Finland: Health system summary, 2023

Health system summary 2023 Finland AUTHORS Liina-Kaisa Tynkkynen, Ilmo Keskimäki, Marina Karanikolos, Yulia Litvinova Anna Maresso (Series Editor) This Health system summary is based on the Finland: Health System Review published in 2019 in the Health Systems in Transition (HiT) series, and is significantly updated by the authors, including relevant reform updates highlighted by the Health Systems and Policies Monitor (HSPM) (www.hspm.org). For this edition, key data have been updated to those available in December 2022, unless otherwise stated. Health system summaries use a concise format to communicate central features of country health systems and analyse available evidence on the organization, financing and delivery of health care. They also provide insights into key reforms and the varied challenges testing the performance of the health system. Main source: Keskimäki I, Tynkkynen LK, Reissell E, Koivusalo M, Syrjä V, Vuorenkoski L, Rechel B, Karanikolos M. Finland: Health system review. Health Systems in Transition, 2019; 21(2): 1–166. Please cite this publication as: Tynkkynen LK, Keskimäki I, Karanikolos M, Litvinova Y (2023). Finland: Health system summary, 2023. ISSN 2958-9193 (online) ISBN 9789289059398 CONTENTS How is the health system organized? . . . . . . . . . . . . . . . . . . 3 How much is spent on health services? . . . . . . . . . . . . . . . . 5 What resources are available for the health system? . . . . 8 How are health services delivered? . . . . . . . . . . . . . . . . . . 10 What reforms are being pursued?. . . . . . . . . . . . . . . . . . . . 12 How is the health system performing? . . . . . . . . . . . . . . . . 13 Summing up . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 HEALTH SYSTEM SUMMARY: 2023 3 How is the health system organized? ORGANIZATION From January 2023, the health system in Finland will be restructured. In the new structure health care is organized by 22 Well-being Service Counties (WBSC), including the city of Helsinki; and the Hospital District of Helsinki and Uusimaa (See Box 1). The WBSCs, which are governed by democratically elected councils, are financed from the state budget. Municipalities, which were responsible for organizing health care and social services until the end of 2022, remain responsi- ble for public health functions, such as environmental health and health protection. For health promotion and well-being programmes, municipalities collaborate with the WBSCs. The WBSCs are responsible for organizing primary and secondary health care as well as social and rescue services for their residents. In addition, each of the After a major reform, from 2023 health services in Finland are centralised from municipal to county level BOX 1 | FROM A HIGHLY DECENTRALIZED SYSTEM TOWARDS MORE CENTRALIZATION Historically, a highly decentralized and fragmented administrative structure encumbered the governance of the Finnish health system. Until the end of 2022, over 300 municipalities were responsible for organis- ing primary and specialist care for their residents, while the central government had limited means for steering. In practice, the municipalities often had a limited capacity in planning, evaluating health system performance and decision-making regarding service delivery models. This led to inequalities and lack of coordination, as well as a high degree of administrative inefficiency. The reform process to centralize healthcare to counties began in the early 2000s, and, after years of debate, refinement and various failed reform proposals, resulted in the establishment of WBSCs which are responsible for the provision of all publicly financed health and social services, and the creation of a central, tax-based funding mechanism for these services at the national level from 2023. The new administrative structure for health system in Finland Source: Government of Finland, 2022. FINLAND4 WBSCs belongs to one of five collaborative areas, organ- ized around five university hospitals. The collaborative areas centralize the organization of tertiary-level ser- vices provided in the university hospitals, and distribute responsibilities between university hospitals for highly specialized care, such as treatment of rare diseases. The Uusimaa region comprises of four WBSCs and the City of Helsinki, which are responsible for primary health care, social care and rescue services. Specialist care for the four WBSCs and for the City of Helsinki is delivered by the Hospital District of Helsinki and Uusimaa. Legislation and general policy guidelines are prepared at the national level by the Ministry of Social Affairs and Health (MSAH). The new health system structure strengthens the strategic role of the central government including steering the WBSCs in how they organize services through recommendations, and supporting collaboration between the counties through collaborative area agreements. PLANNING The MSAH, together with the Ministries of Finance and Interior, are responsible for planning and steering of the health system at the national level. From 2023, national governance takes place through annual negoti- ations with the WBSCs on their investment plans and service delivery strategies. Centralized stewardship also occurs via nationally-funded projects that often reflect the government’s strategic development priorities and long-term planning programmes. In addition to negotiating investment and service provision plans, the WBSCs also need to agree on the distribution of work within their collaborative area, particularly for highly specialized care and services. The MSAH can interject if the WBSCs within a collaborative area are not able to reach agreement. The Finnish Institute for Health and Welfare (THL) plays an important role in supporting planning and governance at the national, regional and local level by collating and disseminating information, producing guidelines, as well as through research and development projects. In the new health system structure, the THL also has a statutory role to evaluate the performance of the counties annually. PROVIDERS There are three parallel systems for health service provision in Finland. The principal system is publicly