5. Provision of services
- Health promotion and disease prevention are the cornerstones of health care in Finland.
- There are three parallel systems for health service provision. The principal system is publicly financed and organized by the municipalities, for all levels of care. The others are private and occupational health care, mostly providing ambulatory primary and some specialist services.
- Municipal primary care is provided by health centres, providing a wide range of services, although waiting times can be long.
- Public specialist and inpatient care are provided through hospital districts; these provider networks have been undergoing centralization, as well as a shift from inpatient care to other settings.
- Centralization of specialized care is increasing. The numbers of district and specialist hospitals have decreased and their service provision has reduced markedly in the 2000s, largely through mergers with larger hospitals. A Government Decree on the further centralization of specialties has recently entered into force and is expected to reduce the number of surgical treatment centres.
- On-call services have undergone a shift towards emergency departments that provide primary and specialist care and are located mostly at hospitals. The array of services in larger hospitals includes the availability of social welfare personnel at all hours.
- Long-term and mental health care are increasingly integrated with social services, and most care is provided closer to patients’ homes. Mental health care is provided closer to somatic specialist care and substance abuse problems have been recognized as an important part of mental illness.
5.1 Public health
Health promotion and the prevention of diseases have been a mainstay of Finnish health policy for decades. The main responsibility of the MSAH is to protect and promote the health of the population. Health promotion is carried out both at the national and municipal level, and involves several agencies and institutions subordinated to the Ministry, as well as NGOs and other actors. The main sources of funding are municipal budgets, with separate allocations from the state budget determined by the MSAH for specific projects. Since 2017, the STEA under the MSAH has managed funding for NGOs from the state-owned Veikkaus Ltd, which has an exclusive right to operate all gambling in Finland.
Environmental health services in Finland cover the health impacts of housing and public areas, noise pollution, the quality of drinking and bathing water, the assessment of adverse environmental health effects and waste management. Environmental health services also include the surveillance of gene technology, chemical control and protection from radiation. The MSAH supervises health protection and is responsible for developing the principal legislation for environmental health services. The MSAH carries the overall responsibility for tobacco control and has joint responsibility with the Ministry of the Environment for the control of chemicals and gene technology. The Ministry of the Environment has the responsibility for all other environmental issues. Other state bodies involved in environmental protection are the Ministry of Economic Affairs and Employment for radiation. The Finnish Food Safety Authority (Evira), a subsidiary of the Ministry of Agriculture and Forestry, ensures food safety and promotes animal health.
Municipalities (sometimes jointly) are responsible for the implementation of environmental health services, either within municipal health centre or under the local municipal environmental protection authority. Municipal health inspectors ensure that environmental health legislation is complied with and provide consultation and guidance. Recent changes in legislation have shifted the responsibility for chemical surveillance from the municipalities to the Finnish Safety and Chemicals Agency (Tukes).
Prevention of communicable diseases is the responsibility of the MSAH and THL. THL investigates infectious diseases, monitors their occurrence, provides guidance for professionals, and studies epidemics in collaboration with hospital districts and local authorities. