE-ZELANDE

FINLANDE

AUSTRALIE (2006/07)

SUISSE

BELGIQUE

SUEDE

CANADA

ISLANDE

IRLANDE

ALLEMAGNE

FRANCE

AUTRICHE

DANEMARK

PAYS-BAS

ETATS-UNIS

NORVEGE

LUXEMBOURG (2006)

SOURCE: ECO-SANTE OCDE 2009

1000

618

1688 1035

1388

1626

1555

REPUBLIQUE TCHEQUE

2000

REPUBLIQUE SLOVAQUE

2727 GRECE

2150

2671 ESPAGNE

2686 ITALIE

2510

2581 JAPON (2006)

3137

2840

2984 OCDE

4417 2992

3000

ROYAUME-UNI

3595 2618

3895

3323

3588

3319

3424

3763

3601

4000

3512

3837

4162

5000

4763

6000

Si l’on ne tient compte que des dépenses publiques de santé, la Suisse se situe légèrement au-dessus de la moyenne des pays de l’OCDE.

15 | Domaine de la santé 3/10

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1380 Photo: Keystone

Pénurie croissante de personnel soignant

Mesures concrètes pour remédier à ce problème

L’étude de Barbara Brühwiler-Müller, parue dans les cahiers d’études de la SSPS sous le titre de « Laufbahnplanung für Pflegefachpersonen ab 40 » (planification de la carrière du personnel soignant à partir de 40 ans) date d’il y a trois ans déjà. Les constats restent malgré tout d’actualité. Elle y présente un certain nombre de mesures fort intéressantes qui permettraient aux collaborateurs plus âgés de travailler dans le secteur des soins jusqu’à l’âge de la retraite. Au regard de la pénurie de personnel soignant qui se profile, il est en effet primordial de résoudre le plus rapidement possible ce problème.

Le système de santé doit relever un double défi de taille : au niveau de la demande, les besoins qualitatifs et quantitatifs en prestations de traitements, de soins et de suivi augmentent ; au niveau de l’offre, la structure d’âge du personnel encore actif dans la profession se modifie et tend à vieillir. S’y ajoutent les conséquences du recul de la natalité, observé depuis plusieurs années, qui ne facilite pas le recrutement de la relève. Suggestions et propositions

L’auteur suggère de mener avec tous les collaborateurs du secteur des soins, âgés entre 40 et 45 ans, un entretien concernant leur avenir professionnel, qui servirait de base à la planification de leur carrière. L’idée est de proposer des horaires et des modèles individuels de travail par équipes alternantes à partir de 55 ans, ainsi que des tâches ou des rôles au sein d’une équipe correspondant à l’âge de la personne soignante. Les aînés doivent également rester actifs grâce à la formation continue et à un perpétuel perfectionnement. Dans le domaine de la santé et du bien-être, il s’agit de mieux faire connaître les offres disponibles au sein des entreprises et d’en créer d’autres, répondant de manière spécifique aux be-

soins de l’âge. Par ailleurs, l’aménagement individuel des postes de travail revêt une importance particulière. Il doit concilier à la fois les exigences de l’entreprise et les aptitudes et les besoins des forces de travail moins jeunes. Pour les soulager, la durée et la répartition du temps de travail devraient être optimisées autant que possible. L’abandon du principe de la progression du salaire avec l’âge constitue un autre paramètre, encore peu discuté. Pourquoi les personnes âgées de 58 ans devraient-elles gagner sensiblement plus que celles âgées de 35 ans ? Il ne faut pas oublier que de nos jours les employés de plus de 50 ans ne trouvent guère de travail. Une des raisons en est souvent des attentes exagérées en termes de salaires et de revenus. Aussi de nombreuses entreprises ont-elles corrigé le principe de la progression du salaire avec l’âge ou l’ont même aboli. Sur ce point, il est indispensable de mettre en place des règles contractuelles équitables pour les collaborateurs et de ne pas sous-estimer les bons et loyaux services d’employés fidèles au poste depuis de longues années. Modèles individualisés

