HEALTH CARE IN DENMARK ORGANIZATION OF THE PUBLIC HEALTH SERVICES Since the beginning of the last century matters pertaining to the health of the population, including care of the sick and disabled, to an evergrowing extent have been considered a public concern. Several of the health services, at present provided for the population as a whole, have grown out of and developed alongside with the set of services that were originally provided only for certain groups of the population as benefits under the social security system and are therefore administered by the authorities that are in charge of social welfare and public relief. Other health services-primarily in the field of preventive health and hospitalization-have been established on a general basis and developed strictly from pure health considerations proper, and therefore are provided by and through another set of government channels, on the local as well as on the national level. Secondly, the present system is the result of a slow but steadfast evolution, marked by constant undertakings for improvement and extension of the services already provided, which explains the somewhat complicated and erratic pattern of the administrative and organizational set-up, which from the outside view may seem to encounter insuperable problems of coordination and thereby counteract the achievement of the most rational and adequate solutions. At the national level almost all of the major ministries are concerned with one or another aspect of the public health services. Actually, none of the ministries may be termed as having general responsibility in matters of health, even though the Ministry of the Interior is generally considered as the supreme health authority, being in charge of the legislation on medical personnel, hospitals, training of nurses and para-medical personnel, drugs, food hygiene in general and a major portion of the matters pertaining to mother and child health as well as environmental sanitation in general and various other matters in the field of public health and medical services. A special department of the ministry is directly in charge of the operation and management of mental hospitals, all of which are operated by the national government (except for the mental hospital of the city of Copenhagen). Also the State Serum Institute and various other laboratories belong under the Ministry of the Interior. Several other matters in the field of public health such as the health insurance scheme, occupational health, care of the old aged, mentally defectives and physically disabled persons, including vocational rehabilitation, belong under the Ministry of Social Affairs, while other health matters primarily training and education of medical personnel and school health-are managed under the auspices of the Ministry of Education, which is also in charge of the operation of the National Hospital in Copenhagen (the Copenhagen University Hospital). In the field of nutritional health the Ministry of Agriculture per forms important functions. When it comes to town planning and hous ing regulations the Ministry of Housing is in charge, while matters of a medico-legal nature belong under the Ministry of Justice. Besides, it is a distinct feature of the Danish system that several important functions in the field of public health and medical care on the local level are performed by locally elected bodies, primarily the local governments, which have a general responsibility to provide and operate sufficient facilities for hospitalization (in-patients) within their area as well as a number of other services, such as the public midwifery-service, public health nurses, home visiting nurses, school doctors and nurses, school-feeding schemes etc. Also the operation of tuberculosis control stations, school dental clinics, family guidance centers, day nurseries for children and nursing homes for old aged are considered to be local government concerns. Other local bodies such as the local "Health Committee", and the local "Building Council" the members of which are appointed by the local government council, are vested with responsibilities mainly in the field of environmental sani tation, including food hygiene, and housing respectively. Finally, it must be mentioned that the responsibility of preventing and combating epidemic diseases is primarily in the hands of special, locally ap pointed committees. The national government, however through the legislation and the administrative authority of the ministries concerned-exerts a rather heavy influence even in those matters, which are formally left to be solved by local bodies. The legislation which empowers or directs the local governments to perform certain functions in the field of public health will often establish rather narrow standards to be followed by the local governments and leave only little space for the discretion of the local authorities. In several other respects it is prescribed that the local government's plans or decisions must be approved by a national government agency before they may be carried out, such as in the case with respect to all plans for construction, extension or altera tion of hospital facilities, nursing homes etc. Also the locally adopted regulations in the field of environmental sanitation must be approved by the Ministry of the Interior, in order to become effective. In some health matters, any citizen who is effected by a decision of the local agency is entitled to appeal the decision to the national government agency concerned, which may revoke or change the local decision. Such is the case, for instance, with respect to all decisions of the local health committees in the field of environmental sanitation and food hygiene. Finally, it must be mentioned that a considerable portion of the local governments' expenses for health and medical care are defrayed by the national government according to standards and criteria which vary with the nature of each specific expense. As an example it may be mentioned that about 65% of the operational costs of all local govern ment hospitals are reimbursed by the national government. HEALTH INSURANCE The health insurance scheme, which is another important feature of the public health system, is not government operated, though subsidized and controlled by the national government. The law prescribes every resident of the country of 16 years of age or above to be a member of the local health insurance society. In principle there mus be only one health insurance society for each local government area, each society being self-governing and independent of the local government, but submitted to supervision of the national government, which has also set up narrow limits as to the annual fees, which may be levied by the societies upon their members, as well as to the amount and nature of the benefits for the members. Those members, who for one reason or another do not want to draw benefits from the society, have to pay a small fee. Each society is divided up into two sections, section A for members whose annual income is below a certain level, fixed by the national government, and section B for others. 