financed and organized by the counties for all levels of care. The WBSCs run health centres and district hospitals, which deliver primary and secondary care respectively. Emergency care is provided by hospitals’ emergency departments. There are four WBSCs which host a university hospital, in the cities of Tampere, Turku, Kuopio and Oulu. The fifth university hospital in Helsinki is hosted by the Hospital District of Helsinki and Uusimaa. The other two systems are the private sector and occupational health care, mostly providing ambulatory primary and specialist services. The latter is organized by employers, who are obliged by law to provide occupational care to their employees. In addition, students in higher education have their own not-for-profit health scheme called the Finnish Student Health Service (FSHS). HEALTH SYSTEM SUMMARY: 2023 5 How much is spent on health services? FUNDING MECHANISMS As of 2023, the state financing of the Finnish health system has become centralized at the national level. However, multiple channels for financing services remain. These include the compulsory contributions to the national health insurance (NHI) system, employ- ers’ expenditure under the occupational care scheme, voluntary health insurance, the FSHS expenditure for students in higher education, and households’ direct out-of-pocket (OOP) payments. In 2019, the state covered 64% of current health expenditure, 14% was contributed by the NHI and 22% by private sources. The key change to state financing from 2023 is that municipalities will no longer be responsible for financing health care via the taxes they levy. Instead, the WBSCs will mainly be funded based on imputed central government funding according to a specific formula. These central transfers for WBSCs will be based on the 2022 health, social and rescue services costs transferred from municipalities. The annual level of national funding will take the following factors into account: i) an annual budget increase of 0.2 percentage points for the years 2023–2029; ii) estimated increase in service needs; iii) change in cost levels; and iv) change in WBSCs’ responsibilities. The funding will be adjusted retrospectively to correspond to the actual costs at the national level. Approximately 80% of the funding will be allocated based on a coeffi- cient for health and social care needs. The remaining part includes funding per capita and other factors (such as bilingualism, foreign languages and population density). A small proportion will come from the revenue from user fees and sales. The NHI scheme is funded by the state and employ- ees through income-based insurance contributions col- lected alongside income tax. Employers also contribute to the income insurance part, which is used for the financing of occupational health services. The NHI scheme reimburses outpatient prescription medicines, the cost of private sector health and dental services, and travel to obtain health care. HEALTH EXPENDITURE Between 2000 and 2020, health expenditure per person in Finland (when adjusted for differences in purchas- ing power) more than doubled, from US$ 1900 to US$ 4897 (Fig. 1), and in 2020 it was above the EU average of US$ 4224 (Fig. 2). As a percentage of GDP, Finland’s health expenditure has grown from 7.1% in 2000 to 9.6% in 2020 and remains above the EU average of 9.2%. Public expenditure on health as a share of GDP has increased from 5.4% in 2000 to 7.8% in 2020. Over 79% of health expenditure comes from public sources, 16.4% from OOP payments, while voluntary health insurance constitutes about 4.5% of spending. Public expenditure on health as a share of general government expenditure was around 13.7%, substantially below other Nordic countries, which spend between 16% and 19%. OUT-OF-POCKET PAYMENTS Over 16% of the health spending in Finland comes from OOP payments (Fig. 3). This share has steadily reduced from a peak of 19.3% in 2016. The four largest areas of OOP health spending are pharmaceuticals (30%), followed by long-term care (16%), dental care (16%) and outpatient care (13%). Pharmaceuticals Public expenditure on health in Finland as a share of GDP is below that of other Scandinavian countries, and reliance on out-of-pocket spending is higher FINLAND6 CHE in US$ PPP per capita 0 2 000 4 000 6 000 8 000 10 000 Kyrgyzstan Tajikistan Uzbekistan Azerbaijan Republic of Moldova Albania Turkmenistan Ukraine Kazakhstan Georgia Türkiye Belarus North Macedonia Bosnia and Herzegovina Serbia Armenia Romania Bulgaria Croatia Poland Montenegro Slovakia Russian Federation Latvia Hungary Greece Estonia Lithuania Monaco Cyprus WHO European Region average Israel Portugal Slovenia Czechia Italy Spain EU average Malta Andorra Finland Iceland San Marino United Kingdom France Belgium Sweden Denmark Austria Netherlands Ireland Luxembourg Germany Norway Switzerland 269 313 533 656 877 895 907 945 1 002 1 108 1 261 1 286 1 295 1 517 1 661 1 721 2 012 2 088 2 229 2 235 2 255 2 268 2 278 2 331 2 408 2 653 2 919 2 932 3 164 3 219 3 352 3 457 3 606 3 767 3 846 4 032 4 048 4 224 4 695 4 720 4 897 5 100 5 167 5 577 5 740 5 883 6 347 6 351 6 401 6 613 6 658 6 844 7 032 7 168 8 493 FIG. 1 TRENDS IN HEALTH EXPENDITURE, 2000–2020 (SELECTED YEARS) Note: GDP: gross domestic product; PPP: purchasing power parity. Source: WHO Global Health Expenditure Database, 2022. FIG. 2 CURRENT HEALTH EXPENDITURE (US$ PPP) PER CAPITA IN WHO EUROPEAN REGION COUNTRIES, 2020 Notes: CHE: current health expenditure; EEA: European Economic Area; EU: European Union; PPP: purchasing power parity. Source: WHO Global Health Expenditure Database, 2022. US $ P P % G DP Current health expenditure per capita Current health expenditure as % of GDP 2000 2005 2015 2016 2017 2018 2019 20202010 0 1 000 2 000 3 000 4 000 5 000 6 000 0 2 4 6 8 10 HEALTH SYSTEM SUMMARY: 2023 7 and outpatient care account for almost half of all OOP payments. User fees exist across all service areas, with occupational health being the only exception. Mechanisms for financial protection are still lim- ited, despite the 2021 changes in user fees, which reduced annual caps on OOP spending, introduced some exemptions for specific population groups (e.g. children) and certain services (e.g. nurse visits, psy- chiatric treatment in primary care, some services in support centres for certain vulnerable groups) and an option to apply for income assistance for people with very low income. FIG. 3 COMPOSITION OF OUT-OF-POCKET PAYMENTS, 2020 Note: OOP: out-of-pocket; VHI: voluntary health insurance. Sources: OECD Health Statistics, 2023. COVERAGE Health coverage in Finland is fragmented and some gaps are persistent (Box 2). The transfer of responsi- bility to organise care from municipalities to counties is expected to address this at least partially. Previously, while all residents were covered by the public system, availability of services, particularly in primary care, varied across municipalities. In addition, many employees are covered by occupational health care, the scope of which also varies. However, employed people usually are able to acquire basic ambulatory outpatient services through the occupational health care system, with no user fees and often quicker access. Inpatient 6.1% VHI 4.5% Outpatient medical care 13.4% Pharmaceuticals 29.9% Other 18.3% Long-term care 16.5% Dental care 15.9% Government/ compulsory schemes 79.1% OOP 16.4% OOP distribution BOX 2 | WHAT ARE THE KEY GAPS IN COVERAGE? Population health coverage in Finland is comprehensive for residents. However, some population groups (e.g. undocumented migrants) currently only have access to urgent care. In recent years, debates on the scope of publicly-financed health care have addressed services, such as fertility treatment for female couples and single women, and very expensive treatments for hereditary diseases and cancer. User fees in Finland apply to a wide range of services provided by the public system. NHI reimbursement levels for medicines are relatively low, with patients paying on average 34% (in 2017) of the costs of prescription medicines. Annual cost ceilings are set at a high level: €692 in 2022 for health services, €592 for prescription medicines and €300 for travel costs per person (with children included within one parent’s ceiling). The recorded level of catastrophic OOP payments has been relatively high in Finland (see section on Accessibility). FINLAND8 PAYING PROVIDERS At the time of writing, the WBSCs were preparing to launch their operations, and no comprehensive infor- mation on the funding mechanisms for providers was available. The counties, being the owners of public health care providers, have an option to prospectively fund providers of both primary care and specialist services. However, the budgeted funding of the public sector is likely an interim solution, and it is expected that mecha- nisms will evolve. For instance, in the previous municipal system, typical funding for hospital districts providing specialist care consisted of a fixed part, accounting for population size, and a part based on service use. Most hospital districts used diagnosis related groups (DRGs) at least for a part of the funding. In addition, bed day charges or treatment package pricing were also applied. Regarding purchasing of services from private pro- viders, the contracts and payment mechanisms continue to vary between counties with payment types, including capitation and a mix of capitation and fee-for-service in primary care and various case-based and fee-for-service contracts for specialized care. Occupational health care services are paid for by employers according to contracts with providers (mainly private), also using a variety of methods. What resources are available for the health system? HEALTH PROFESSIONALS Overall, the number of practicing physicians in Finland per 100 000 population is lower than the EU average, while the number of practicing nurses is considerably higher. In 2019, there were 348 practising physicians and 1357 practicing nurses per 100 000 population in Finland compared to the averages of 393 physicians and 835 nurses per 100 000 in the EU. (Figs. 4a and 4b). Most professionals working in the health sector are employed in county-run health services (health centres and hospitals), with only 16% working in private medical centres. Moreover, it is common for doctors practicing in public hospitals to also have out-of-hours private practices in private health care clinics. As in other countries, there are regional variations in the distribution of human resources in Finland, with the northern districts recording lower numbers (fewer than 200 physicians per 100 000 inhabitants) than southern ones. HEALTH INFRASTRUCTURE There are about 300 public sector inpatient care facilities in Finland, such as specialist and primary care com- munity hospitals (the latter mainly containing nursing beds). As in other EU countries, the number of acute and long-term care hospital beds has decreased mark- edly since 2000 (Fig. 5). The decrease has been most pronounced in primary care beds, where between 2006 and 2013 these fell by over 40% in some regions. During the same period, specialist care beds decreased in some areas by 20–30% (Mikkola et al., 2015). A shortage of qualified health workers and limited finances played a role in this development, along with the centralization of emergency care services. The current implementation of the social and healthcare reform and an increase in digital services can further accelerate this process. Most public hospitals in Finland were built in the 1960s and are in need of renovation or the construction of new buildings. An earlier wave of capital spending began in 2001 and by 2012 had led to a cumulative national-level investment of €3.3 billion, although overall investment Regional differences persist in the availability of human and physical resources HEALTH SYSTEM SUMMARY: 2023 9 FIG 4A NUMBER OF PHYSICIANS PER 100 000 POPULATION IN FINLAND AND SELECTED COUNTRIES, 2000–2019 Notes: EU27: European Union 27 countries. Data are for practicing physicians. The latest data for Finland are for 2018. Source: Eurostat, 2022. FIG 4B NUMBER OF NURSES PER 100 000 POPULATION IN FINLAND AND SELECTED COUNTRIES, 2000–2019 Note: EU27: European Union 27 countries. Data are for practicing nurses. The latest data for Finland are for 2018. Source: Eurostat, 2022. FIG 5 BEDS IN ACUTE HOSPITALS PER 100 000 POPULATION IN FINLAND