From the dark days of recession in the 1990s Finland has built an impressive and cost-effective system of delivering healthcare, and Ireland should consider the Finnish approach, suggests James Fogarty
Finland has many similarities with Ireland. It has a similar population size of about five million, struggled for independence and is heavily dependent on foreign trade. It also went through one of the most complete financial collapses in the early 90s, leaving its economy severely dented and its unemployment rate close to 20 per cent. But Finland managed not just to recover, but recover quite spectacularly, becoming the epitome of the smart economy.
The Finnish health system has improved dramatically over the last number of decades and has, according to a 2009 SITRA report (Finnish Innovation Fund), been an international success story. One of the greatest indicators of this success can be seen in the rise in life expectancy and in the increased number of doctors working in Finland. During the 1960s, Finland had the third lowest number of medical doctors in Europe, after Turkey and Albania. It now has around 22,000 doctors, over half of whom are female and 94 per cent of whom are members of the Finnish Medical Association. This translates to a ratio of one doctor for every 307 citizens, just below the European average. However, Finland has a high percentage of nurses, who carry out many of the duties performed by GPs in other countries.
The amount Finland pays for its health system is also impressive. In 2006 €13.6 billion was spent on health, similar to Ireland’s health budget. Finland spends about €2,586 per person annually or 8.2 per cent of GDP versus the OECD average of 9.0 per cent. It has been suggested that one of the reasons for this cost-efficiency is the comparably low salaries paid to healthcare professionals. The average annual wage for a doctor in Finland is €61,284 and according to Dr Lasse Viinikka, Director of Research in the Helsinki Hospital District, hospital physicians’ salaries are much less than in Ireland. He said that senior physicians in leading positions earn €90,000, specialised physicians not in a leading position earn €70,000 and physicians in specialist training earn €45,000.
In healthcare centres GPs earn €80,000 and non-specialised physicians earn €70,000.
Many physicians get extra incomes from private practice, where they work in private clinics outside office hours. However, while Finland has somehow managed to spend less on healthcare than similar countries, and still provide a service most Finns are happy with, financial realities will force some reassessment. Like other OECD countries, Finland also has an ageing population and with it a shrinking tax base. In order to meet these challenges Finland needs to get more for less.
Finland has compulsory National Health Insurance (NHI) which covers a comprehensive range of health services and can be accessed by everyone regardless of income. Dr Viinkka said: “The majority of treatments are free, some require a small payment, but everyday medical treatments are free. Treatments, even expensive ones, are available to all patients. It’s a very democratic system, and we keep expenses down, partly due to the low salaries of the doctors and nurses.”
The system, which is widely acclaimed both at home and abroad, evolved over time, from the end of the World War II to the present day. It is funded through a number of different sources, though mainly through taxation. In 2002 about 43 per cent of total healthcare costs were borne by local government, the central government subsidies provided 17 per cent, NHI provided 16 per cent, and the remaining 24 per cent came from private sources. People wishing to access Finland’s small private healthcare sector receive partial reimbursement for private healthcare services through the obligatory NHI system.
Like any comparable healthcare system, Finland is keen to keep costs down; one of the ways it has managed to achieve this is through tightly controlling the pharmaceutical sector. Although pharmacies in Finland are privately owned, pharmacists can own only one pharmacy and they cannot be owned by companies. The National Agency of Medicines also controls pharmacy locations and selects the pharmacists to run them. Retail drug prices must be the same in all pharmacies and are determined by a combination of the wholesale price, the pharmacy’s profit margin, which is set by the government, and VAT. The Pharmaceuticals Pricing Board regulates the prices of those drugs that are reimbursed by the NHI. For a pharmaceutical to be licensed as a reimbursable drug, its wholesale price must be considered reasonable by the board. In 2006, the sale of pharmaceuticals amounted to €2.4 billion, or about €470 per capita. In 2005, pharmaceutical sales accounted for 18 per cent of total healthcare expenditure.