Barbara Brühwiler propose des modèles d’horaires et de service, qui occupent une place centrale dans son étude. Il est en effet, manifeste que le personnel jeune est de moins en moins disposé à fournir sur une longue durée un travail d’équipe dont les horaires sont irréguliers et d’autant plus que cette disponibilité n’est pas attendue des aînés. Les hôpitaux pourraient renverser la tendance en rémunérant mieux les modèles de travail aux horaires irréguliers. Cette mesure entraînerait toutefois une hausse des coûts. Des problèmes pourraient aussi survenir si les places vacantes ne sont pas repourvues intégralement et si trop peu de collaborateurs au sein d’équipes d’âge hétéroclite sont disposés à assumer toutes les tranches horaires. Selon l’auteur, ce n’est pas tant le fait de devoir fournir un travail

en équipes se relayant qui rebute, que la fréquence et l’irrégularité de l’alternance des horaires, et notamment le travail de nuit. Une solution serait de permettre aux aînés encore en activité, de pouvoir travailler par roulement régulier ou d’avoir le privilège de n’assumer que certaines tranches horaires. On pourrait très bien imaginer qu’à partir de 55 ans, les collaborateurs aient l’opportunité de quitter progressivement un modèle de travail rigide impliquant une rotation fixe des équipes. Un tel modèle signifie aussi qu’à partir de 60 ans, les collaborateurs d’une équipe, par exemple celle de nuit, pourraient être totalement libérés du service ou, à l’inverse, assumer presque exclusivement du travail de nuit. La planification du service est déjà à l’heure actuelle une tâche très exigeante pour les supérieurs hiérarchiques. En plus des nombreux autres impératifs professionnels, ils doivent, dans la mesure du possible, tenir compte des requêtes du personnel employé, et notamment des mères de famille professionnellement actives devant encore s’occuper d’enfants et d’autres tâches familiales. L’auteur conclut son étude somme toute avant-gardiste en affirmant que « du point de vue de la politique sociale et sociétale, il est très important que les entreprises créent les conditions cadres permettant aux collaborateurs plus âgés de maintenir leur santé et leur compétitivité aussi bonnes que possible et de rester plus longtemps dans la vie active grâce à la réactualisation de leurs connaissances ». On ne peut qu’abonder dans ce sens. Dans les prochaines années, la création de telles conditions cadres constituera pour les entreprises un important avantage concurrentiel. Mais c’est dès à présent une tâche de première urgence. Josef Ziegler Babara Brühwiler-Müller, «Erfahrung ist Gold wert. Laufbahnplanung für Pflegefachpersonen ab 40», Cahier d’études de la Société suisse pour la politique de la santé (SSPS) no 94, 2007.

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infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1381 Registre des codes créanciers de santésuisse : les nouveautés

Pourquoi le RCC reste important et absolument nécessaire

Depuis de nombreuses années, le registre des codes créanciers est une prestation de service centralisée offerte par santésuisse aux différents assureursmaladie. Le RCC gère les données maîtresses de tous les fournisseurs de prestations facturant les prestations médicales dans le cadre de l’assurance de base – et des assurances complémentaires également. Le numéro RCC est un label de qualité garantissant qu’un prestataire de soins est en droit de fournir des prestations. Seuls en effet les fournisseurs remplissant les critères d’admission de la LAMal et ayant adhéré aux conventions tarifaires peuvent l’obtenir. Trois champs d’application

Le RCC gère trois domaines différents : tout d’abord, la masse des créanciers et le trafic des paiements, ensuite le contrôle des factures et l’admission à pratiquer à la charge de l’assurancemaladie et enfin les statistiques, y compris les contrôles d’économicité effectués auprès des médecins. Ces données centrales sont reprises en permanence par les assureurs et, le cas échéant, complétées par des informations internes. La SASIS SA, filiale de santésuisse, gère le registre depuis le 1er janvier 2009. Cette prestation de service offerte par l’association faîtière évite aux différents assureurs de se procurer les coordonnées personnelles de chaque prestataire de soins et de les contrôler. Le

registre simplifie aussi la vie des fournisseurs de prestations : ils ne doivent pas, pour chaque cas particulier, fournir à chaque assureur des renseignements tels que l’adresse, l’autorisation d’exercer la profession, les coordonnées bancaires, etc. Au-delà des avantages offerts, le RCC sert de base fondamentale à la constitution de statistiques et aux examens d’économicité. Au moyen du RCC, les prestations brutes des différents assureurs-maladie par fournisseur de prestations sont consolidées dans le pool des données et le pool tarifaire de santésuisse. Ensuite, ces chiffres ventilés par groupes de fournisseurs de prestations permettent d’avoir une vue d’ensemble des coûts de la santé. Quelles nouveautés ont été introduites dans le registre des codes créanciers ?

