I.The Finnish health system
According to the Constitution of Finland, public authorities must guarantee adequate social, medical, and health services and promote the health of the population. The Finnish healthcare system is based on public healthcare services, with municipal social and health care implemented with state support. In addition to the public sector, services are also provided by the private sector.
Everyone living in Finland is entitled to use public healthcare services and to receive those services in a reasonable timeframe, which is defined by law. Emergency care and first aid must be available immediately regardless of the place of residence. If a health center or hospital is unable to provide healthcare within the prescribed time, they must enable it elsewhere.
The national tax-based health insurance (NHI) system applies to all residents of Finland and municipal health services to residents of a given municipality. In addition, the NHI is organized and delivered by the Social Insurance Institution (SII, or Kela in Finnish).
Roles and responsibilities
The Finnish healthcare system has been described as very decentralized because much of the decision-making takes place within the around 300 municipalities in Finland. Despite this, the Finnish healthcare system is able to provide high-quality services with a reasonable budget.
Leadership and governance
The Ministry of Social Affairs and Health’s administrative agencies and institutions are responsible for policy evaluation and setting, research, and development. Healthcare is supervised by regional government agencies, Valvira (The National Supervisory Authority for Welfare and Health) and Fimea (The Finnish Medicines Agency). Valvira is responsible for supervising and guiding healthcare professionals and medical facilities both in the private and public sector and issuing permits to operate for private service providers. Expertise institutes THL (the Finnish Institute for Health and Welfare), TTL (the Finnish Institute of Occupational Health), and STUK (the Radiation and Nuclear Safety Authority) are responsible for information guidance.
Municipalities are responsible for organizing the health services needed by the population. Primary healthcare must be organized in municipalities or joint municipal authorities. Every municipality belongs to a hospital district and that hospital district is responsible for organizing specialized medical care.
The resources that municipalities have for organizing these services vary considerably. The objective of providing people with equal access to services is not currently realised – there are differences between population groups and regional differences have increased, which is reflected as inequalities in health and wellbeing. Inequality is one of the most pressing problems in the Finnish healthcare system, and for this reason, the proposed health and social services reform would transfer the responsibility for organizing services to 22 health and social services counties.
In Finland, healthcare is financed by municipalities from tax revenues and the statutory social insurance system, which is accountable to parliament. Outpatient medicines, travel expenses for healthcare, maternity leave, and sick leave benefits are the responsibility of the national health insurance system. It also covers half of employers’ statutory healthcare costs and reimburses a percentage of services provided by the private sector.
The role of private health insurance has steadily risen during the past decade. At the end of 2019, more than 22% of Finns also had private health insurance to supplement the public offering.
Source: Finance Finland, FFI
Medical technologies and information
Finland has one of the most innovative economies in the European Union, and this is also true for healthcare. Finland is also among the leading countries when it comes to health-related digitalization, and one of the top health technology economies globally – digital health is Finland’s major high-tech export. Much of this innovation can be attributed to Finland’s long and successful history in the high-tech sector, such as the flourishing mobile technology ecosystem fuelled by the rise of Nokia in the 1990s. Besides a boost to the economy, a technologically savvy population and high-quality ICT infrastructure makes adopting new technologies faster and easier in a clinical setting.
Importantly, the digitalization of information has a long tradition in Finnish healthcare. Patient records, for example, have been 100% digital since the 1990s, and the Finnish Cancer Registry (FCR) has collected population-based data on cancer incidence for scientific research and statistical purposes since 1953, all of which is available digitally. This provides exceptional opportunities for predictive population health analytics, research, and other uses.
The health workforce
Health workforce imbalances and shortages are a major concern in Finland. Finland has the third largest share of people over 65 years of age in the EU (21.9% of population in 2018) and the number is growing. This will cause increasing difficulties for the health system in coming years.
Although the number of physicians jumped by 35 per cent between 2000 and 2015 – from roughly 16,000 to 22,000 – and special healthcare consultations rose from seven to 10 million, it is unlikely that this increase will be stable and sufficient to cover the needs of an aging population.
While the number of doctors in Finland is relatively low, the number of nurses is quite high.
Source: World Health Organization
According to the Ministry of Social Affairs and Health, “health services are divided into primary healthcare and specialized medical care: Primary healthcare refers to the municipally arranged services and they include monitoring of the health of the population; promoting wellbeing and health; prevention, diagnosis and treatment of diseases, in particular public health diseases. Primary healthcare services are provided at municipal health centres.”
In Finland there are approximately 150 health centers providing primary healthcare. They can provide services by themselves or with other municipalities as a joint municipal authority. Municipalities can also buy services from other municipalities or from organizations or private service providers.
Specialized medical care
Specialized medical care refers to secondary and tertiary healthcare, provided by experts in medical (or dental) specialities. To a large extent, specialized medical care is performed in hospitals, but it is also available as consultations in primary healthcare. Five university hospitals are responsible for the most demanding medical operations.
Hospital districts are formed by the municipalities and are responsible for special medical care. There are 20 hospital districts on the mainland plus the island of Åland’s hospital district. Hospital districts are part of a specific catchment area formed around five university hospitals (ERVA). It is the responsibility of the hospital districts to provide specialized medical care services.
Hospital districts are also responsible for the guidance, quality control, research, development, and training activities of laboratory and medical imaging services, medical rehabilitation, and other special services provided by municipal healthcare, as well as the coordination of municipal health information systems.
