The Finnish healthcare system is based on public healthcare services to which everyone residing and working in the country is entitled. According to the Constitution of Finland, the public authorities shall guarantee for everyone adequate social, health and medical services. The wellbeing services counties (21) and the City of Helsinki are responsible for organising public healthcare.
Establishment of the wellbeing services counties
The organisation of public healthcare, social welfare and rescue services in Finland was recently reformed. The responsibility for organising these services was transferred from municipalities to the newly established wellbeing services counties on January 1st, 2023. The key objective of the reform was to improve the availability and quality of basic public services throughout Finland.
Decision-making
The highest decision-making power in each wellbeing services county belongs to the county council, whose members and deputy members are elected in county elections. The first county elections took place on January 23, 2022 and going forward they will be held every four years in conjunction with municipal elections. The City of Helsinki is not a wellbeing services county, and does not belong to any of the counties, and thus there will be no county elections in Helsinki.
Source: Kela, the Finnish Social Insurance Institution
Responsibility for organising services
The responsibility for organising health, social and rescue services was transferred from municipalities (309) to wellbeing services counties (21) at the beginning of 2023. Municipalities will remain responsible for promoting the health and wellbeing of their residents. The public sector will remain the organiser and primary provider of the services. Private sector actors and the third sector will supplement public health and social services. Five collaborative areas for healthcare and social welfare will be created to secure the most specialised services. People will continue to be allowed to use health and social services across regional boundaries.
Access to care and public health insurance
Everyone permanently residing or employed 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 social and health center or hospital is unable to provide healthcare within the prescribed time, they must enable it to be provided 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 health services are divided into primary and specialised healthcare. Primary healthcare refers to the services organised by the wellbeing services counties, and they include monitoring the population’s health; promoting health and wellbeing; and preventing, diagnosing and treating diseases, in particular public health diseases. Primary healthcare services are provided at health centres. The majority of specialised healthcare services are organised in hospitals belonging to a wellbeing services county. Uusimaa region is an exception as it has a joint region’s counties and the City of Helsinki owned hospital / specialised care provider the HUS Group.
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.
Financing
In Finland, public healthcare is financed from the state’s 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 most often 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
Service delivery
Primary healthcare
Wellbeing services counties may organise primary healthcare services themselves or together with other wellbeing services counties, or they may purchase them from the private sector. In defined medical conditions, patients may also use service vouchers to purchase services from private healthcare providers, according to their own preference.
Health and social services centres are the nearest and most familiar care facilities to residents, providing many of the healthcare services organised by the wellbeing services counties. Health and social services centres provide particularly primary healthcare services and closely related social services guidance and counselling. In addition to these, health and social services centres monitor and promote the population’s health. There are some 130 health and social services centres providing primary healthcare.
Specialized medical care
The wellbeing services counties are in charge of providing the necessary specialised healthcare. Each wellbeing services county has either a university or central hospital. The HUS Group, which is the joint authority of Helsinki and Uusimaa, is responsible for organising specialised healthcare and maintaining hospitals in Uusimaa region. Each wellbeing services county belongs to one of the five collaborative areas. Each area has one university hospital, which provides highly specialised healthcare.
First aid and emergency care are provided at hospitals for everyone in need of care irrespective of their place of residence. To receive non-urgent specialised care, patients must have a referral issued, for example, by a general practitioner at the health centre or an occupational health physician. Access to specialised healthcare must be arranged within a specified period of time by the law. Patients in need of specialised healthcare services may choose the treatment facility with the referring physician or dentist.
The role of the private sector
The private healthcare sector, such as healthcare companies and NGOs, supplement public health services. Most of the private services are financed by the patients themselves or through health insurances. The wellbeing services counties may also purchase services from private service providers for their residents.
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.
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 basic reimbursement for a novel EMA approved drug in Finland, the Pharmaceuticals Pricing Board evaluates the added therapeutic value and the proposed reasonable wholesale price against other reimbursed treatment options available. A relatively new conditional reimbursement option allows confidential agreements between the Pricing Board and a pharma company. This is to mitigate the uncertainties related to a new therapy. In Finland HCP administered drugs like infusions are taken into use in the hospitals and via public hospital procurement channel (reimbursement not applicable).
There is a constant debate on the right definition of value, as it is related to health economic assessments; the innovators tend to aim for broader definition where i.e. decreased productivity losses would be taken into account while the payers are more supportive of less risky and more narrow direct healthcare cost / savings approaches. Finland’s post-reform healthcare system is highly integrated which increases the pressure towards more holistic evaluations when one budget-holder is responsible for not only healthcare but also social services.