Le registre est ainsi devenu un instrument de travail non seulement important mais indispensable pour tous les intéressés. Les informations utiles aux assureurs sont constamment enrichies. Depuis cette année, le registre contient de nouveaux renseignements complémentaires : • Dans le domaine hospitalier, le genre de laboratoire est désormais précisé afin de faciliter le contrôle des factures effectué par les assureurs (type 0 : hôpital sans laboratoire ; laboratoire d’hôpital de type A : analyses relevant des soins de base au sens strict ; laboratoire de type B : hôpital du site, ne pouvant effectuer sur mandats externes que les analyses relevant des soins de base au sens strict ; laboratoire de type C : autorisé à effectuer pour ses propres besoins et sur mandats externes tout le spectre des analyses). • Conformément à l’art. 7, alinéa 2bis OPAS, une expérience professionnelle de deux ans est requise depuis juillet 2007 pour les personnels soignants du domaine psychiatrique, pour évaluer des besoins en soins gérontologiques et psychiatriques. Le certificat de perfectionnement établi par l’ASI (As-

sociation suisse des infirmières et infirmiers) figure désormais également dans le registre. • Conformément à l’art. 36a LAMal et à l’arrêt du Tribunal fédéral du 20 avril 2009, les numéros RCC doivent également être attribués aux institutions de soins ambulatoires dispensés par les médecins. Le registre précise maintenant s’il s’agit d’une telle institution. • Conformément à l’art. 52, let. a OAMal, les organisations de physiothérapie sont désormais admises. De même que pour l’ergothérapie, le RCC comprend désormais un sousgroupe pour les physiothérapeutes exerçant à titre indépendant (SG 00) et un sous-groupe pour les organisations de physiothérapie (SG 01). • Il est déjà prévu que l’adhésion des pharmacies à la convention RBP IV figure dans le RCC dès que ladite convention sera en vigueur. Franz Wolfisberg/Gregor Patorski

Photo: màd.

Tout hôpital, médecin ou autre fournisseur de prestations du domaine de la santé doit pouvoir facturer correctement son travail. Dans ce but, il est nécessaire de s’inscrire sur le registre des codes créanciers (RCC) de santésuisse. Ce registre garantit le déroulement des opérations de paiement, confirme l’admission à pratiquer à la charge de la LAMal et permet d’établir des statistiques. Depuis le 1er janvier 2009, le RCC est géré par la SASIS SA. Cette année encore, de nouvelles informations complémentaires ont été introduites dans le registre.

Même à l’ère de l’informatique, la gestion du RCC nécessite beaucoup de papiers.

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infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1382 Démarrage réussi

La nouvelle carte d’assuré a fait son entrée à l’hôpital La nouvelle carte d’assuré conforme à l’art. 42a LAMal et à l’ordonnance sur la carte d’assuré (OCA) est toujours controversée mais sa production et sa distribution aux assurés tournent à plein régime. 928 cartes à puce ont déjà été lues ces premières semaines à l’hôpital de l’Île à Berne depuis le démarrage de la production.

L’hôpital de l’Île à Berne est prêt à accueillir la nouvelle carte d’assuré électronique : il dispose de 77 lecteurs de cartes à puce. La carte garantit à chaque assuré l’accès uniformisé au système de santé. Elle comporte le nom et le numéro AVS de l’assuré – imprimé et enregistré dans le microprocesseur – et facilite ainsi l’identification de l’assuré chez le fournisseur de prestations. Sur demande, d’autres données médicales pourront également être enregistrées électroniquement. Six millions de cartes d’assuré jusqu’à la fin mai