To counteract regional inequities, the Finnish government heavily subsidises medical facilities in certain areas, particularly in the far north, but it is the 400 or so local governments or municipalities that control the delivery of healthcare on a day-to-day basis. The Finnish system, like the Dutch one, relies heavily on GPs. Under the Primary Healthcare Act 1972, a new focus on primary care was established, moving away from the traditional hospital-based model. This new legislation introduced the concept of primary care teams, which eventually operated under one roof and provided such services as GP medical care, home nursing, family planning, and dental care. Unsurprisingly the number of doctors in primary care has tripled since the 1970s and one of the most distinct aspects of the Finnish health system is the presence of small GP-run hospitals, which have persisted due to the long travelling distance to specialist level hospitals. There are 237 of these healthcare centres throughout Finland and in the isolated Northern region, these centres also provide emergency department care.
Secondary care is provided in Finland’s 20 hospitals, each one with its own catchment area, ranging from just over a million people to a couple of thousand. Municipalities must belong to one of these catchment areas and must contribute to the funding of the individual hospitals on a fee-for-service basis. In order to maintain equality, hospital districts use risk equalisation mechanisms to spread the risks of very high costs between the district’s member municipalities. If an individual patient’s treatment costs exceed a specified threshold (agreed within the hospital district), all municipalities that are members of the same district will pay all or part of the excess.
In Finland, as elsewhere, GPs acts as gatekeepers to hospital care. According to studies on the Finnish health system, an estimated 5 per cent of visits to a health centre doctor lead to a hospital referral, and in 2005, about 39 per cent of the referrals to in-patient care in hospital districts came from health centres. Most of the remaining referrals came from other hospital physicians (22 per cent) and private physicians (15 per cent).
In 2006, day surgeries represented 40 per cent of all surgical procedures, increasing from 77,000 to 171,000 between 1997 and 2006. In addition to the 20 general hospitals, the state operates two psychiatric hospitals. Hospital-based physicians and other personnel in public hospitals are salaried employees of the hospital districts. About 37 per cent of physicians working in hospitals in the public sector also worked in the private sector in 2006.
According to an EU report, Finland has experienced a steep decline in hospital beds, perhaps because of a shift towards day surgery that began in the 1990s. In the early 1990s there were an estimated 4.3 acute hospital beds per 1,000 inhabitants, comparable to the EU average. During the period 1990-2003 the number of acute care beds decreased to 2.3 per 1,000 population, as a result Finland had the lowest number of acute hospital beds among the Nordic countries at the turn of the century. While Finland no longer compiles data on general hospital bed numbers, it is estimated that there are 3.1 hospital beds per 1,000 inhabitants in hospital districts, 3.8 per 1,000 inhabitants in health centres and 0.3 per 1,000 inhabitants in private healthcare facilities.
Due to the decentralised nature of the healthcare system, Finland suffers from a certain amount of disconnection between primary and secondary care. One of the most common complaints from health centres is of not always being given sufficient feedback about the treatment of patients after their referral to hospital. This is a real difficulty when one considers that the system aims to have one coordinator of care, the GP, to maintain an overall responsibility for patients when they are treated at different levels of the health system. This disconnect is no doubt exacerbated by the sometimes large geographic distances involved. The recent introduction of a new IT system should tackle the lack of information between primary and secondary care. According to Finnish media, the Central Finland Healthcare District was the first healthcare district to introduce the patient information system as dictated by the new Finnish Healthcare Act. Approximately 70 per cent of the region’s population is covered by the system, which is the country’s largest single patient information system.
Unlike Ireland, the private sector in Finland plays a relatively small role in the system. There are few private hospitals in Finland, and the private sector provides just 5 per cent of hospital care in the country. However, choosing a private hospital means shorter waiting times, the opportunity to choose a physician, and the perception of better quality services. Furthermore, patients do not need a referral for private hospitals and NHI reimburses part of the expenses to the patient. Some municipalities and hospital districts purchase specific services from private hospitals; however, this is not very common. Physicians also operate private practices that provide specialised out-patient care services that are partly reimbursed by NHI. Private out-patient services are much more common than private in-patient care. In 2006, 3.5 million private out-patient physician visits were recorded (compensated by NHI), of which 79 per cent were visits to specialists. The specialties with the most private out-patient visits were gynaecology and ophthalmology, together making up more than one-third of the total specialist visits.
Life expectancy in Finland has increased dramatically over the last 50 years when Finnish men had a notably high mortality rate, mainly because of coronary heart disease. At present, life expectancy for men and women is around 74 years and 81 years respectively and, accor-ding to a WHO report Highlights on Health in Finland, this is largely due to the rapid decline in coronary heart disease and other cardiovascular diseases. Life expectancy in Finland also reflects class and education and there are also big differences in geographical regions. The average life expectancy of a well-educated man aged 35 years is five to six years more than that of a man of the same age but with basic education; for women the corresponding difference is three to four years.