AND SELECTED COUNTRIES, 2000–2019 Source: Eurostat, 2022. Norway Sweden Finland Netherlands Denmark EU27 (estimate) 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 20 20 21 20 19 20 00 20 01 20 02 20 03 Ph ys ic ia ns p er 1 00 0 00 p op ul at io n 200 300 400 250 350 450 500 550 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 20 00 20 01 20 02 20 03 Norway Sweden Finland Netherlands Denmark EU27 (estimate 2020) Nu rs es p er 1 00 0 00 p op ul at io n 600 1 200 1 000 800 1 400 1 600 1 800 2 000 20 04 20 05 20 06 20 07 20 08 20 09 20 10 20 11 20 12 20 13 20 14 20 15 20 16 20 17 20 18 20 19 20 00 20 01 20 02 20 03 Norway Sweden Finland Netherlands Denmark EU27 Ac ut e ca re b ed s pe r 1 00 0 00 in ha bi ta nt s 100 200 300 400 500 FINLAND10 needs were estimated at €6 billion (Punnonen, 2013). In 2022, the hospital districts were carrying out or planning investments of over €6 billion on facilities (Maakuntien tilakeskus, 2022). From 2023, the national government is responsible for steering the investments of WBSCs. The ratio of mammography machines in Finland has remained at around 3 per 100 000 population between 2010 and 2020. The number of CT scanners has decreased from 2.1 to 1.7, while the number of MRI scanners has increased from 1.9 to 3.1 over the same period (Fig. 6). FIG. 6 MAGNETIC RESONANCE IMAGING (MRI) AND COMPUTED TOMOGRAPHY (CT) SCANNERS IN FINLAND, 2020 Note: Data for MRI and CT scanner units include those in ambulatory facilities and acute hospitals. Source: Eurostat, 2022. DISTRIBUTION OF HEALTH RESOURCES Historically, the central hospitals have been located in the major cities and have been surrounded by a network of district and primary care inpatient facilities in more sparsely populated areas. When evaluated in 2015, marked differences between regions were found; there was a preponderance of small munici- pality-owned primary care hospital buildings in the eastern and southwestern parts of Finland. Since then, seeking to improve efficiency, these regions have merged hospitals into larger entities and some facilities have been closed or premises rented out for other purposes. This development has accelerated since 2017, following a policy that sought to centralize high-level specialist healthcare through defining the minimum annual number of deliveries and certain operations. How are health services delivered? PRIMARY AND AMBULATORY CARE Primary care is provided through three overlapping health systems: the health centre-based system operated by counties from 2023, occupational health care and private for-profit care. In addition, the FSHS provides primary health care services, including mental and oral health care services for students at universities and other institutions of higher education. Primary care is mainly delivered in health centres that employ GPs, nurses and other professionals, depending on the size and needs of the population. Furthermore, eHealth services are developing, and digitalization is playing an increasing role in health care (Box 3). Ambulatory specialized care is provided in outpatient departments of hospitals or in larger health centres. The latter may collaborate with their local or central hospitals for delivery of specialist consultations and to carry out small procedures, such as endoscopies and stress ergometry. Primary care has gradually expanded to deliver more specialized services MRI scanners per 100 000 population CT scanners per 100 000 population Finland 3.1 1.7 Lowest and highest in EU (range) 0.49 (Hungary) to 3.45 (Germany) 0.96 (Hungary) to 4.64 (Iceland) HEALTH SYSTEM SUMMARY: 2023 11 HOSPITAL CARE Inpatient care is organized by WBSCs and provided by district, central and university hospitals, but there are also some private hospitals specializing in orthopaedic surgery, cardiology and cancer care. Private providers of ambulatory care also may have operating theaters for smaller day surgery operations. Inpatient care has been transformed since the early 1990s towards more centralized services, as well as a shift into other settings. This is reflected in a reduced number of hospitals, a decreased number of inpatient care beds, a shortened average length-of-stay, and an increase in day surgery. Many inpatient wards have been closed or combined with other general-purpose wards, aiming to shift the bulk of health care services into outpatient settings. This is especially true for some specialties, such as pul- monology, rheumatoid diseases and dermatology. The coordination of care remains fragmented throughout the country (Box 4). BOX 3 | WHAT ARE THE KEY STRENGTHS AND WEAKNESSES OF PRIMARY CARE? A GP in Finland is expected to be able to diagnose and treat patients independently to a degree typically seen in specialized care in other EU countries (Parkkila-Harju, 2018). Many somewhat specialist services are now taken care of by health centres and thus their duties have expanded rapidly. Moreover, because of the occupational health care system accessed by those in employment, the population base served by health centres is biased towards those with higher health care and social care needs, that is, children and older people, as well as those of lower socioeconomic or educational level (Kestilä & Karvonen, 2019). In theory, primary care is the backbone of the Finnish health care system. But in reality, primary care services are marred by accessibility problems. Extensive user charges notwithstanding, follow-up waiting times for non-emergency GP consultations after initial assessment are substantial, with 41% of the population waiting for an appointment for a week or more, and 29% for more than one month (THL, 2022). The figures vary to some extent across the different counties. BOX 4 | ARE EFFORTS TO IMPROVE INTEGRATION OF CARE WORKING? The ongoing Health and Social Care Reform has introduced vertical and horizontal administrative integration within the system, which is also expected to ensure that: • people who need integrated services are identified; • their service and care chains and packages are defined; • health and social welfare services are coordinated with other services provided by municipalities (e.g. education); and • information about clients is exchanged