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Structural reform in Denmark - follow-up

Country: 
Dänemark
Partner Institute: 
University of Southern Denmark, Odense
Survey no: 
(14) 2009
Author(s): 
Terkel Christiansen
Health Policy Issues: 
Organisation/Integration des Systems, Politischer Kontext, Zugang
Current Process Stages
Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein nein nein nein ja nein

Abstract

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.

Neue Entwicklungen

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.

 Suchhilfe

Characteristics of this policy

Innovationsgrad traditionell innovativ innovativ
Kontroversität unumstritten recht kontrovers kontrovers
Strukturelle Wirkung marginal fundamental fundamental
Medienpräsenz sehr gering sehr hoch sehr hoch
Übertragbarkeit sehr systemabhängig recht systemneutral systemneutral
current current   previous previous

 

Purpose and process analysis

Current Process Stages

Idee Pilotprojekt Strategiepapier Gesetzgebung Umsetzung Evaluation Veränderung/Richtungswechsel
Implemented in this survey? nein nein nein nein nein ja nein

Initiators of idea/main actors

  • Regierung: Divergent attitudes among the two government parties towards the very existence of the Danish regions. The Liberal Party is the biggest party and controls the most relevant ministries (Prime Minister's Ministry, Ministry of Interior and of Health).
  • Leistungserbringer: Health care personnel deals with the regions as their employer in the same way as with the former counties.
  • Wissenschaft: In general, political experts see the administrative structure with regions taking care of planning and running the hospital sector as the most feasible.
  • Andere: In general, citizens are rather ignorant as to who represents them in the regional boards and what are the political issues apart from restructuring the hospitals.
  • Politische Parteien: Opposition parties are in favour of keeping the regions.

Stakeholder positions

The stakeholdes' positions seem unchanged since the creation of the regions as of January 1st 2007 (an interim board reigned during 2006).

Actors and positions

Description of actors and their positions
Regierung
Liberal Partysehr unterstützendsehr unterstützend stark dagegen
Conservative Partysehr unterstützenddagegen stark dagegen
Leistungserbringer
Providers of health caresehr unterstützendunterstützend stark dagegen
Wissenschaft
Political expertssehr unterstützendunterstützend stark dagegen
Andere
Association of Municipalitiessehr unterstützendunterstützend stark dagegen
The electoratesehr unterstützendneutral stark dagegen
Politische Parteien
Danish People's Partysehr unterstützenddagegen stark dagegen
Social democratssehr unterstützendsehr unterstützend stark dagegen
Socialist Partysehr unterstützendsehr unterstützend stark dagegen
current current   previous previous

Influences in policy making and legislation

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.

Legislative outcome

n/a

Actors and influence

Description of actors and their influence

Regierung
Liberal Partysehr großsehr groß kein
Conservative Partysehr großsehr groß kein
Leistungserbringer
Providers of health caresehr großneutral kein
Wissenschaft
Political expertssehr großneutral kein
Andere
Association of Municipalitiessehr großgroß kein
The electoratesehr großgroß kein
Politische Parteien
Danish People's Partysehr großgroß kein
Social democratssehr großgering kein
Socialist Partysehr großgering kein
current current   previous previous
Social democrats, Socialist PartyLiberal PartyProviders of health care, Political expertsAssociation of MunicipalitiesThe electorateDanish People's PartyConservative Party

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

As a fundamental reform, the implementation process involves politicians, administrative personnel, health care professionals and patients alike.

Monitoring and evaluation

No systematic evaluation has been carried out so far.

Expected outcome

The intended reform has been accomplished to a great extent.

Impact of this policy

Qualität kaum Einfluss starker Einfluss starker Einfluss
Gerechtigkeit System weniger gerecht neutral System gerechter
Kosteneffizienz sehr gering neutral sehr hoch
current current   previous previous

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.

References

Sources of Information

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.

 

 

Author/s and/or contributors to this survey

Terkel Christiansen

University of Southern Denmark

Empfohlene Zitierweise für diesen Online-Artikel:

Christiansen, Terkel. "Structural reform in Denmark - follow-up". Health Policy Monitor, October 2009. Available at http://www.hpm.org/survey/dk/a14/3