|Implemented in this survey?|
The Danish government aims to reduce inequality in health through prevention and health promotion measures directed towards vulnerable groups, in particular measures which would increase individual welfare, reduce health care costs and increase the work force. A new survey underlines the importance of these measures. A pilot project, "Equality in Health", and a new commission on prevention of ill health were already set up in 2006 and 2007 respectively. Results are expected in 2009.
The present liberal-conservative government, which has been in power since 2002, has continued the public health strategy of the former Social Democratic government (see "Political and Economic Background"), but with a broader approach to prevention through its document "Healthy Throughout Life 2002-10" (Indenrigs- og Sundhedsministeriet, 2002). It has recommended a strengthened effort against eight defined, widespread diseases (eg. diabetes, cardiovascular diseases, COPD, mental disorders, etc.). In particular, the government has highlighted preventive measures directed towards groups with weak resources, stressing that equality in health is a fundamental value in a welfare society (page 6). New survey results confirm the importance of these measures.
2008 survey shows lower health status for vulnerable groups
Together with the National Institute of Public Health the Council for Socially Marginalised People carried out a survey among the socially exposed in Denmark (SUSY-UDSAT, April 2008). According to the survey, 31% of the exposed claim that their general health is really good or good compared to 80% of the general population (www.udsatte.dk). At the same time the life style of the exposed are often unhealthy, and they often suffer from a long-standing illness. The chairman of the council declared that the results are alarming.
With the survey the council wished to influence decision-makers and health professionals to make efforts to reduce inequalities in health. After the publication of the report the Prime Minister asked the government's prevention committee to look into prevention for socially disadvantaged groups.
In its 2008 annual report the council supports the initiative by the government to open a possibility for prescribed heroin for a small group of hardcore drug users; a quality enhancement project in the area of treating drug misuse; and the establishment of an emergency social services for mentally ill people not needing emergency hospitalisation. The report also mentions some scandal cases, based on hidden-camera recording; one showing how institutionalised mentally ill have been filled with addictive sleeping and nerve medicine (Rådet for socialt udsatte, 2008). The council supports the coming years' efforts to reduce social inequality in health and it underlines the importance of the National Board of Health's project on health promotion that started in 2006 (see below) and preventive model projects. It also underlines the importance of the National Board of Health taking responsibility as an expression of sector accountability. Thus, it is stressed in the annual report (page 69) that sector accountability is important for all people, but unfortunately this is not always firm when is come to socially disadvantaged groups.
"Equality in Health" project to identify effective prevention initiatives
Already in 2006 the National Board of Health initiated a project, "Equality in health", in collaboration with 6 model municipalities. The aim is to obtain knowledge about health-promoting initiatives that could promote healthier lifestyles among socially exposed groups. The target groups are individuals who had taken early retirement, individuals on welfare support and unemployed skilled and unskilled workers. The project will last until 2009.
Independent commission elaborates recommendations for cost-effective activities
Moreover, a new independent commission on prevention of ill-health was set up by the liberal-conservative government in 2007. The commission is expected to publish a report in 2009 with recommendations for preventive activities, in particular recommendations with documented cost-effectiveness that focus on groups with weak resources. Prevention is a high priority of the government, one of whose prime goals is to increase Danish life expectancy by 3 years in the period 2007-2017 (which is slightly above the average increase during the last century). In the commission's mandate it is recognised that unhealthy lifestyle is associated with a considerable share of all health problems and early deaths. The new Health Law from 2005 and the organisational reform have created new frames for prevention directed towards citizens as well as patients. While the citizen-directed prevention should be anchored in the new municipalities, the patient-directed prevention should be anchored in the municipalities and regions.
Among the arguments for setting up the commission on prevention of ill-health was a prognosis of a steady increase in the future number of patients with long-standing illness that was related to lifestyle. It is well known that there is a social gradient in unhealthy lifestyle, and potential gains may be high among groups with weak resources.
Reduce inequalities in health, reduce costs of health care, increase work force
Individuals (in particular exposed groups), healthcare sector
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The incentives by the politicians to reduce inequality in health by promoting the health of exposed groups have been enlarged from welfare concerns to concerns for health costs and the size of the work force.
Reducing inequality to improve efficiency
The initiatives that have been undertaken during the most recent years seem to indicate a change from equity as a solidarity issue to equity as an efficiency issue. Thus, the focus on groups with weak resources can be seen as an attempt to increase cost-effectiveness in prevention. Prevention can be seen as an investment in health and a means to increase welfare. In a society with high demand of labour, there is a high opportunity cost of having patients outside the labour force. Moreover, the costs of treating patients with longstanding illness are increasing. Along the same lines, the Welfare Commission has argued that prevention would increase welfare and reduce costs of illness (Velfærdskommissionen 2005, chapter 15).
The issue of inequality of access has also been discussed in the political debate in relation to suggestions for increased user charges. Currently there are relatively high user charges on pharmaceuticals and dental care, but no user charges on visits to a general practitioner or to hospital. Each time user charges for these services are suggested, it has been rejected politically from all dominating parties as well as the medical associations. The argument is that user payment would be socially unequal, as it would discourage those most in need from seeking medical care.