between different providers. In addition, there are recommendations based on the national Care Guidelines (Nuutinen, 2017) and adapted at the county level, which address integration of primary and secondary levels of care, and outline patient pathways. Despite these efforts, a lack of continuity of care between different parts of the system remains. A specific bottleneck is the point of discharge from hospital care for patients who no longer need specialist care but lack suitable follow-up care at their place of residence. Consequently, in some WBSCs, dedicated teams of nurses, coordinated by a primary care physician, have been established to ensure that patients return to their home safely. These teams can also include physiotherapists and occupational therapists, and the follow up may include a short, intensive home rehabilitation period. FINLAND12 PHARMACEUTICAL CARE Community pharmacies are privately owned by phar- macists. There were 632 privately owned pharmacies and 190 subsidiary pharmacies run by pharmacists in addition to their main pharmacy, totalling 822 com- munity pharmacies in Finland in 2021 (Association of Finnish Pharmacies, 2021). The Finnish Medicines Agency (FIMEA) grants permissions to run phar- macies and it may allow the pharmacists to establish additional subsidiary pharmacies in areas where it is not economically viable to run an independent pharmacy. In rural areas, there may be a service point for provi- sion of over-the-counter and pre-ordered prescription medicines. Finland has used electronic prescription since 2013. In 2017, e-prescription became the only method of prescribing except in cases of technical failure and emergency cases. MENTAL HEALTH CARE Outpatient psychiatric services are provided by health centres and outpatient departments of psychiatric hos- pitals. Additionally, the role of psychiatric nurses has increased in outpatient care, particularly in the detection of depressive disorders. Social services, parishes, NGOs and private provid- ers, as well as occupational care services for employees, play an important part in the provision of care. NHI compensates psychotherapy for people aged between 16 and 67 years (subject to certain eligibility criteria) (Kela, 2022). This so-called rehabilitative psychotherapy is provided by privately practising psychotherapists accredited by the NHI. An NGO, A-Clinic Foundation, provides a substantial share of outpatient and rehabili- tative substance abuse services. Remote appointments in outpatient care, including online psychotherapy by the Helsinki University Central Hospital, were introduced in 2009. This service contains a part tailored specifically for adolescents, reflecting the recent focus of policies on the improvement of child and youth mental health. DENTAL CARE In 2023 counties have taken over from municipalities in organizing dental services for their residents. These include prevention and care for oral diseases, as well as referrals to specialist-level care when necessary. Dental services are located within health centres and over half of all dentists work in these facilities as salaried employees. Patients have the option to use private services and receive a small reimbursement (about 15% of the total cost in 2017) from the NHI (Kela, 2018), with the exception of cosmetic procedures (e.g. tooth whitening) and prosthodontics. Orthodontic treatment is reimbursed only in specific cases. There is no price regulation for private services. What reforms are being pursued? Attempts to substantially reform health care and social services began in the early 2000s when, in the aftermath of the deep recession of the 1990s, it became clear that the municipalities (over 400 at the time) were too small as administrative units to effectively organize services, especially purchasing specialized care from hospital districts. Policy experts and successive governments rec- ognised that the health and social service system should be reformed to reduce inequalities (socioeconomic, geographical), ensure the quality of health, social and rescue services, improve access to care, particularly primary care, and to control costs. To meet these objectives, over the next two decades successive governments introduced varying proposals on structural reform, which have incrementally shaped the final structure of the new system, notably a major reform package in 2015-2019, that failed to be After two decades in the making, a major structural reform has led to the establishment of counties as units responsible for health service provision from 2023 HEALTH SYSTEM SUMMARY: 2023 13 adopted at the time because of its extremely broad scope and because some aspects were deemed to be incompat- ible with the country’s Constitutional law. With the election of a new government in April 2019, the reform remained high on the agenda, retaining many of the features and objectives of the 2015–2019 pro- posals. The Health and Social Care Reform was finally passed by the Parliament in the summer of 2021, taking full effect in January 2023. It has centralized responsi- bility for the organisation of health and social services from municipal to regional level, and health system financing has moved to the national level. The election of WBSC councillors was concluded in the spring of 2022, establishing the councils for each county, and leav- ing a relatively short timeframe to develop operational processes. Some WBSCs, however, were ahead in the implementation of the reform because in some parts of the country municipalities had already established more centralized joint authorities for health and social care, aiming to achieve a greater integration of services. Some elements of the reform have been controversial and there have been debates about the number of WBSCs, including their incentives to operate efficiently, and the lack of competition in the system. Thus, it is probable that the next government, expected to be elected in the spring of 2023, will continue to make adjustments to the system. The implemented reform can be described as a first step in the series of reforms, which at a later stage may also include adjustments to financing, particularly the share that is channelled through the NHI