Healthcare in Finland

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Health care in Finland consists of a highly decentralized, three-level publicly funded health care system and a much smaller private health care sector. Although the Ministry of Social Affairs and Health has the highest decision making authority, the municipalities (local governments) are responsible in providing health care to their residents.

Finland offers its residents universal health care. Health promotion, including prevention of diseases has been the main focus of Finnish health care policies for decades. This has resulted in the eradication of certain communicable diseases and improvement in the health of population. Current challenges in the Finnish health care are waiting lists in ambulatory care, staff shortages in some municipalities, the increasing health care expenditures due to an aging population, and the increasing costs of the health care technology.1

The quality of service in Finnish health care is considered to be good; according to a survey published by the European Commission in 2000, Finland has the highest number of people satisfied with their hospital care system in the EU: 88% of Finnish respondents were satisfied compared with the EU average of 41.3%.2

History

A child welfare clinic in 1938

Finland’s journey to a welfare state has been long, from a very modest start. The history of modern medicine in Finland can be considered to have begun at 1640 when the first university of Finland, The Royal Academy of Turku, was established. At the time Finland was a part of the Swedish Empire. As the field of medicine did not enjoy very high status in society at the time, the importance of trained medical faculty remained low for a long time. Until 1750, the professor of medicine was the only trained medical doctor in Finland.3

An example of early treatment facilities for tuberculosis and leprosy was a hospital on the island of Själö (or Seili in Finnish) which was established on the 1624 and run by the church. It was chosen due to its remote location from the mainland. It was not however until 1759 that the first hospital, albeit a modest hospital, was established in Turku.4 Consisting of six patient beds in a simple wooden building, it nonetheless marked the first step toward the modern Finnish medical system. It is noteworthy that at the time, Finland had a much lower doctor-patient ratio comparing to neighboring countries. This lasted all the way until the 20th century.3

Mainly due to the poor hygiene, famine, and poverty, the most common causes of death in the mid-19th century consisted of infectious diseases such as tuberculosis, dysentery and typhoid fever.citation needed

Arvo Ylppö portrayed on a postage stamp published in 1987.

While the number of hospitals increased rapidly from the late 19th century onward, it was still uncommon to be treated in one.3 The largest causes of mortality were coronary heart diseases for men and breast cancer for women.3 In 1929, a special committee was established to evaluate the status of health care in Finland. Due to the lack of service providers outside cities, it was suggested that municipalities establish local hospitals for their citizens.3 The decision to establish publicly funded hospitals can be considered the base of the current model of modern health care in Finland.citation needed

The plans to reform the health care system were delayed due to the Second World War, but the increased need of medical care due to injuries to the soldiers may have enhanced the development of the hospital network.3 In the 1950s, Finland had two university hospitals, in Helsinki and Turku. Due to the increased demand of medical care and lack of medical doctors, more medical faculties and university hospitals were established.3

During the 20th century a notable contribution to the reduction of infant mortality was done by Arvo Ylppö. He conducted research about children’s pathological anatomy and attracted international recognition for his efforts. He has also contributed to the development of nursing education, pharmacy industry and public awareness about health issues.

Health status

Health care indicators

Finnish health care can be considered good by several indicators. For example, due to public health interventions and progress in medical care there have been remarkable improvements in life expectancy in Finland over the past few decades.5 Life expectancy on 2011 is 82 years for women and 75 years for men,6 which ranks Finland high on a global comparison.

Also good results have also been achieved regarding Infant mortality and maternal mortality rates, which are one of the among the lowest in the world. The infant mortality rate in Finland, as in other OECD countries, has fallen greatly over the past decades. It stood at 2.6 deaths per 1 000 live births in 2009.7

In 2009, Finland had 2.7 practicing physicians per 1 000 population which was the lowest among the Nordic countries.8 This can partly be explained by the important role that nurses which reduces the need for physician consultations.8 In 2009 there were 9.6 nurses per 1 000 population.8

Finland is successful in particular with regards to specialized medical care and the coverage of screenings and vaccinations. Finland has a very comprehensive screening program for breast cancer and as much as 84 per cent of women aged 50 to 69 years take part in screenings for breast cancer. The vaccination coverage of young children is very high in Finland and 99 per cent of the children under 2 years of age are vaccinated against whooping cough (pertussis) and measles.8

