|Implemented in this survey?|
The Danish structural reform of 2007 resulted in the establishment of 5 regions instead of the former 15 counties as well as fewer, but larger municipalities. The regions are governed by politically elected councils who have the health care sector as their most important area of responsibility, but have no right to taxation. The upcoming election for the next 4 years has spurred some debate about the actual and future role of the regions, and their efficiency.
The Danish structural reform of 2007 resulted in the establishment of 5 regions replacing the former 15 counties as well as 98 municipalities instead of the former 272 municipalities. The regions are governed by politically elected councils of 41 members each, and their most important area of responsibility is the health care sector by running the public hospitals and negotiating agreements on fees and terms of delivery health care by general practitioners. Their activity is financed from funds allocated by the state (80%) and contributions from the municipalities according to the extent of use of the health care facilities by their citizens (20%).
The upcoming election in November 2009 of new regional councils for the next 4 years has spurred some debate about the actual and future role of the regions, and their efficiency. The creation of the regions was a compromise between those politicians who wanted to keep the counties, although by a reduced number, and those who wanted to abolish this administrative layer altogether, considering the small size of the country (Peter Christiansen et al., 2008). This compromise has also influenced how the regions are organized and financed. The most important task of the regions since their creation has been a modernization of the health care sector, and planning of a new hospital structure according to guidelines formulated by the government (Pedersen, HPM report 10/2007) and a subsequent plan suggested by an expert committee (Pedersen, HPM report 13/2009). The restructuring of the hospital sector which entails a concentration of hospital activities in 18 acute hospitals with a greater coverage of specialties (in addition to the highly specialized Copenhagen University Hospital) has created some local debate, in particular due to a greater distance to the nearest acute hospital for citizens in some rural areas or areas with small islands. The plan involves building of 5 new acute hospitals. In some instances the government intervened and decided the number or location of the hospitals.
Because the regional boards have no right to fund their activities by direct taxation, and their budgets are fixed from outside, their role has been limited. In short, they have responsibility for expenses, but not for generation the income. Furthermore, the politicians have no chance to specialize as there are no possibilities creating permanent sub-committees for different areas of responsibility within the council. Some among the regional politicians have voiced disappointment as to their tasks and roles, having seen that the government has involved itself more in the current running of the health care than before, or are demanding certain policies fulfilled in return for the allocated funds. During the negotiation in 2008 between Danish Regions and various associations of health care providers, the government had a strong influence.
Following an agreement between the government and Danish Regions, an independent audit firm has investigated the efficiency of the regions. It pointed out in a report that some regions have build up larger administrative units than necessary. Various reasons have been forwarded to explain this; among these are that the regions inherited the former administrative personnel from the counties and that is has been difficult to reach an efficiency gain by reducing the staff in the short run; another explanation may be an internal interest in growth (Pihl-Andersen, 2009). Hospital doctors have experienced that administrative duties have increased (increased demand on documentation, accreditation processes, or even work on goals, visions and strategies ect.). It is difficult to determine whether this is due to establishment of stronger administrative units, or it is due to a more general trend in society.
An actual debate concerns the future survival of the regions as responsible for planning and running hospitals (Nielsen et al., 2009). One line of argument is that there is no ideal alternative (Chéret, 2009). The government needs a subordinate political layer with task of taking necessary decisions with local impact. Moreover, complaints from citizens in case of adverse events can be addressed to the local politicians rather than the parliament. Having the hospitals run by associations of municipalities does not seem to be a relevant issue in Denmark, but hospitals run by the state is seen by some as a desired alternative.
|Medienpräsenz||sehr gering||sehr hoch|
|Implemented in this survey?|
The stakeholdes' positions seem unchanged since the creation of the regions as of January 1st 2007 (an interim board reigned during 2006).
|Liberal Party||sehr unterstützend||stark dagegen|
|Conservative Party||sehr unterstützend||stark dagegen|
|Providers of health care||sehr unterstützend||stark dagegen|
|Political experts||sehr unterstützend||stark dagegen|
|Association of Municipalities||sehr unterstützend||stark dagegen|
|The electorate||sehr unterstützend||stark dagegen|
|Danish People's Party||sehr unterstützend||stark dagegen|
|Social democrats||sehr unterstützend||stark dagegen|
|Socialist Party||sehr unterstützend||stark dagegen|
The reform started as a surprise to many observers and politicians as well, as it was not a part of the document on which the then ruling government was formed. It was decided upon after a short period of hearing and discussion in the public. The original idea is still being implemented through, in particular, a large hospital reform which also entails large investments in new hospitals. In addition, the collaboration with municipalities within the health care and with general practitioners is strengthened.
|Liberal Party||sehr groß||kein|
|Conservative Party||sehr groß||kein|
|Providers of health care||sehr groß||kein|
|Political experts||sehr groß||kein|
|Association of Municipalities||sehr groß||kein|
|The electorate||sehr groß||kein|
|Danish People's Party||sehr groß||kein|
|Social democrats||sehr groß||kein|
|Socialist Party||sehr groß||kein|
As a fundamental reform, the implementation process involves politicians, administrative personnel, health care professionals and patients alike.
No systematic evaluation has been carried out so far.
The intended reform has been accomplished to a great extent.
|Qualität||kaum Einfluss||starker Einfluss|
|Gerechtigkeit||System weniger gerecht||System gerechter|
|Kosteneffizienz||sehr gering||sehr hoch|
As a consequence of the structural reform many initiatives have been taken which eventually will increase quality. It is difficult to determine whether cost-effectiveness will change in the long run.
Munk Christiansen, Peter; Klitgaard, Michael Baggesen. Den utænkelige reform: Strukturreformens tilblivelse 2002-2005.[The unthinkable reform. The origin of the structutal reform 2002-2005]. Odense: Syddansk Universitetsforlag 2008.
Phil-Andersen, Axel. Velpolstrede regioner. Jyllands-Posten November 2, 2009.
Nielsen, Hanne Fall; Phil-Andersen, Axel. Overlever regionerne. [Will the regions survive?] Jyllands-Psoeten, November 3, 2009.
Chéret, Helene. Politikere truer regionerne på livet. [Politicians threathen the very existence of regions]. Dagens Medicin November 6, 2009.
University of Southern Denmark