scheme and occupational health care. Other changes that have taken place over the past decade have largely been incremental and mainly focused on modifying existing features of the health system (Box 5). In particular, a series of measures were taken to reduce the share of public spending on health: some of these translated into reduced levels of reimbursement for medicines, and increased user fees. How is the health system performing? HEALTH SYSTEM PERFORMANCE MONITORING AND INFORMATION SYSTEMS The health system performs relatively well overall in international comparisons (see for example Fullman et al., 2018). A number of national and regional organi- zations in Finland supervise and monitor the adequacy of services delivered by health care professionals and providers. In addition, THL runs and maintains several systems for assessing different aspects of health system performance. However, they are specific to a particular area, such as waiting times, vaccination rates and hospital efficiencies. National or regional systems providing a BOX 5 | KEY HEALTH SYSTEM REFORMS OVER THE LAST 10 YEARS • 2010: Health Care Act • 2013: MSAH Decree on Criteria for Acute Care and Specialty-specific Prerequisites for Emergency Services • 2013–2017: Pharmaceutical cost containment and changes to pharmaceutical coverage • 2014: Cross-border Healthcare Act • 2014: All-party Proposal on Reforming Healthcare and Social Services (failed) • 2015: Decree on User Fees in Social and Health Care • 2017: Decree on the Centralization of Specialist Services • 2015–2019: Government Proposals for the Regional Government and Health and Social Care Reform (failed) • 2021: The Act on Social and Health Care Client Fees • 2021 & 2023: Health and social care reform passed by parliament and implemented Health services are fairly effective, but long waiting times and high levels of cost sharing may undermine access FINLAND14 comprehensive assessment of the health system have been lacking until recently. In 2018, MSAH piloted an assessment of health and social care services at the regional level. To complement this, in 2019 THL published the first ever national-level, expert evaluation of the health system (Rissanen, 2019), designed to help national and regional level authorities and decision-makers in their steering and financing of health and social care. The 2021 Health and Social Care reform established this function as a permanent part of THL’s remit, with the yearly evaluation reports intended to be used in the annual negotiations between the counties and the government. ACCESSIBILITY AND FINANCIAL PROTECTION Finland reported the EU’s third-highest level of unmet need for medical care due to either cost, waiting time or travel distance: 5.2% in 2020 (Fig. 7). Waiting lists are the main reasons for unmet need for medical care in Finland, and are frequently encountered by unem- ployed people (8.3%), a group that does not have access to occupational health care. Although the availability of health and social services has improved over time, there are regional differences for some types of services. For example, while access to maternity and paediatric services is fairly equal, there are considerable regional differences in access to primary care. User charges are extensively applied and although there are caps and various exemptions from cost-sharing, the proportion of people affected by catastrophic OOP payments (defined as over 40% of disposable income) has been relatively high, at around 3.8% on average and over 8% among retired persons in 2018 (Tervola et al, 2021). FIG. 7 UNMET NEEDS FOR A MEDICAL EXAMINATION (DUE TO COST, WAITING TIME, OR TRAVEL DISTANCE), BY INCOME QUINTILE, EU/EEA COUNTRIES, 2020 Note: EEA: European Economic Area; EU: European Union. Data refer to 2020 except for Italy (2019), Iceland (2018) and United Kingdom (2018). Source: Eurostat, 2022, based on EU-SILC. 0 5 10 15 20 Malta Austria Luxembourg Germany Netherlands Cyprus Spain Czechia Switzerland Hungary Norway Bulgaria Sweden Croatia Belgium Portugal Lithuania Denmark Italy EU27 Poland Ireland France Slovenia Slovakia Iceland United Kingdom Romania Latvia Finland Greece Estonia Fifth quintile First quintile Total % of population HEALTH SYSTEM SUMMARY: 2023 15 HEALTH CARE QUALITY One indicator reflecting the quality of primary care is avoidable hospital admissions: for asthma and COPD in Finland admissions were substantially below the EU average in 2019 (166 compared to 211 per 100 000, respectively). For congestive heart failure, however, the rate was closer to the EU average (272 compared to 278 per 100 000). Diabetes-related hospital admissions have decreased markedly since 2000 and in 2019 were also below the EU average (112 compared to 140 per 100 000, respectively) (Fig. 8). In secondary care, the share of mortality within 30 days of hospital admission for ischaemic stroke was 8.4% in 2020. It was also fairly low for 30-day mortality for myocardial infarction (6.8%), but above the rate for Sweden (3.5%), Norway (3.2%) and Denmark (4.5%). The Health Care Act (2010) and subsequent regula- tions emphasized patient safety and quality of care, which can be measured in various settings (Box 6). Since 2010, all health care providers are obliged to adhere to a quality control plan. The Finnish Patient Safety Association and other stakeholders have been closely involved in this work, emphasizing prevention of adverse incidents and the fostering of a safety-prone cultural change. Increasingly detailed and up-to-date patient safety and care quality-related data are collected by THL and assessed by relevant authorities (MSAH, Ministry of Finances). FIG. 8 AVOIDABLE HOSPITAL ADMISSION RATES FOR ASTHMA AND CHRONIC OBSTRUCTIVE PULMONARY DISEASE, CONGESTIVE HEART FAILURE AND DIABETES, 2019 Note: Data for congestive heart failure is not available in Latvia and Luxembourg. Data for diabetes for Luxembourg is from 2015. Source: OECD Health Statistics 2022 (data refer to 2019 or nearest year). BOX 6 | WHAT DO PATIENTS THINK OF THE CARE THEY RECEIVE? Increasing patients’ involvement in their own care has been one of the key improvement goals of the Finnish health care system (Linnanmäki, 2017). Patients’ viewpoints continue to be reflected using different methods, including: • specific patient satisfaction surveys on user experience; • population surveys including questions on patients’ opinions of care and public satisfaction with the health system, which show generally high levels of satisfaction and trust in health care providers; • the FinSote National survey on the views of the population on social welfare and health care system, and the availability, quality and use of services; • patient forums and panels organized by providers and WBSCs; • expert patients, employed by providers to help their peers to navigate the system and contribute to service development; • Patient-reported outcome measures (PROMs) and patient reported experience measures (PREMs), especially for specialized care, are embedded in quality registers. 