The most significant public health problems are currently circulatory diseases, cancer, muscoloskeletal diseases and mental health problems. Emerging problems are obesity, chronic lung diseases and type 2 diabetes.1 Major causes of deaths in Finland are cardiovascular diseases, malignant tumors, dementia and alzheimers disease, respiratory diseases, alcohol related diseases and accidental poisoning by alcohol.9

Suicide mortality in Finland has generally been one of the highest in Europe, but it has reduced to 18 per 100 000 population in 2005. One reason for this may be the large national suicide prevention project which was carried out between 1986 and 1996.1 The World Health Organization has compiled a list of countries by suicide rate

HIV/AIDS is not a major public health concern in Finland. The prevalence among adult population on 2009 was 0.1%.10 HIV/AIDS in Europe is much more common than in Finland, and the countries very near to Finland have much higher prevalence rates, due to increased travel HIV/AIDS rates in Finland may rise.

Lower fertility rates and an aging population, due to increased life-expectancy, 11 brings new challenges to the Finnish health care system because there will be fewer people to pay for the health and social care of the quickly aging population.12 It is estimated that the old age dependency ratio in Finland will be the highest of all EU countries in 2025.13

Risk factors

Percentages of smoking adult population in Finland, Norway, USA, Japan and the Netherlands in 2011

The total annual alcohol consumption has risen from 7.6 litres (in 1985) to 10.0 litres of 100% alcohol equivalent per capita in 2010. There has been a small reduction in alcohol consumption in the recent years. Alcohol use is highest in the Northern Finland with 10,9 liters and lowest at the Åland Islands with 5,7 liters per person.14 Although the consumption is average to other western countries, binge drinking with especially teenagers and becoming intoxicated has remained as a characteristic of Finnish drinking habits.15 Finland has a national alcohol programme to reduce the long-term effects of alcohol. The World Health Organization has published a list of countries by alcohol consumption.

Smoking among adults has shown a marked decline over the past thirty years in most OECD countries. Much of this decline also in Finland can be attributed to policies aimed at reducing tobacco consumption through public awareness campaigns, advertising bans and increased taxation. Smoking in Finland has reduced, and now the smoking rates among adults in Finland in 2009 stood at 18.6%, lower than the OECD average of 22.3%.7

Drug use is not a major public health problem in Finland. The most commonly used drug is cannabis. According to a study from 2008, the percentage of the population aged 15 to 69 who had at some point in their lives tried cannabis was 13%; 3% of the population had used cannabis within the previous 12 months.16

Organizational structure

The Government decides on general national strategies and priorities and proposes bills to be discussed by the parliament. Health care policy is primarily the field of Ministry of Social Affairs and Health. The Ministry also directs and guides the development and policies of social protection, social welfare and health care. Due to the decentralized public administration, municipalities decide themselves how the local services are provided.1 Every municipality has a responsibility to offer health care services to their residents and it is usually provided municipal health care centers.

Maria Hospital, Helsinki

Primary care is obtained from the health care centers employing general practitioners and nurses that provide most day-to-day medical services. Health centers are also active in health promotion activities. The general practitioners are also gatekeepers to the more specialized services in the secondary and tertiary care sectors, as a referral from primary care provider is necessary to receive care on the secondary and tertiary levels. Primary health services provided by municipalities are defined in the Primary Health Care Act.

Secondary care is provided by the municipalities through district hospitals where more specialist care is available. Secondary care is provided by regional hospitals. Finland also has a network of five university teaching hospitals which makes up the tertiary level. These contain the most advanced medical equipment and facilities in the country. These are funded by the municipalities, but national government meets the cost of medical training. These hospitals are located in the major cities of Helsinki, Turku, Tampere, Kuopio, and Oulu. All these five cities have a medical faculty.

Health financing

The health care system receives funding from two sources. Municipal financing is based on taxes and is used to provide primary health care services. They also have a right to collect user fees, and receive state subsidies if their tax levy is not adequate for providing the public services required, based on the demographic factors on their area. Municipalities fund the health centers on the primary care level and regional hospitals on secondary care level.1 As municipalities are both the providers and purchasers of the health services it does not encourage for cost-efficiency. National Health Insurance (NHI) is based on compulsory fees and it is used to fund private health care, occupational health care, outpatient drugs and sickness allowance. Regional and university hospitals are financed by federations of participating municipalities, often using the diagnosis-related group system.17

User fees

The out-of-pocket fee amount for a doctor's visit or treatment in the primary health care is set at a maximum of EUR 13.70 (in 2010) and the amount varies from one local authority to another. Hospital out-patients pay EUR 27.40 per consultation; in-patients pay a per diem charge of EUR 32.50. For long-term illnesses, the charges are based largely on income.18 Although a vital part for health financing and provision, the current system of the user fees has been discussed to contribute to the inequities in the access of health services among the low-income residents.19