1 872% of the total membership belong to section A, the members of which pay an annual fee of approximately 200 kroner 1 (equivalent to appr. 30 U.S. dollars), which entitles them to free medical attention by a general practitioner, whenever need arises. According to special agreements between the health insurance societies and the medical association, the health insurance societies pay the doctor a certain basic annual fee for each member of the society, registered with the doctor, regardless of the number of consultations, if any, given to the patient during the year. Further, the members of the health societies' A-sections are entitled to reimbursement of a considerable part of expenses for certain kinds of medicine, prescribed by the doctor, reimbursement of all fees for examination and treatment by a specialist by reference of the general practitioner in charge and of the costs of such laboratory tests and X-ray examinations as the doctor may prescribe. Finally the health insurance society will pay the fees for certain kinds of dental care and all hospital fees, incurred by members of section A or their minor children. Incidentally, these latter feeswhich in all hospitals are on a daily "all-inclusive" basis, regardless of the extension and kind of the examinations and treatment received are much below the hospital's actual daily operational costs. per bed, especially in the hospitals operated by the national or local governments, but even the fees of the few private hospitals, are relatively low, due to the heavy national government grants, which are paid also to private hospitals. The fees for members of section B of the health insurance societies are somewhat bigger than for section A members, while the benefits are less extensive than those offered to members of section A. While the B-sections are in principle supposed to be economically self-contained, the A-sections depend on national government support. Besides the regular health insurance societies there exist a few entirely private societies or companies, which operate more or less along the same lines as the B-sections of the regular societies. PLANNING AND COORDINATION The ever growing variety of public health services and of agencies, concerned with one or another aspect of public health-on the national as well as the local level-obviously has given rise to an increasing demand for coordination while at the same time the availability of medical and technical knowledge has become increasingly indispensable for the agencies concerned. To fulfill these needs, the national government already at an early stage of the history of public health in Denmark has established a 1 central agency, the National Health Service, headed and staffed by members of the medical profession and vested with the responsibility of advising all public health agencies concerned with public health, supervising all public and private institutions in the field of public health and being the supreme authority of all medical, pharmaceutical and public health personnel in technical matters. Accordingly, the Na tional Health Service is in charge of licensing of all medical personnel. but apart from this the National Health Service has only few directly executive functions, being, as it is, outside the politically responsible hierarchy. But even in its advisory capacity the agency excerpts a heavy influence in the policy-making process as well as in the day to day management of the regular government agencies in the field of public health. Only when it comes to matters concerning control of production, import and sale of drugs, the National Health Service traditionally has been charged with direct executive functions, performed through a special section of the service, which is authorized to issue regulations concerning the operation and management of dispensing pharmacies, including regulations concerning restriction on sale of certain drugs (narcotics, prescription-drugs etc.). Further, the pharmaceutical section of the National Health Service-through spe cial laboratories and a team of pharmaceutical inspectors-controls the purity, composition, pricing etc. of all medical remedies offered for sale in the country, whether imported or produced here. In this connection it should be mentioned that this section is in charge of determining whether factory-made remedies fulfill the rather restric tive requirements for being marketed under a proprietary name in the original packing of the factory. Finally, the National Health Service also is in charge of collecting and publishing all medical statistics. Besides the staff, attached to the National Health Service headquarters in the capital, the service is represented at the local level by a number of public doctors, each one being in charge of a certain district, usually corresponding to the local police districts. The public district doctors serve as a link between the National Health Service and the local agencies, concerned with public health, as well as the local medical and health personnel, thus at the local level performing the advisory and supervisory responsibilities of the National Health Service. An important part of the district public doctor's functions consists of advice and guidance to the local health committees, when performing their tasks in the field of environmental sanitation and food hygiene. While the staff of the ministries concerned with matters of health is almost entirely composed of members of the administrative or legal profession, the staff of the National Health Service is dominated by members of the medical, pharmaceutical and nursing professions. When dealing with matters which require medical or pharmaceutical expertise the ministries or other government agencies are obliged according to the law to consult with the National Health Service. which thereby has most effectively established itself in a politically neutral center position in the field of public health. Even if the 1 In matters, belonging under the administration of justice, the medical expertise and medico-forensic evaluations, however, are provided by a special medico-legal board under the Ministry of Justice. Na 201 Ind ΠΡ N National Health Service is independent of the traditional central government hierarchy, it formally belongs under the Ministry of the 1 Interior, which is in charge of the annual budget of the service as well as its staffing. The Ministry of the Interior also is in charge of the State Serum Institute, which serves as a national laboratory for microbiological and serological tests and for production of sera, vaccines etc., while at the same time providing research facilities in the field of microbiology. Also the State Vitamin laboratory for control of vitamine additives in food products and various other government laboratories, operated for control and research purposes in the field of public health, belong under the Ministry of the Interior. So far, no centralized government laboratory for food toxicological control and research has existed in Denmark, but a special institute to be in charge of all matters pertaining to nutritional health is at present under construction under the auspices of the Ministry of the Interior. A special research laboratory in the field of occupational health is operated by the Ministry of Labour which is also the supreme authority for a team of factory inspectors, each being in charge of his district of the country. Apart from the mental hospitals and a few general hospitals, which are operated by the national government, the general hospital service is formally in the hands of local governments. It should be mentioned, however, in this connection that special associations have been formed by private citizens to promote the fight of certain diseases such as tuberculosis, cancer, poliomyelitis, rheumatic diseases, disseminated sclerosis, etc. These associations receive national government grants for their activities, which include research projects as well as operation of curative institutions. Another semi-public association operates nursing home, orthopaedic hospitals and rehabilitated centers for cripples. Apart from these institutions only a few private hospitals are operated and even these hospitals are under government supervision while at the same time receiving national government grants to cover about 65% of operational expenses. In 1964, a Social Reform Commission was established by the Danish legislature to review the workings of the country's existing social welfare system. The existing system has remained intact since its inauguration in 1933. The study concluded that the entire social welfare system needed administrative reform, and that the present practice of dispensing funds on a categorical basis to specific populations sub-groups must be changed. The recommendations called for a new system which would blend the needs of all individuals suffering from "social accidents" (e.g.: illness, death of the bread winner), with society's need to convert them as quickly as possible into productive members of the community. Although a final legislative program has not yet been developed, there is a broad consensus as to the nature of the administrative forms to be carried out as well as what the orientation of the news system is to be. Essentially, this concensus calls for administrative reforms to combine the new physically and juristically scattered operations |