0 200 400 600 800 1 000 1 200 Po la nd Li th ua ni a Ro m an ia Ge rm an y Sl ov ak ia M al ta Cz ec hi a De nm ar k EU 22 Be lg iu m Ire la nd Au st ria Fr an ce Fi nl an d No rw ay Es to ni a Sw ed en Ne th er la nd s Sl ov en ia Sp ai n Ic el an d Ita ly La tv ia Po rtu ga l Lu xe m bo ur g Ag e- st an da rd iz ed ra te o f a vo id ab le a dm is si on s pe r 1 00 0 00 p op ul at io n 15 + Asthma and COPD Diabetes Congestive heart failure FINLAND16 HEALTH SYSTEM OUTCOMES Mortality due to treatable causes (deaths that can be mainly avoided through timely and effective health care interventions, including secondary prevention and treatment for people under 75 years of age) in Finland has reduced by 20% since 2011 and in 2019 was 69.0 per 100 000 (compared with 86.5 per 100 000 in 2011), well below the EU27 average but generally a little higher than the levels found in the other Nordic countries (Fig. 9). However, Finland has not been able to reduce the differences in treatable mortality between various soci- oeconomic groups over the past few decades (Lumme et al., 2018). Cardiovascular mortality has decreased substantially from its peak in the 1970s: premature ischaemic heart disease (IHD) mortality decreased by a third between 2011 and 2019. Most of this improvement is considered to be related to changes in risk factors supported by health policy measures, although in recent decades, treatment of cardiovascular diseases has also improved. Moreover, secondary prevention of IHD and hypertension, and hospital care for cardiovascular diseases, including streamlining of emergency care pro- cesses, have become more effective. In terms of preventable mortality (deaths from causes that could be avoided through public health and primary prevention policies) Finland’s rates in 2019 are just below the EU27 average: 154 per 100 000 population compared with 160 per 100 000 population (Fig. 9). Overall, the preventable mortality rate has declined by some 18% since 2011, thanks in part to public health interventions (see Box 7). FIG. 9 MORTALITY DUE TO PREVENTABLE AND TREATABLE CAUSES IN FINLAND AND EU COUNTRIES, 2011 AND 2019 Note: Data are for 2011 and 2019 or latest available year. Data for France are from 2017; and from 2018 for Malta and the United Kingdom. Source: Eurostat, 2022. 2011 2019 Treatable mortality Preventable mortality 0 50 100 150 200 250 Switzerland Iceland Norway Sweden Netherlands France Spain Luxembourg Italy Belgium Denmark Finland Ireland Slovenia Austria Cyprus Portugal Germany Malta United Kingdom EU27 Greece Czechia Croatia Estonia Poland Slovakia Hungary Lithuania Latvia Bulgaria Romania 0 50 100 150 200 250 300 350 400 Cyprus Italy Malta Switzerland Iceland Spain Sweden Luxembourg Norway Netherlands Ireland France Portugal Greece Belgium Germany United Kingdom Denmark Austria Finland EU27 Slovenia Czechia Poland Bulgaria Slovakia Croatia Estonia Lithuania Romania Latvia Hungary HEALTH SYSTEM SUMMARY: 2023 17 HEALTH SYSTEM EFFICIENCY A very cursory way of illustrating how the Finnish health system is performing in terms of input costs and outcomes is to plot current expenditure on health against the treatable mortality rate. On this metric, while spending comparatively less in Finland than the other Nordic countries, the rate of mortality due to treatable causes has been falling consistently since 2011 and in 2019 was at a similar level (Fig. 10). In many respects, the structure of the Finnish health care system supports efficiency. Primary care services are generally well developed and offer a wide scope of services. On the other hand, high levels of decen- tralization and fragmentation undermine allocative efficiency of Finnish health care. This has been one of the arguments used to back the Health and Social Care Reform and centralize health care organization to counties. Although there is now the THL’s remit to conduct annual evaluations of WBSCs, there is no compre- hensive framework for evaluating the efficiency of the entire health system, and performance assessment is not systematic beyond the hospital sector. Moreover, to date there have been no regular follow-up actions to address unwarranted geographical variations in health care. Comparative information on efficiency in hospital care has been published as part of official national statistics since 2007. The national hospital information system is managed by the THL and contains data on use, costs and productivity of hospital activities by hospital district (county level from 2023), hospital, municipality, specialty and DRG. Other efforts to improve the efficiency of the health system could lay in targeting pharmaceutical spending, especially given high OOP expenditure for medicines (Box 8). BOX 7 | ARE PUBLIC HEALTH INTERVENTIONS MAKING A DIFFERENCE? Overall, public health interventions addressing risk factors for disease in Finland can be deemed to be effective. In particular, smoking has decreased, abstinence from alcohol use and levels of physical activity have increased, and blood glucose and cholesterol values show trends that indicate less car- diovascular disease in the future. Nevertheless, a number of challenges remain, for example obesity prevalence is on the rise with a quarter of the population having a BMI over 30 kg/m2 (Koponen et al., 2018). In addition, high prevalence of raised blood pressure and psychological distress, including depression, is