Health expenditure

Health expenditure in 2009 amounted to EUR 15.7 billion.20 The public sector is the main source of health funding, 74.7% of health spending was funded by public sources in 2009, slightly more than the average of 71.7% in OECD countries. The share of public spending in Finland was, however, lower than in all other Nordic countries (Denmark, Iceland, Norway and Sweden) where it exceeds 80%. As in other OECD countries the health expenditure has been growing steadily since the year 2000.7 In 2009 health spending per capita in Finland is equal to the OECD average, with spending of EUR 2936 (or USD 3226 adjusted for purchasing power parity).7 Municipalities spent on average about 1300 euros per inhabitant on health care in 2005. Health care accounted for about 25% of the municipal budget.1

In a comparison of 16 countries on 2008 by Swedish Association of Local Authorities and Regions, Finland used the least resources and attained average results, making Finland the most efficient public sector health service producer according to the study's authors.21 One of the possible explanations for the low total health care expenditure in Finland is the low salary of health care professionals, especially that of nurses.1

Private sector

Due to the comprehensive public sector, private health care sector is relatively small. Between 3-4% of in-patient care is provided by the private health care system. Physiotherapy, dentistry and occupational health services are the most often used health services on the private sector.1 Approximately 10% of medical doctors work solely on private sector.22 Although high user fees may cause a barrier to use the private sector services as most is paid for out of pocket, a significant share of the cost is reimbursed by the Social Insurance Institution (SII) KELA.

Employers are obliged by law to provide occupational health care services for their employees, as are educational establishments for their students and staff. This can be done on public, or private sector.

National health insurance

The statutory National Health Insurance (NHI) scheme covers all Finnish residents, and it is run by the Social Insurance Institution (SII) through approximately 260 local offices all over the country. The responsibilities of this institute include coverage of some family benefits, National Health Insurance, rehabilitation, basic unemployment security, housing benefits, financial aid for students and state-guaranteed pensions. The NHI system offers varying levels of reimbursement for outpatient drugs, care from private providers, transport costs to health care facilities, sickness and maternity leave allowances, and some rehabilitation services. The NHI also partially reimburses occupational health care costs for services delivered to employees, but not to dependents.12

Additional voluntary health insurance has a very marginal role in the Finnish health care system and is mainly used to supplement the reimbursement rate of NHI.1

Pharmaceuticals

Outpatient pharmaceuticals, including over-the-counter drugs, can only be sold to patients by pharmacies. Providers can only deliver drugs that are actually administered within their facilities. Health centers can give outpatient drugs to patients when local pharmacies are closed, but only in the dosage needed to cover the time until the pharmacy reopens. Finland limits medicine sales to about 800 licensed pharmacies.1

Electronic prescribing used widely by Finnish health care setting. ePrescribing is used in about a half of the pharmacies and pharmacies are expected to prescribe electronically during 2012.23

Health information technology

Electronic Patient Records (EPR) have been in used since 2007 virtually in every health care provider. The development of health information systems has been largely uncoordinated at the national level, partly due to the decentralized health care system. As a result, several non-interoperable information systems are often used even within a single health care organization, which inhibits information exchange within and across provider organizations. Efforts are underway to create a common, national structure for communication between patients and providers over the internet.12

The Finnish Office for Health Technology Assessment FinOHTA is an independent, public assessment agency working as a part of National Institute for Health and Welfare since 1995. The aim is to assist decision-making by supplying information that is of a high scientific standard. The service is for all professional groups in health care, political decision-makers and the general public. Another main aim of for this office is for foreign results to be appraised in local conditions and their applicability in Finland is evaluated.24 FinOHTA is a member of INAHTA, the International Network of Agencies for Health Technology Assessment. FinOHTA also participates to the EUnetHTA project.

