5. Provision of services
ublic health services are partly integrated with curative services and partly organized as separate activities run by special institutions. Since 1999, the government has launched a number of national public health programmes and strategies focusing on risk factors such as diet, smoking, alcohol intake and physical activity. The primary sector consists of private (self-employed) practitioners (GPs, specialists, physiotherapists, dentists, chiropractors and pharmacists) and municipal health services, such as nursing homes, home nurses, health visitors and municipal dentists. The GPs act as gatekeepers, referring patients to hospital and specialist treatment. 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. Most public hospitals are general hospitals with different specialization levels. Community pharmacies are privately organized but subject to comprehensive state regulation on price and location to ensure that everyone has reasonable access, even in rural areas. A collective financial equalization system requires pharmacies with above-average turnovers to contribute to pharmacies with below-average turnovers. Many actors are involved in rehabilitation care within the health care sector, the social sector, the occupational sector and the educational sector, with each sector carrying out a different aspect of work. One area attracting attention within rehabilitation and intermediate care is, therefore, the problem of securing coherent patient pathways. Palliative care has been slowly developing in recent years and national initiatives are being developed at the time of writing. Oral health care for children and adolescents is provided by the municipal dental services. Dental health care for citizens older than 18 years is offered by private dental practitioners. The Danish Institute for Quality and Accreditation in Healthcare (Institut for Kvalitet og Akkreditering i Sundhedsvæsenet) manages the DDKM. The DDKM is based on the principle of accreditation and standards and includes monitoring of quality of care in the primary and secondary sectors. Special population groups have different kinds of access to the statutory health system. Recognized refugees are included in regional health care coverage and have the same rights as inhabitants registered with the Central Person Registry. Asylum seekers are not covered by regional health care and have fewer entitlements. Undocumented immigrants are only entitled to acute treatment. However, a new private clinic for undocumented immigrants that will not require immigrants to register with the authorities has recently been established by the Danish Medical Association, the Danish Red Cross and the Danish Refugee Council.
5.1 Public health
Public health services are partly integrated with curative services and partly organized as separate activities run by special institutions. The 2007 structural reform shifted responsibility for primary disease prevention and health promotion tasks from the regions to the municipalities. Since 2007, municipalities have been responsible for the aspects of prevention, care and rehabilitation that do not fall under hospital admission. Every fourth year, municipalities and regions have to elaborate a mandatory joint health plan in regard to their tasks on disease prevention and health promotion and how these are to be coordinated. Sixty-five of the municipalities and two of the regions are members of the Danish Healthy Cities Network, which was established in 1991 and is an active member of WHO’s international Healthy Cities Network. The Healthy Cities Network aims to be a platform for dialogue and collaboration between public health authorities and provides support for members in their disease prevention and health-promoting efforts.
The main responsibility for surveillance and control of communicable diseases rests with the National Serum Institute (Statens Serum Institut) and medical public health officers employed by the National Board of Health, who work at the regional level. GPs and hospital doctors are obliged to report instances of certain communicable diseases to medical public health officers. The medical public health officers are also in charge of individual and community interventions to control communicable diseases. While their function is largely advisory, they do have the power to prevent infected children from entering institutions, or even to close institutions to avoid the spread of infection. Other measures to prevent epidemics are in the hands of a special regional commission for epidemic diseases or, in the case of infectious foodborne diseases, local food control agencies. For information on immunization services and national vaccination programmes, see section 1.4.3.
A special state agency, the Danish Working Environment Authority, which forms part of the Ministry of Labour, is responsible for surveillance and maintenance of standards of occupational health and safety. Through inspection of workplaces, regulation and information, the Authority aims to contribute to a safe, healthy and developing Danish work environment. The provision of these tasks makes the Danish Working Environment Authority an influential actor in the public health arena. Other institutions also regularly perform safety inspections, for example of workplaces, food provision services and the condition of roads and accommodation. The institutions performing these inspections include the Danish Veterinary and Food Administration, the Ministry of Employment, the Ministry of Transport and the Ministry of the Environment.
National public health programmes
Over the past few decades, Denmark has experienced unfavourable trends in average life expectancy in comparison with other OECD countries (see section 1.4). In response to the low increase in average life expectancy, the government in 1999 launched the second 10-year national public health programme. This programme has many similarities to WHO’s target-based strategy for the 21st century (Ministry of Health, 1999). The programme lists 17 targets that cover specific risk factors (e.g. tobacco, alcohol, nutrition, physical inactivity, obesity and traffic accidents), age groups (e.g. children, young people, older 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).