La production des nouvelles cartes à puce a débuté le 4 janvier 2010. La livraison a pris du retard en raison des nombreux changements d’assureur survenus en début d’année 2010. D’ici fin mai 2010, plus de six millions d’exemplaires de la nouvelle carte d’assuré seront distribués aux assurés. La nouvelle carte est exclusivement utilisée à des fins administratives et servira à optimiser les processus entre les fournisseurs de soins (hôpital, pharmacie, médecin, etc.) et les assureursmaladie (coordonnées personnelles du patient, couverture d’assurance et facturation des prestations médicales). Les premières applications concernant les données médicales pour les cas d’urgence sont attendues à la mi-2010. Utilité de la nouvelle carte rapidement reconnue par l’hôpital de l’Île

Pour une fois, les Bernois ont été plus rapides que le reste de la Suisse. En collaboration avec la SAP (Systems, applications and products for data proces-

sing) et au moyen d’un logiciel de gestion spécifique aux hôpitaux, une solution adéquate a été mise en place et a démarré fin février. 77 lecteurs de cartes à puce sont actuellement en activité et ont déjà lu 928 cartes à puce. La mise à jour des données administratives enregistrées s’effectue par le biais d’un service de consultation électronique abrité par le centre CADA. L’hôpital de l’Île voit dans cette solution un gros avantage : lors de l’admission d’un patient, les informations nécessaires sont déjà disponibles, ce qui évite les facturations incorrectes. De plus, il est possible de se procurer les renseignements indispensables quant à la couverture d’assurance et aux catégories de séjour, en dehors des heures d’ouverture officielles des bureaux des assureurs-maladie. Lors de l’établissement du formulaire d’entrée dans les centres de traitement décentralisés, les données peuvent déjà être vérifiées grâce au service de consultation électronique de la banque de données centralisée. L’hôpital de l’Île a donc réussi, en tant que premier hôpital de Suisse, à intégrer la carte à puce dans sa gestion et à en tirer profit. L’hôpital universitaire de Bâle a aussi commencé début mars à utiliser la nouvelle carte d’assuré et d’ici début avril, ce sera au tour des hôpitaux universitaires de Zurich et de Saint-Gall de rejoindre le peloton de tête. H.-P. Schönenberger, chef de projet du centre CADA, SASIS SA

La nouvelle carte d’assuré est arrivée. L’hôpital de l’Ile à Berne est prêt à l’accueillir.

18 | Domaine de la santé 3/10

Hanami rime-t-il toujours avec allergie ? Pour beaucoup, le printemps est synonyme de renouveau, de gaîté et de journées ensoleillées. Les Japonais le célèbrent ainsi avec le Hanami, coutume traditionnelle qui consiste à apprécier la beauté des fleurs, principalement les fleurs de cerisier (sakura). À partir de la fin du mois de mars ou au début du mois d’avril, les sakura entrent en pleine floraison dans tout le Japon. Cette coutume est au printemps ce que momijigari, « le changement de couleur des feuilles », est à l’automne. Durant la période de floraison des cerisiers, les Japonais pique-niquent en famille ou entre amis sous ces arbres. Les moments les plus appréciés sont l’apparition des premières fleurs, que guettent les photographes, et la période de pic de floraison. En revanche, pour tous les allergiques, le cauchemar commence. Le début du printemps associé au redoux entraîne une explosion des pollens d’arbres, en particulier des aulnes, des cyprès, des peupliers et des frênes. Avec eux, s’ensuit un cortège de désagréments : rhume des foins, conjonctivite, asthme… L’allergie est une réponse disproportionnée de notre corps face à un agent extérieur habituellement inoffensif (pollens, poils de chats, fraise,…). Pour que la réaction allergique se produise, il faut d’abord que l’organisme ait été une première fois en contact avec la substance incriminée, appelée allergène, par voie respiratoire, alimentaire ou cutanée. A la suite de ce contact, le corps fabrique des anticorps spécifiques dirigés contre l’allergène, c’est la phase de sensibilisation. Elle peut durer plusieurs années et l’on ne sait pas très bien pourquoi le corps fabrique des anticorps contre tel ou tel allergène.