Immigrant health care

As per to the principle of the universal health care coverage immigrants who live in Finland permanently are entitled to all the same health services as the Finnish people. Holders of the European Health Insurance Card are also entitled for care in Finland. According to the Act on Adaptation of Immigrants and Reception of Asylum Seekers, asylum seekers are entitled to the same health services as permanent residents. These services must be organized by reception centres for refugees.1 It has been reported that immigrant health problems often may go untreated, and that immigrants use the public health system less than the general population.25 Health information to immigrants are provided with several languages by Infopankki.fi.26

On December 9th, 2013 the City of Helsinki decided, that all minors under the age of 18 and all pregnant mothers living in Helsinki without a valid visa or residence permit, are granted the right to the same health care and at the same price as all citizens of the city. This service will be available sometime early year 2014. Volunteer doctors of Global Clinic have tried to help these people, for whom only acute care has been available. This means that the Finnish health care system is open for people coming outside of the European Union. The service covers special child health care, maternity clinics and specialist medical care etc. practically for free. It is still unclear if this will increase so called health care tourism, because all you have to do is come to Helsinki as a tourist and let the visa expire.

Health equity

Equity is highly valued in Finland and the law provides same rights for all citizens, including in health care. There still exists some geographic and socioeconomic disparities in health care. Perhaps one of the most important reasons for the socioeconomic differences in the use of services is that the private sector and occupational health care, which are less accessible to the low-income population, offer better access to services (e.g. a major difference is waiting times) than the municipal sector.1 Narrowing health gaps has been the objective of Finnish health policy since the 1980s, however, this objective has not been fully achieved.27

References

  1. ^ a b c d e f g h i j k l "Finland - Health system review 2008". European Observatory on Health Systems and Policies. Retrieved 2011-12-13. 
  2. ^ "Health and long-term care in the European Union". European Commission. 2000. Retrieved 2011-12-13. 
  3. ^ a b c d e f g "Suomen terveydenhuoltojärjestelmän ja sairaaloiden kehittyminen". Kasvatus & Aika. Retrieved 2011-12-15 (in Finnish). 
  4. ^ "Turun lääninlasaretti — Suomen ensimmäinen sairaala". Arno Forsius. Retrieved 2011-12-15 (in Finnish). 
  5. ^ "Better Health Initiative". OECD. Retrieved 2011-12-15. 
  6. ^ "The World Factbook - Finland". CIA. Retrieved 2011-12-13. 
  7. ^ a b c d "How Does Finland Compare". OECD Health Data 2011. Retrieved 2011-12-13. 
  8. ^ a b c d "Health at a Glance 2011. OECD Indicators". OECD. 2011. Retrieved 2011-12-15. 
  9. ^ "Causes of Death 2009". Statistics Finland. Retrieved 2011-12-13. 
  10. ^ "European HIV and AIDS statistics". Retrieved 2011-12-13. 
  11. ^ "Population change at regional level". European Commission - Eurostat. Retrieved 2011-12-15. 
  12. ^ a b c "The Finnish Health Care System". SITRA. 2009. Retrieved 2011-12-13. 
  13. ^ "Ageing population - will public finances cope?". State Treasury. Retrieved 2011-12-15. 
  14. ^ "Alkoholijuomien kulutus 2010". Terveyden ja Hyvinvoinnin Laitos. 2011. Retrieved 2011-12-13 (in Finnish). 
  15. ^ "Alcohol use in Finland". National Research and Development Centre for Welfare and Health (Stakes). 2005. Retrieved 2008-04-18. 
  16. ^ "Drug Situation in Finland 2010". National Institute for Health and Welfare. Retrieved 2011-12-13. 
  17. ^ "Nordic DRG system". Nordic Casemix Center. Retrieved 2011-12-15. 
  18. ^ "Your social security rights in Finland". European Commission. Retrieved 2012-02-15. 
  19. ^ "Pitäisikö Terveyskeskusmaksu poistaa?". Kansanuutiset. Retrieved 2012-2-15 (in Finnish). 
  20. ^ "Health Expenditure and Financing in 2009". National Institute for Health and Welfare. Retrieved 2011-12-13. 
  21. ^ "Svensk sjukvård i internationell jämförelse". Swedish Association of Local Authorities and Regions. 2008. Retrieved 2011-12-15 (in Swedish). 
  22. ^ "Private Healthcare". Finnish Medical Association. Retrieved 2011-12-15. 
  23. ^ "Sähköinen resepti pian kaikkien kansalaisten käytössä". KELA. Retrieved 2011-12-15 (in Finnish). 
  24. ^ "About us". FinOHTA. Retrieved 2011-12-13. 
  25. ^ "Immigrant Health Problems Often Untreated". YLE News. Retrieved 2011-12-13. 
  26. ^ "Health". Infopankki.fi. Retrieved 2011-12-13. 
  27. ^ "National Action Plan to Reduce Health Inequalities 2008–2011". Ministry of Social Affairs and Health. Retrieved 2011-12-13. 

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