worrisome. BOX 8 | IS THERE WASTE IN PHARMACEUTICAL SPENDING? Price regulation by the Pharmaceutical Pricing Board is strong, so wholesale prices are rather low in Finland. In addition, reference pricing and compulsory generic substitution have induced strong price competition among pharmaceuticals with generic alternatives. The weak point in the Finnish system in terms of rational pharmacotherapy is the structure of the retail price in outpatient care. Pharmacies are private monopolies in their catchment areas and due to national regulation there is no price competition among them. The state payer for outpatient medicines (Kela, the organisation managing the NHI) does not have any means to steer prescribing. There is some national level steering by the Current Care Guidelines but cost–effectiveness is not the primary focus of these guidelines. The focus of current discussions is on how to increase the use of biosimilars in outpatient care. These medicines are used widely in inpatient settings and hospitals have strong economic incentives to increase their use. But due to the lack of an effective steering mechanism, and despite the fact that the use of the cheapest pharmaceutical product is obligatory, the use of biosimilars has been negligible in outpatient care. FINLAND18 FIG. 10 TREATABLE MORTALITY PER 100 000 POPULATION VERSUS HEALTH EXPENDITURE PER CAPITA, FINLAND AND SELECTED COUNTRIES, 2019 Note: PPP: purchasing power parity. Data are for 2019 except for France (2017), Malta (2018) and United Kingdom (2018). Source: Eurostat, 2022. Summing up From 2023, the Finnish health system is implementing a major structural reform as a result of which the organization of health and social services are centralized from approximately 200 entities (munic- ipalities and joint municipal organisations as well as hospital districts) to 21 counties, the city of Helsinki and the Hospital District of Helsinki and Uusimaa. Revenue generation and pooling for the health system has been shifted to the national level, while purchasing will happen at the county level. The other parallel funding (NHI and occupational health) and provision (occupational health and the private sector) channels remain. The summer of 2021 marked an end in the long pro- cess of bottom-up incremental adjustments in the core structures of the health care system. The reformed system will rely largely on the ideas of centralized responsibility both at the national and regional levels and on the strong role of public provision in service delivery. Full evaluation of the reform and whether it meets the goals set will require time. The implementation of the reform is taking place in challenging condi- tions: the aftermath of the COVID-19 pandemic and in the midst of soaring energy prices, economic downturn and war in Europe. This may hinder the WBSCs’ abilities to develop their operations and new ways of working. In turn, this may affect the results that can be expected from the reform. At the very least, the reform has streamlined the structure of the health system and is expected to improve the national government’s abilities to steer the system. Nonetheless, the existing parallel funding and delivery systems remain, as does the substantial reliance on OOP payments. With the restructuring underway, another challenge is waiting times, particularly in primary care and elective specialist care, as these remain a barrier to access, particularly for people not eligible for occupational health services. The long-awaited reform of the health system is being implemented but matching service provision to population needs remains a challenge Tr ea ta bl e m or ta lit y pe r 1 00 0 00 Health expenditure €PPP per capita 1 0000 2 000 3 000 4 000 5 000 6 000 0 50 100 150 200 250 Norway Denmark Sweden Netherlands Finland REFERENCES Association of Finnish Pharmacies (2021). Annual Review. https://www.apteekkariliitto.fi/media/vuosikatsaus_2021_en_ lowres_final.pdf Eurostat (2022). Database – Eurostat. European Commission, Luxembourg. Fullman et al. (2018). Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: a systematic analysis from the Global Burden of Disease Study 2016. 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POPULATION HEALTH CONTEXT KEY MORTALITY AND HEALTH INDICATORS LIFE EXPECTANCY (YEARS) Life expectancy at birth, total 82 Life expectancy at birth, male 79.2 Life expectancy at birth, female 84.8 MORTALITY (SDR PER 100 000) All causes 913.1 Circulatory diseases* 310.9 Malignant neoplasms* 214.5 Communicable diseases* 3.5 External causes* 58.1 Infant mortality rate (per 1 000 live births) 2.1 Maternal mortality rate (per 100 000 live births) 3 Notes: *Age-adjusted rates with the European standard population 2010. Life expectancy data are for 2020. Mortality data are for 2019. Infant mortality data are for 2019. Maternal mortality data are from 2017. Source: Eurostat, 2022; World Bank, 2022 for maternal mortality. Maakuntien tilakeskus (2022). Sairaanhoito- ja erityishuolto- piirien rakennusinvestoinnit 2022. [Construction investments of hospital and special care districts in 2022. Survey 2022]. Helsinki. The State Centre of the Provinces. Mikkola M et al. (2015). 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Alkoholijuomien kulutus 2018 [Consumption of alcohol beverages 2018]. Statistical Report 17. Helsinki: Finnish Institute for Health and Welfare. THL (2022). Access to services in primary health care spring 2022 (Available only in Finnish). Tilastoraportti 24/2022, 14.6.2022. Vaalavuo (2018). Social and health care client fees: allocation, effects and fairness. Helsinki: Prime Minister’s Office. World Bank (2022). World Development Indicators database. Washington DC. World Health Organization (WHO) (2022). Global Health Expenditure Database. Geneva. Keywords: DELIVERY OF HEALTH CARE EVALUATION STUDIES FINANCING, HEALTH HEALTH CARE REFORM HEALTH SYSTEM PLANS – organization and administration FINLAND The European Observatory on Health Systems and Policies is a partnership that supports and promotes evidence-based health policy-making through comprehensive and rigorous analysis of health systems in the European Region. 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