However, despite the improvements in health, cardiovascular disease continues to be the biggest killer in Finland, accounting for 41 per cent of all deaths. Among both men and women aged 45 to 59, death rates due to digestive diseases increased by almost 20 per cent in men and 58 per cent among women between 1995 and 2002. Finland’s total mortality from cancer has been lower than the European average, with deaths due to tracheal, bronchial and lung cancers about 30 per cent lower in Finland than the European average. However, rates of these types of cancer are more than four times higher in Finnish men than women. Prostate cancer appears to affect Finnish men disproportionally, with the mortality rate from prostate cancer at about 20 per cent the European average.
Finland is blessed with one of the lowest rates of infant mortality in the world, a much improved situation from the 1960s and 1970s. At the beginning of the 1970s, almost 15 out of every 1,000 newborn infants died; since the mid-1990s the rate has been less than five per 1,000, one of the lowest in Europe. Helsinki boasts one of the best paediatric hospitals in the world, the HUCH Children’s Hospital, which has an annual budget of €100 million and serves a population of 200,000.
One of the biggest challenges facing the Finnish health system is an obesity crisis. More than two-thirds of men and over half of all women are overweight and one-fifth of both men and women are obese. About 14 per cent of 15-year-old boys are pre-obese and 3 per cent are obese. Around 8 per cent of girls are pre-obese. To deal with this problem, public health campaigns have attempted to highlight the benefits of exercise and healthy eating.
One of these campaigns is attempting to make Finland a tobacco free society. While it already has a impressively low rate of smokers – less than the European average – more can be done, according to Mr Kari Passo, head of harm prevention at the Finnish Ministry who delivered the Irish Cancer Society’s annual Charles Cully lecture recently.
“Some people have said that this isn’t realistic and maybe we will never be smoke free, but as a policy aim, as a goal, it’s excellent. Usually, we just talk about harm reduction but this is the first time we’re declaring the aim to be tobacco free,” he told the Medical Independent.
Under new legislation, smo-king has been banned at outdoor events, as have cigarette vending machines. He added that the main priority of the campaign is to prevent young people from taking up smo-king.
“I would say here that the key word in the campaign is comprehensiveness. We’ve had a massive input from NGOs and interested parties and everything is included and everyone is on board. Now we have municipalities that are smoke free and work places that are smoke free. This campaign is about the mobilisation of society to de-normalise smoking,” he said.
One of the most enduring perceptions of Finland is that it has a high suicide rate. Suicide is certainly a complex problem in the country, although some of the evidence disagrees about the scale (pa-radoxically many internati-onal surveys say Finnish people are amongst the happiest in the world). The death rate in Finland from intentional and unintentional injuries is high compared with the European average and in spite of decreases over the last 10 years, suicide and self-inflicted injuries account for about a third of preventable deaths, with both men and women aged 25-64 years being most at risk.
Furthermore, according to the European Observatory on Health Systems, the number suffering from depression and other mental health disorders increased in recent decades. According to its report Health Systems in Transition, during the 1990s about twice as many people in Finland drew a disability pension owing to mental illness than in the 1970s. Six per cent of the working age population suffered from depression diagnosed by a physician in 2007, while the occurrence of other mental illnesses has remained static.
Mental health services in Finland, as in many other countries, complain that they are ignored and underfunded. Mental health services were affected by the recession of the 1990s and by the closure of institutionalised psychiatric care, leaving a shortfall in the quantity and quality of psychiatric services. In response to this the government decided to introduce an action programme called Mielekäs Elämä!, or Meaningful Life!, to highlight mental health, to enhance cooperation between services and to improve the delivery of mental health services.
The medical profession was not immune to the recession of the 1990s, which led to significant unemployment among doctors, dentists and nurses and a decrease in the number of places at medical colleges. A significant doctor and dentist shortage developed and persists in some of the more isolated regions of the country. For example, 26 per cent of doctor posts in health centres were vacant in the northern Kainuu area. That said, there was a 41 per cent increase in the number of working age doctors in Finland between 1990 and 2005, the vast majority of whom worked either in health centres or the hospital system. In 2006, the same year that the number of doctors per capita reached the European average, 47 per cent of doctors worked in hospitals, 23 per cent in health centres, 5 per cent in occupational healthcare, 6 per cent in the academic field and 11 per cent in full-time private practice. In spite of these increases, and in comparison to the Scandinavian countries, Finland’s complement of doctors remains one of the lowest in Europe.