19 | Service 3/10

Image

Mois

Photo : Prisma

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1383

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1384

Prises de position de la commission paritaire de confiance physioswiss – santésuisse/AA/AM/AI Factures des physiothérapeutes

La loi sur l’assurance-maladie (cf. art. 42) définit les rôles des physiothérapeutes et des assureurs lors de la facturation. Le fournisseur de prestations (en l’occurrence le physiothérapeute) doit remettre à l’assureur une facture détaillée et compréhensible. L’assureur peut, de surcroît, exiger un diagnostic précis ou des renseignements supplémentaires d’ordre médical (cf. art. 42 LAMal). Le physiothérapeute doit aussi transmettre à l’assureur toutes les indications nécessaires lui permettant de vérifier le calcul de la rémunération et le caractère économique de la prestation. La convention tarifaire de septembre 1997 précise, à l’art. 7 al. 4 : dans les cas discutables, le physiothérapeute doit, à la demande des assureurs, justifier les mesures thérapeutiques prévues et/ou la facturation des positions tarifaires correspondantes. L’assureur est en droit de poser des questions d’ordre médical au médecin prescripteur. L’interlocuteur compétent pour les renseignements spécifiques au tarif est le partenaire tarifaire correspondant. Circulaire de santésuisse no 67/2004

Photo: Keystone

Vous connaissez peut-être la circulaire de santésuisse no 67/2004. Celle-ci se réfère à la convention tarifaire passée entre la FMH et santésuisse régissant la physiothérapie et les autres prestations paramédicales en cabinet médical, comme le précise clairement le document mentionné. Les recommandations contenues dans la circulaire no 67/2004 n’ont donc pas été rédigées pour les physiothérapeutes indépendants travaillant dans leur propre cabinet. Dans l’intérêt de toutes les parties, les conventions qui s’appliquent aux physiothérapeutes travaillant dans leur propre cabinet ou, suivant le cas, aux physiothérapeutes employés par les médecins en cabinet médical doivent être considérées comme des documents autonomes.

Nouvelles du monde

Service

Physiothérapie en cabinet médical

Barack Obama signe la réforme historique sur l’assurance santé : Le président Barack Obama a promulgué le 23 mars 2010 la loi sur l’assurancemaladie, qui permettra à plus de 32 millions d’Américains de se doter enfin d’une couverture de santé. Après avoir frôlé l’échec et remporté la bataille de haute lutte au Congrès, le président américain va désormais tenter de convaincre ceux de ses concitoyens qui ne voient dans la réforme que dépenses et mainmise du gouvernement fédéral sur leur santé. Londres ouvre un centre pour soigner les « accros à la technologie » : A Londres, un hôpital se propose de traiter les patients « accros » aux réseaux sociaux sur Internet et aux jeux vidéo. Le traitement dure 28 jours. Son but n’est pas d’éloigner les patients de toute technologie mais de les aider à contrôler leur utilisation. Glasgow, frappée par un fort taux de mortalité : La ville écossaise de Glasgow connaît un niveau de mortalité supérieur à celui d’autres villes ayant le même niveau de pauvreté. 900 personnes de plus qu’à Liverpool ou à Manchester meurent chaque année à Glasgow, quelle que soit la tranche d’âge et la classe sociale. Les principales causes sont les cancers et les attaques cardiaques. Les experts peinent à expliquer « l’effet Glasgow ».

20 | Service 3/10

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1385

Manifestations Organisateur

Faits particuliers

Date/Lieu

Pour plus d’informations

22 – 23 avril 2010 Université de Bâle

www. asim.unibas.ch

Die Basler Arzthaftpflichttage asim Academy of Swiss Insurance Medicine

Thème : «Médecin – Patient – Assurance : qui nui à qui ?»

