4.2 Human resources
4.2.1 Planning and registration of human resources
There are few state-level mechanisms to steer the health care workforce geographically (see Box4.2) or in terms of skill-mix, except with regard to the education of health professionals (see below). However, the MSAH and THL have issued several national recommendations for workforce sizing for care for the older people, and for preventive care (see MSAH, 2017a; Klemetti & Hakulinen-Viitanen, 2013). Needs assessments and human resources planning have been conducted in the context of overall labour projections in collaboration with the Ministry of Education and Culture, the Ministry of Economic Affairs and Employment, the MSAH, Statistics Finland and municipal organizations.
The Ministry of Education and Culture is responsible for regulating and supervising the training of health professionals. In theory, universities are autonomous foundations and under public law can decide on the number of students to be enrolled. In practice, the Ministry of Education and Culture together with the universities reach an agreement on the budget and the number of students. The universities of applied sciences (polytechnics), which provide training for nurses, are public limited companies and mainly governed by municipalities. They are autonomous but operate under the guidance and financial support of the Ministry of Education and Culture.
The governance of specialist training of physicians and dentists has been a responsibility of the MSAH since 2015. In practice, the steering focuses on monitoring and securing collaboration between different actors, and it is carried out by an advisory expert group representing the main specialist training stakeholders (MSAH Coordination division for medical and dental specialist training and specific training in general medical practice). The intake of interns for physician and dentist specialist training was previously not covered by the MSAH steering mechanism at the national level, and instead determined through recruitment decisions by hospital districts and universities. However, since 2016 a new open selection procedure has been introduced following the national level regulation on the intake to specialist training based on current and future needs.
The Valvira is responsible for licensing, registration and, together with the RSAAs, supervision of health personnel. It also undertakes disciplinary procedures concerning health personnel.
There is no re-accreditation system in Finland; medical and other health care professionals are responsible for engaging in continuous education themselves. According to the legislation, employers are responsible for providing professional training, but the implementation varies across health care organizations.
4.2.2 Trends in the health workforce
Most professionals working in the health sector are employed in municipally operated health services (health centres and hospital districts). In 2014, the health sector employed 180 724 employees, more than three quarters of whom were working in the municipal sector (THL, 2019d). Of all employees, just under 100 000 were working in hospitals and 66 000 worked for other providers, such as health centres. The total health workforce has increased by 15% since 2005.
As the public sector gradually recovered from the economic crisis in the late 1990s, a significant physician and dentist shortage developed in primary care. In order to rectify this situation, the yearly intake of medical students was doubled between 1995 and 2016, from 365 to 750. In addition to Finnish faculties, many students study medicine abroad (about 750 students in 2016), for example in Sweden, Estonia and Latvia, with an estimated 150 students graduating annually and returning to Finland (Finnish Medical Association, 2016).
After 2008 the shortage of medical doctors in health centres has decreased substantially – from 11% of unfilled posts to 6% in 2018 (Finnish Medical Association, 2018). However, there are significant variations in vacancies between regions. Currently the shortage is by far the largest in the north-eastern parts of Finland and in particular in Kainuu with one in five vacancies unfilled (Finnish Medical Association, 2018). In specialized care there were more than 9% unfilled positions in 2008 but by 2015 this share had decreased to 6% (Finnish Medical Association, 2016). The numbers of unfilled positions were highest in psychiatric fields, respiratory medicine and pathology.
Between 2000 and 2014 the number of practising physicians in Finland increased by 28% (Fig4.3). According to national data, in 2016, 66% of physicians worked in the municipal sector with 44% working in hospitals and 22% in health centres; 18% of physicians worked in private medical centres or clinics. Over the past two decades (1996–2016), the number of physicians working in hospitals increased by 29%, compared with 21% increase in physicians working in primary care, while the number of physicians working in other places (mainly private and occupational health care) increased by 67% (Finnish Medical Association, 2016).
In 2014, there were 14.3 nurses per 1000 population, an increase of 33% compared with 2000 (Fig4.4). In comparison with other Nordic countries, Finland has a smaller physician to population ratio, while the ratio for nurses is higher than in Sweden and Denmark, but lower than in Norway. The nurse-to-doctor ratio in Finland is one of the highest among the OECD countries with 4.4 nurses per doctor in Finland in 2014. There is a movement towards a larger role of nurses in coordinating patient processes especially in terms of chronic, long-term and minor acute health conditions at primary care level. In 2018, nurse consultations covered 50% of the total number of non-urgent outpatient visits in health centres and they typically work in multidisciplinary teams or in pairs with physicians. After attaining a regulated postgraduate qualification the nurses have also been able to prescribe some drugs to patients suffering from common conditions (Keskimäki et al., 2018).