The role of the private sector
There are several private health service providers in Finland, which complement the public services. Private service providers can sell their services to municipalities, the joint municipality authority, hospital districts, or to customers.
Statutory occupational healthcare in Finland is largely operated by private providers. Employees are entitled to preventive occupational healthcare financed and arranged by their employer, but the provision of medical care is voluntary for employers. Kela, the Social Insurance Institution of Finland, compensates a percentage of the expenses of occupational healthcare to the employer or entrepreneur if they are necessary and reasonable. For many Finns, occupational healthcare is the de-facto primary care provider.
The role of the EU
The EU supports national health policies and helps to overcome shared challenges by supporting common objectives and pooling resources at an EU level. In addition to providing funding for health-related projects, the EU sets laws and standards for health services and products.
The goal of EU health policy is to protect and improve health, ensure equal access, and coordinate serious health threats that affect multiple countries in the EU. Prevention and response are key and include vaccination efforts, food labelling, and overcoming antimicrobial resistance.
The European Centre for Disease Prevention & Control (ECDC) and the European Medicines Agency (EMA) are the two main responsible organizations. The ECDC monitors emerging diseases and coordinates response, while the EMA oversees the quality, safety, and efficiency of medicines used in the EU.
Difficulties and challenges in the Finnish healthcare system
The 2019 OECD report assesses Finland’s healthcare system as complex, decentralized, and multitiered. Mostly because of long waiting times, Finnish people have reported more unmet needs for medical care than the average EU citizen. One of the main challenges is how to improve access to primary care and how to achieve greater care coordination across sectors. Long waiting times, especially for the unemployed, a lack of coordination between primary and specialized care, lack of common standards, and uneven service quality are recognized issues in the Finnish healthcare system.
For 15 years there have been attempts to change the way health and social services are organized. The plan has been to shift responsibility from local authorities (municipalities) to regional authorities (counties), but this has proved difficult to implement in practice. The purpose of the reform is to improve equal access to healthcare and manage costs by centralizing responsibilities and resources at a regional level.
In terms of access to healthcare, people in Finland are unequal in many ways: geographically, socioeconomically, and according to employment status. Employed people have better access to healthcare services through occupational healthcare than the unemployed and pensioners. University students have access to the Finnish student health service FSHS, and in the future university students of applied sciences will also have similar access. The uneven distribution of healthcare resources reinforces disparities in access to care. Geographically uneven distribution of resources contributes to long waiting times for people living in remote regions because the density of healthcare professionals is greater in the capital area and in other big cities where hospitals and specialized care units are concentrated.
People from higher socioeconomic groups have better access to healthcare not only through occupational health but also because they are usually able to pay for private health insurance as well. With private insurance, people gain access to healthcare faster and also have a wider choice of providers. People from lower economic groups and the unemployed usually have less provider choice and longer waiting times for healthcare services.
Because of the aging population, health and long-term care expenditure is expected to grow in the coming years. At the same time there will be fewer working-age people to pay for the services.
Finland´s unique health system structure has been recognized for being able to adjust to the needs of a dispersed population but also criticized for contributing to inefficiencies and inequalities.
Challenge: Access to novel therapies
The World Health Organization has pointed out that even the wealthiest nations have difficulty in making the newest and most effective drugs available for their residents. Both patient organizations and physicians have expressed their concerns over this situation in Finland, where new cancer medicines are often made available to patients with a long delay – if they are made available at all. There is an ongoing debate about the therapeutic effectiveness of some of those novel drugs, particularly compared to the high price.
Outpatient prescription drugs are regulated at the European level by the European Medicines Agency (EMA). When evaluating if a new drug should be awarded a sales permit within the EU, the EMA considers therapeutic benefits and disadvantages of those drugs. The EMA does not, however, evaluate the added benefits these new drugs have over already available drugs and the appropriate reimbursement level for those drugs. This is the role of local authorities such as the Pharmaceuticals Pricing Board (PPB) in Finland, which is subordinated to the Ministry of Social Affairs and the Health Department for Insurance and Social Security.
Individualized drug therapies, for example biological drugs and gene therapies, are often much more expensive compared to incumbent therapies. A key explanation for the high price is the much smaller target population (market) for those drugs – even as drug development remains very expensive. While these novel drugs are expensive, they are vastly more effective and often have significantly less side effects.
When a pharmaceutical company seeks a public reimbursement for a novel EMA-approved drug in Finland, the Pharmaceuticals Pricing Board evaluates the added therapeutic value the new drug has compared to the most effective or widely used drugs available for the same purpose. In some instances reservation prices – the highest price the PBB is willing to pay and the lowest price at which the manufacturer is willing to sell – don’t meet, typically because PBB value-added modeling cannot justify a higher price, and those drugs are not reimbursed by the public sector.
However, there is a growing debate over the real-world value of these new therapies. The PBB evaluates the added therapeutic value of new drugs over and above previous-generation drugs, so the key question is, are the new drugs so much more effective in treating a disease that a higher price can be justified? If the PBB would instead consider the broader societal value of those treatments, they might arrive at a different conclusion. For instance, a new drug with fewer side effects might support the ability to work and generate substantial savings at a societal level, which would mean it might make sense for the PBB to accept a higher price.