SwissDRG Forum 2010 SwissDRG SA

Thème : Expériences avec les forfaits 30 avril 2010 par cas et préparatifs pour 2012 avec la Congress Center, participation entre autres de Carlo Conti et Bâle de Pius Gyger

www.swissdrg.org

12e Forum Suisse de l’assurance-maladie RVK

Thème : Catalogue des prestations : Soins de base ou soins à souhait

19 mai 2010 Centre des congrès, Zurich

www.rvk.ch

Dessin : Marc Roulin

Informez-nous de vos manifestations : redaction@santesuisse.ch Plus d’informations sur www.santesuisse.ch

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infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1386

spital interlaken Die Akutspitäler Frutigen und Interlaken sowie das Gesundheitszentrum Meiringen bilden unter dem Namen spitäler fmi ag das Regionale Spitalzentrum für das östliche Berner Oberland Für die Patientenadministration des fmi Spitals Interlaken suchen wir per sofort oder nach Vereinbarung eine/einen

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Sachbearbeiter/in ambulantes Controlling (80-100%)

Ihr Aufgabengebiet: 

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Kontrolle und Bearbeitung der erfassten Spitalleistungen anhand der Krankengeschichte zusammen mit den Leistungserbringern Vorbereiten und Durchführen von Abrechnungen Ambulante Tarifverantwortung TARMED Bearbeitung von Rechnungsanfragen Mithilfe bei der Schulung für Leistungserfassung Kontakte zu internen/externen Stellen

Wir erwarten von Ihnen Medizinische Ausbildung mit Berufserfahrung (Notfall, Pflege)  Kaufmännische Weiterbildung  Tarifkenntnisse TARMED  Durchsetzungsvermögen und Belastbarkeit  Verantwortungsbewusstsein und Selbständigkeit 

Wir bieten Ihnen Interessante und abwechslungsreiche Tätigkeit  Lebhaftes und teamorientiertes Umfeld  Zeitgemässe Arbeitsmittel 

Weitere Informationen erteilt Ihnen gerne Frau Elsbeth Zurbrügg, Leiterin Patientenadministration Tel. 033 826 25 52. Ihre schriftliche Bewerbung mit den üblichen Unterlagen richten Sie bitte an: spitäler frutigen meiringen interlaken ag, spital interlaken personaldienst, weissenaustrasse 27, 3800 unterseen oder i.personaldienst@spitalfmi.ch www.spitalfmi.ch

Neue Spital- und Pflegefinanzierung ante portas: Praktische Herausforderungen bei der Umsetzung des revidierten Krankenversicherungsgesetzes (KVG) Donnerstag, 26. August 2010, Grand Casino Luzern

Themen/Referierende • Einführung Dr. oec. HSG Willy Oggier, Gesundheitsökonomische Beratungen AG, Küsnacht

Die Umsetzung der neuen Spitalfinanzierung: Stand der Dinge • Sicht des zuständigen Bundesamtes lic. iur., RA, Sandra Schneider, Leiterin der Abteilung Leistungen, Bundesamt für Gesundheit, Bern • Sicht der Eidgenössischen Preisüberwachung lic. rer. pol. Manuel Jung, Leiter Fachbereich Gesundheit, Eidgenössische Preisüberwachung, Bern • Sicht eines Universitätsspitals Dr. med. Werner Kübler, MBA, Vorsitzender der Spitaldirektion, Universitätsspital Basel, Basel • Sicht einer Privatspital-Gruppe Peter Kappert, Direktor Klinik Sonnenhof und Präsident der Swiss Leading Hospitals, Bern • Sicht eines Krankenversicherers lic. iur. Peter Fischer, Exec. MBA, CEO Visana-Gruppe, Bern

Die neue Pflegefinanzierung • Was wollte der Bundesgesetzgeber? Ständerätin Christine Egerszegi, Mellingen

Die Umsetzung der neuen Pflegefinanzierung: Stand der Dinge • Sicht des Kantons Solothurn Regierungsrat lic. iur. Peter Gomm, Vorsteher des Departements des Innern des Kantons Solothurn, Solothurn • Sicht von santésuisse lic. rer. pol. Stefan Kaufmann, Direktor santésuisse, Solothurn • Sicht des Spitex Verbands Schweiz lic. rer. soc. Silvia Marti Lavanchy, Wissenschaftliche Mitarbeiterin Politik und Grundlagen, Spitex Verband Schweiz, Bern

Tagungsleitung Prof. Dr. Dr. h.c. René Schaffhauser, Universitäten St. Gallen und Banská Bystrica/Slowakei, St. Gallen Dr. oec. HSG Willy Oggier, Küsnacht Monika Merki Frey, Beraterin im Gesundheitswesen, TROVACON AG, Zürich