There were 0.7 dentists per 1000 population in Finland in 2013, a ratio similar to Denmark but lower than in Sweden and Norway. The number of unfilled dentist posts in health centres has been relatively constant in recent years – 6% in 2018. About 37% of all dentists are working in the private sector (Finnish Dental Association, 2016a).
The ratio of pharmacists per population in Finland is higher than in other comparable countries – 1.1 per 1000 in 2013, representing an increase of 12% from 2000. There are two university degrees in pharmacy in Finland: Master of Science and Bachelor of Science. In 2017, about 2600 people had the degree of Master of Science in Pharmacy. About 600 of them ran their own pharmacy and about 750 were employed in a pharmacy owned by another person. Pharmacies additionally employ about 3700 assistant pharmacists having the degree of Bachelor of Science in Pharmacy (Association of Finnish Pharmacies, 2018).
4.2.3 Professional mobility of health workers
Geographical mobility of health professionals in Finland is fairly limited, mainly due to the language barrier, with health professionals being required to speak sufficient Finnish (or Swedish in some areas). However, during the peak shortages of physicians in the 2000s there was a substantial influx of medical doctors from Estonia and the Russian Federation. In 2016 there were 935 physicians who were not Finnish citizens living and practising in Finland. The majority of foreign physicians are from Estonia (425 physicians) and the Russian Federation (183 physicians) (Finnish Medical Association, 2016). There has also been an active, but not very large-scale, recruitment of nurses, from abroad; for example, from the Philippines or Spain.
Migration of Finnish health professionals to other countries has been moderate. According to statistics of the Finnish Medical Association, about 2060 Finnish physicians (including researchers), corresponding to about 10% of working-age physicians resident in Finland, were working abroad in 2016. The greatest proportion (41%) of them was working in Sweden. At the same time, 3550 nurses from Finland were employed abroad, of whom 37% were working in Sweden (THL, 2019d). Overall, migration of health professionals to or from Finland has not been a major issue, except for the impact on neighbouring Estonia, where the health workforce is consequently diminishing (Lai et al., 2013).
4.2.4 Training of health personnel
Physicians are educated at five universities. University education leading to a degree is free of charge for EU/EEA citizens. However, tuition fees were introduced for students from other countries in 2017. Basic medical education lasts six years and contains a considerable amount of guided practical training. Dentists are trained in four university faculties and their studies last five years in total. Training of pharmacists takes place in three universities and takes five years (Master’s level) for pharmacists or three years (Bachelor degree) for assistant pharmacists.
To become a specialist, physicians and dentists must register with the faculty of medicine for the relevant specialist training programme. Specialization lasts five to six years depending on specialty and includes theoretical studies, clinical work and national examination. Specialization begins with the resident working as a junior hospital doctor at a central or district hospital under the supervision of an experienced physician. This is followed by working at a central university hospital, although at least half of the training must be done outside of central university hospitals. All specialization programmes require a nine-month residency at a health centre. Specialist training also includes compulsory management studies. Occupational care physicians, irrespective of the employer, can either be specialists in occupational health care (which is a medical specialty in Finland) or have additional training in occupational health care.
Nurses (including acute care, public health nurses and midwives) and other health professionals (e.g. dental hygienists, physiotherapists, laboratory personnel) have basic upper secondary level training lasting 3–4.5 years, which takes place at universities of applied sciences (polytechnics). The course for nurses covers general nursing. A separate specialist training includes, for example, surgery and internal medicine, paediatrics, geriatrics, anaesthetic and operating theatre, and psychiatric nursing. In addition, universities have programmes on nursing science and health sciences, leading to Bachelor and Master Degrees.
After graduation, continuous medical education for physicians and dentists is provided by employers, medical societies, universities and pharmaceutical companies. Health care professionals in Finland are licensed for their entire active careers, with no periodic revalidation. According to the Health Care Act, health centres and hospital districts are responsible for arranging continuous medical education for their personnel.
4.2.5 Physicians’ career paths
About 59% of working-age doctors have a specialist diploma and 20% of them are specialized in general practice. However, specialization in general practice is not a requirement for working as a GP in a health centre, although the salary is usually higher. Typically, medical graduates start their career from working at health centres for at least nine months, often as part of their specialist training.
Health centres and hospital departments decide independently on the recruitment of doctors to junior and specialized doctor positions, and the promotion of their staff. They also decide independently on the number of positions in each clinic.
4.2.6 Other health workers’ career paths
Dentists have similar career paths as medical doctors, except that specialization is rarer. Nurses are specialized already in their basic nurse training programme. Higher administrative positions in hospitals usually require for nurses to have a university degree in nursing or health sciences.