The increasing use of private health insurance (mostly paid for by employers, but indirectly also by taxpayers due to tax exemptions for health premiums) has also raised an equity debate. There is a fear that the population would be divided into an A- and B-team, with the A-team having easier access to immediate health care through private suppliers rather than being exposed to a waiting time for hospital treatment in the public health care system. It has been claimed that if the universal principle of access to health care in Denmark were abandoned, there would be a risk of losing solidarity from groups with strong resources.
Reducing inequality in health and securing equal access to health care seems to be an ever present issue on the political agenda, but it can be questioned whether it is a high priority topic for the electorate.
The present government seems to have focused on prevention and health promotion for vulnerable groups in particular for several reasons, including concerns for individual welfare, cost reductions in the health care sector, and as a means of increasing the work force. The following relates to the 2007 Commission on Prevention and the pilot project "Equality in Health".
|Implemented in this survey?|
The initiatives to settle a commission on prevention of ill-health (2007) and the initiative by the National Board of Health's "Equality in Health" pilot project can be seen as a continuation of a long-standig policy to reduce inequality in health and promote health through prevention, in particular directed towards exposed groups:
Free and equal access - traditional values in Danish health care
Inequality in health has been on the political agenda in Denmark for decades. Free and equal access to health care have long been traditional values. The present Health Law (2005) calls for respect for the individual person and its integrity and self-determination, as well as easy and equal access to health care. The present liberal-conservative government also adheres to free and equal access to health care.
While Danes have the highest self-assessed health among Europeans, there is still some inequality in health (van Doorslaer et al., 2004). Life expectancy in Denmark is below the OECD average (OECD, 2007), as it remained stagnant from the mid-1970s to the mid-1990s. This stagnation was considered to be mainly due to unhealthy lifestyles (tobacco and alcohol) (Middellevetidsudvalget 1994).
While free and equal access should be seen as a means to achieve reduced inequality in health for those who are ill, a number of more general measures have been taken to reduce inequality in health through prevention and health promotion.
Two main health goals of the former Social Democratic government were to increase life expectancy and to reduce social inequality in health, according to its Public Health Programme 1999-2008 (Sundhedsministeriet 1999).
Social inequality in health and life expectancy has been extensively documented by the research community. It has been clearly documented that an unhealthy lifestyle has both a social gradient and an educational gradient. Even survival after cancer treatment has been proven to be unequally distributed. According to some studies, the health gradient has increased recently during a period of economic growth. Thus, there seems to be possibilities for improving both life expectancy and quality of life, as well as reducing social inequalities in health, through interventions that improve lifestyle.
Creation of Council for Marginalized People in 2002
A Council for Socially Marginalised people was created in 2002 by the liberal-conservative government. The council includes 8-12 members who are personally appointed by the Minister of Social Welfare on the basis of their particular knowledge about and experience in dealing with exposed groups. The council embraces expertise in dealing with the homeless, drug abusers, prostitutes, psychiatric patients and alcoholics. The council is independent of the ministry.
The purpose of the council is to strengthen the common responsibility for the weakest and most vulnerable citizens. The council should - according its mandate - be seen as a voice for the marginalized citizens. Among its tasks is to follow the social efforts for the weakest and publish an annual report on the situation of the weakest groups and suggest initiatives, including suggestions as to how the civil society can be included in the solutions.
Special fund to support projects directed at vulnerable groups
In order to support exposed and vulnerable groups, a specific effort fund has been decided upon each year through the Finance Act. The yearly fund, agreed upon among most parties in parliament since 1990, amounts to more than 800 million DKK in 2008. The fund is distributed to various purposes by the political parties to activities within the area of social-, health- and labour market affairs. In some cases there is an opportunity to apply directly for support from voluntary organisations or institutions dealing with the exposed and vulnerable, for example alcoholics. A share of the fund is used to regulate the cash payments within the social area with the inflation.
The original idea was to support small projects within the social area with the aim to improve the conditions for weak groups - often projects which could be seen a small-scale, preliminary projects. But as time went on, the projects under the fund have increased.
Voices have been raised - among others by the chairman of the Council for Socially Marginalised people - that the support for exposed and weak groups should be decided upon directly through the yearly Finance Act rather than separately at the discretion of politicians after passage of the act.
The approach of the idea is described as:
There seems to be consensus about the aim to reduce inequality in health. A policy paper is expected in 2009 as well as a report on a pilot project on how to reduce inequality in health.
|National Board of Health||very supportive||strongly opposed|
|Municipalities||very supportive||strongly opposed|
|Political parties||very supportive||strongly opposed|
The preventive and health promoting measures can be taken within the frames of the new organisation of the public sector after the recent structural reform (see HPM report (5)2005).
|National Board of Health||very strong||none|
|Political parties||very strong||none|
Main actors will be health promoting personnel in mulicipalities, including the municipal health centres to be created.
Inproved health of the vulnerable groups in society. Better care of patients with long-standing illness.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
There is a lack of knowledge of which measures work well in the area of prevention and health promotion, hence the effects are difficult to predict.
Rådet for socialt udsatte [Council for Socially Marginalised People]. Copenhagen: Årsrapport 2008 [Annual Report 2008].
Institute of Public Health, University of Southern Denmark.