Programme/Anmeldung Institut für Rechtswissenschaft und Rechtspraxis (IRP-HSG), Bodanstrasse 4, 9000 St. Gallen Tel. 071 224 24 24, Fax 071 224 28 83, e-mail: irp@unisg.ch/www.irp.unisg.ch

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1387

Congrès national pour la promotion de la santé en entreprise 2010 Jeudi, 2 septembre 2010, Université de Fribourg

GSE – comment la réussir? Objectifs du congrès La gestion de la santé en entreprise (GSE) est efficace si elle parvient à s’ancrer dans l’ensemble de l’organisation d’une entreprise et à y porter ses fruits. Le congrès abordera donc la question cruciale suivante: quels sont les facteurs déterminants pour l’intégration de la GSE dans les processus et les structures centraux d’une entreprise? Dans ce contexte, les éléments principaux sont notamment une planification participative, des indicateurs permettant l’évaluation du succès, mais également des résultats rapidement perceptibles. En d’autres termes, une organisation consciente et active du processus est gage de succès. Le congrès doit permettre de réfléchir aux questions suivantes et d’y apporter le cas échéant des réponses: Motivation pour la promotion de la santé: Quelles possibilités les divers acteurs de l’entreprise ont-ils pour lancer et piloter un processus PSE? Assurer une mise en œuvre efficace du projet: Comment peut-on intégrer la PSE dans d’autres systèmes (système ASA, Balanced Score Card, systèmes de gestion, …)? Utiliser les soutiens externes: Quels rôles les experts externes jouent-ils dans ce processus? Quelle plus-value telle ou telle qualification professionnelle apporte-t-elle? Planifier adéquatement le processus: Comment garantir le soutien en amont et en aval, jusqu’à l’évaluation? Tenir compte de la taille de l’entreprise: Quelles sont les contraintes et exigences spécifiques aux petites, moyennes et grandes entreprises?

Etablir des standards: Quels critères de qualité peuvent être considérés comme des standards suisses? Retour sur investissement: Quelle est l’importance des indicateurs pour l’évaluation? Comment peut-on montrer les bénéfices obtenus? Public cible – Cadres et spécialistes des ressources humaines – Personnes chargées de la santé dans les entreprises, spécialistes de la sécurité au travail – Représentantes et représentants d’institutions publiques – Décideurs des milieux politiques, économiques et des administrations Organisateurs Promotion Santé Suisse en coopération avec le Secrétariat d’Etat à l’économie SECO Frais de participation CHF 300.–/EUR 200.–, y compris le repas de midi, les rafraîchissements et le dossier du congrès Partenaires du congrès Association suisse pour la promotion de la santé dans l’entreprise ASPSE | Société suisse de psychologie du travail et des organisations SSPTO | Suva | CFST – Commission fédérale de coordination pour la sécurité au travail | Association Suisse d’Assurances ASA | santésuisse | Swiss Re | Helsana Assurances SA | Trust Sympany | Office fédéral de la santé publique OFSP | Vivit Gesundheits SA | Association faîtière des sociétés pour la protection de la santé et pour la sécurité au travail suissepro Programme détaillé et inscription: www.promotionsante.ch/conference

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1388

Weiterbildungskurs Erwerb Fähigkeitsausweis Vertrauensarzt Die Schweizerische Gesellschaft der Vertrauens- und Versicherungsärzte führt in Zusammenarbeit mit dem Winterthurer Institut für Gesundheitsökonomie WIG den Kurs zum Erwerb des Fähigkeitsausweises Vertrauensarzt durch.

Développez votre carrière dans le domaine de la santé

Formation postgrade

Master of Advanced studies en économie et management de la santé * Formation à temps partiel sur 2 ans

Teilnehmerkreis:

Ärzte/innen aus allen Sozial- und Personenversicherungen sowie weitere interessierte Ärzte/innen

Kurssprache:

Deutsch. Zweisprachige Modulbegleitung unterstützt Kursteilnehmende mit französischer Muttersprache im Bedarfsfall

Kursdaten:

Modul Modul Modul Modul Modul

* S’adresse aux professionnels de la santé : médecins, gestionnaires, assurance maladie, administration, industrie pharmaceutique...