In 2002, the newly elected government launched the third national public health programme Healthy throughout Life 2002–2010 (Ministry of Interior and Health, 2002). This programme retained important goals and target groups from the 1999–2008 programme but focused specifically on reducing major preventable diseases and disorders, namely type 2 diabetes, cancer, heart disease, osteoporosis, musculoskeletal diseases, allergy diseases, psychological diseases and COPD. A key aspect of the 2002–2010 programme was to provide individuals with the necessary knowledge and tools to be able to promote their own health status and health care. The programme also targeted the quality of life of the population through systematic efforts in terms of counselling, support, rehabilitation and other patient-oriented measures. Important elements of the programme were, therefore, the individuals’ own contribution, and patient guidance, support and rehabilitation. A list of indicators was 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 of efforts to promote health and prevent disease. Key indicators include life expectancy; the number of healthy life years lost; 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 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; and serious occupational accidents, including fatal ones (Ministry of Interior and Health, 2002).
The 2002–2010 Healthy throughout Life programme differed from other Scandinavian programmes in that it focused strongly on health-related behaviour and less on social and structural factors that influence health. Political responsibility for the health of the population was also less pronounced in the 2002–2010 programme, compared with both previous Danish public health programmes and those of Norway and Sweden (Vallgårda, 2010, 2011).
In 2009, the Danish Government launched the Health Package 2009 (Sundhedspakke 2009), a national strategy for disease prevention that, among other things, focused on the municipalities’ role in disease prevention targeting citizens (non-patients). According to the Health Package 2009, the government’s goal is to increase average life expectancy by three years within the subsequent decade. This goal is to be fulfilled by strengthening health care treatment, by giving the municipalities stronger economic incentives to conduct disease prevention and by introducing 30 disease-preventing initiatives. According to the government, the Health Package is a continuation of the Healthy throughout Life programme, as the package also focuses on risk factors such as diet, smoking, alcohol intake and physical activity (Danish Government, 2009). The newly elected government has only been in power for a short time at the time of writing, so no new programme for public health has been issued yet.
National screening programmes, antenatal care and sex education
Currently, there are two national systematic disease-specific screening programmes in Denmark; both programmes target women and screen for cervical and breast cancer. The national screening programme for cervical cancer has been operating since 1986. Systematic breast cancer screening (mammography) has been in effect since 2007 and is offered to women aged 50–69 years every other year. The government has decided that a third national screening programme is to come into effect in 2014. The programme will offer screening for colon cancer every other year to citizens 50–74 years of age (Ministry of Interior and Health, 2010a). The regions are responsible for operating and monitoring all three screening programmes. Other national screening programmes include neonatal screening for hearing disability and for inborn errors of metabolism.
Since 1973, all women over 18 years of age have had access to free-of-charge pregnancy terminations on request within the first 12 weeks of pregnancy. However, a regional abortion and sterilization council can provide dispensation to terminate a pregnancy after the first 12 weeks on special clinical or social circumstances, including the pregnant woman being too young and immature to take care of the baby (Region Zealand, 2011). All pregnant women have direct access to antenatal services provided by GPs, midwives and obstetricians in hospital obstetric departments. These include a number of screening procedures. Rates of utilization of these antenatal services are overall very high. However, there is a lower utilization rate among lower socioeconomic groups and immigrants. Women can choose to give birth at home or in hospital, free of charge. Almost 99% of deliveries take place in hospital (National Board of Health, 2008). In 2010, screening of pregnant women for hepatitis B, HIV and syphilis was made standard procedure (National Board of Health, 2010d).
All parents of infants are offered consultations with health visitors in their home, who also perform health checks. Most parents use this service. Infants and toddlers are offered free health checks by GPs, which is combined with the vaccination programmes. Schools offer all children at least two health checks during primary and secondary school. Health checks are performed by health professionals, typically a nurse trained in examining and monitoring the health of schoolchildren. Schools also 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.
National plan on AIDS/HIV
A key principle of Denmark’s AIDS policy is that prevention should be carried out without compulsory measures and, if necessary, based on anonymity (National Board of Health, 2011d). The AIDS prevention programme involves close collaboration between the National Board of Health, the regions, the municipalities and private organizations. 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 allows better information to be obtained on the incidence of HIV and the spread of infection in Denmark. The number of new cases of infected people has stabilized during recent years (National Serum Institute, 2011).
In 2009, the National Board of Health launched a new strategy, which recommended that health care personnel proactively offer HIV tests to patients with an increased risk of acquiring HIV, for example men who have sex with men, patients being tested for syphilis or gonorrhoea, patients whose partners are HIV positive, and drug addicts (National Board of Health, 2009b).
A wide array of private and public institutions as well as nongovernmental organizations provide general health education to the public in the form of mass media campaigns, the most important of these being the Centre for Health Promotion at the National Board of Health, the municipalities, the Danish Committee for Health Education, the Danish Road Safety Council, the Danish Working Environment Authority and the Tryg Foundation, which is a large private foundation. The National Board of Health collaborates with the municipalities when performing national campaigns. The Board develops the campaign for mass media, while those municipalities who are interested perform local activities on the basis of the attention created by the national campaign. Collaboration between the Board and the municipalities differs in intensity, but often the Board offers the municipalities support in terms of inspirational campaign material, courses, and so on (National Board of Health, 2011e).