“Although we have more doctors than ever, we have a shortage of certain specialities such as ophthalmologists and orthopaedic surgeons. Also its very difficult to get people to practise in remote areas in the north and east of the country.”
The payment system of GPs in municipal health centres varies between municipalities. The traditional payment method, a monthly salary with some extra fee-for-service payments, applies to about 45-50 per cent of health centre doctors. Over the last 10 years outsourcing of the medical workforce has emerged, where firms lease doctors to the primary healthcare sector. These firms are mainly owned by physicians themselves and the salary is negotiated with the company. Consequentially these firms can offer better salaries and more flexible working conditions than municipalities. Municipalities use these services mainly when they have difficulties in recruiting physicians, especially for out-of-hours duties. In 2004 about 5 per cent of Finnish physicians, mainly young doctors, worked in these firms. Doctors working in hospital districts are usually salaried employees with a basic monthly salary depending on the post and length of career. Various bonuses can be paid, such as for increased responsibility, but this practice is rare. Usually there are no financial incentives for physicians to increase efficiency and quality.
In one of its brochures, the Finnish Medical Association proudly proclaims that the country’s medical education is “highly respected internationally”, which of course it is. But it too was affected by the crash of the 1990s. During the recession, the number of medical students decreased with inevitable consequences. Once the economy stabilised, the government and the colleges increased the number of places at medical schools from 365 to 627.
Finnish universities are publicly-owned and education is free of charge. Entrance is based on grades from secondary school and on entrance exams. Five universities provide undergraduate medical education. Six years of study is required to obtain the degree of Licentiate of Medicine. Two years of practical work and training is required, both in hospitals and in health centres, to obtain a licence to practise independently. Part of this training may be completed in the private healthcare sector, depending on the approval of the medical faculty, or by doing research. After obtaining a licence, doctors may continue working at a health centre, specialise in one of the 49 medical specialties or establish a private practice.
One of the notable aspects of the Finnish system is the length of postgraduate medical training. For example, specialisation in general medicine takes six years of training. This includes a specified period working in a hospital and a health centre, a specified number of theoretical courses, and successful completion of a national examination organised by medical faculties. Similarly to Ireland, doctors who wish to specialise must register with the relevant faculty and specialisation lasts five to six years depending on the speciality, and involves working at a hospital under the supervision of an experienced doctor. In order to obtain a specialist diploma, a doctor must pass both a theoretical and clinical exam, followed by at least one to two years working at a university hospital in a structured training programme. Almost two-thirds of all Finnish doctors are specialists.
One of the ways that Finland is attempting to compensate for its medical manpower shortage is by attracting foreign doctors to its shores. Doctors from within the EU and EEA can work in Finland on the basis of mutual recognition. No language test is necessary for doctors from within these areas, however, this can vary. Doctors coming from outside these areas must pass a language exam. Of the 1,200 non-Finnish doctors working in Finland, the vast majority are Swedish, with Russian doctors being the second largest group.
One of the most interesting things about the Finnish health system has been the empowerment of patients. Finland brought forward the first law on patients’ status and rights in Europe, which came into effect in 1993. This act gives patients many rights including the right to information and the right to see any relevant medical documents. Specifically, the act also requires the consent of the patient for treatment and those on a waiting list must be told the reason for the delay and its estimated duration. It also requires medical organisations to hire a patient ombudsman to handle patient complaints. However, doctors are also protected from most legal actions under a Patient Injury Law. This act gives patients the right to be compensated for unforeseen injuries that result from a treatment or diagnosis but does not assign liability to medical personnel.
Finland’s health system is not without its problem as we have seen: the system continues to deal with doctor shortages and the geographical and social inequalities. However, these challenges are not unique to Finland and the country’s successes in health would seem to be nothing short of staggering, especially given the amount of money it spends in this area. It has improved life expectancy, involved patients in the success of the health system, and is one of the countries leading the way in stem-cell research. Perhaps Ireland should consider emulating the Finnish model rather than the Dutch.