26. 23. 14. 11. 16.

28.08.2010 25.09.2010 16.10.2010 13.11.2010 18.12.2010

Fähigkeitsausweis: Wird nach Kursabsolvierung und Schlussprüfung erteilt Kosten: Für Vertrauensärzte/innen mit KVG-Mandat: Fr. 1'250.Für Ärzte/innen ohne KVG-Mandat, (FMH-Mitglieder): Fr. 5’625.übrige: Fr. 7’500.-

* Délai d’inscription : 15 juin 2010 Contact : mashem@unil.ch Tél. : +41 21 692 34 68

1: 2: 3: 4: 5:

Informations : www.hec.unil.ch/mashem

Auskünfte und Anmeldung: Sekretariat SGV, Tel. 052 226 06 03, Fax 052 226 06 04, E-Mail: info@vertrauensaerzte.ch Ausschreibung Online: www.vertrauensaerzte.ch und www.medecins-conseils Anmeldeschluss:

31. 07. 2010

12. Schweizerisches Forum der sozialen Krankenversicherung Mittwoch, 19. Mai 2010, 09.30 – 16.00 Uhr im Kongresshaus Zürich

Fachleute diskutieren über Massnahmen im Gesundheitswesen

Leistungskatalog im Kreuzfeuer: Grundversorgung oder Wunschversorgung ?

Charles Giroud Dr. rer. pol., Präsident RVK

Erika Ziltener Kantonsrätin SP Zürich, Präsidentin Schweizer Patientenstelle

Werner Widmer Dr. rer. pol., Direktor Stiftung Diakoniewerk Neumünster

Niklaus Brantschen lic. phil. und lic. theol. Jesuit, Gründer und Projektleiter Lasalle-Institut

Urs P. Gasche lic. sc. pol., Gesundheitsökonom, freier Publizist

Beat Kappeler Dr. h.c., Kommentator NZZ am Sonntag

«ForumTALK » Tagungsmoderation: Markus Gilli

Tilman Slembeck Prof. Dr. oec. HSG, Zürcher Hochschule für Angewandte Wissenschaften

Sarah Kleijnen M. Sc., Fachberaterin des Niederländischen Krankenversicherungsgremiums (College voor Zorgverzekeringen)

Warum? Wie? Wann? Fachleute und Meinungsführer diskutieren, hinterfragen und vertiefen auf dem Podium die Thesen der Referenten.

Informationen und Anmeldung: www.rvk.ch Verband der kleinen und mittleren Krankenversicherer – Haldenstrasse 25 – CH-6006 Luzern – Telefon +41 (0) 41 417 05 00

Pascal Strupler lic. iur., Direktor Bundesamt für Gesundheit

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1389

Dossier infosantésuisse Liens utiles Organisations internationales OCDE www.oecd.org/ Euro HealthConsumer Index http://www.healthpowerhouse.com/ OMS http://www.who.int/fr/ Ministères et services nationaux : Ministère de la santé allemand : http://www.bmg.bund.de/ National Health Service britannique : www.nhs.uk/ Ministère de la santé français : http://www.sante-sports.gouv.fr/ Haute autorité de la santé française : www.has-sante.fr Services de santé aux Pays-Bas : Ministère de la Santé, du Bien-être social, la Jeunesse et les Sports: www.minvws.nl Institut National pour la Santé (RIVM): www.rivm.nl Conseil de la Santé: www.gr.nl Autorité pour la Sécurité des Aliments: www.vwa.nl Services de santé en Suède : Services du gouvernement suédois www.sweden.gov.se Direction nationale de la santé et des affaires sociales www.sos.se Association suédoise des autorités locales et régionales www.skl.se Conseil national pour l’évaluation des technologies médicales M:\02\11\03\36\

infosantésuisse : dossier Comparaisons internationales (4e partie) 1/2010 1390

www.sbu.se Institut national de la santé publique www.fhi.se Institut suédois de prévention des maladies infectieuses www.smittskyddsinstitutet.se Conseil des prestations pharmaceutiques www.lfn.se Agence suédoise du médicament www.lakemedelsverket.se

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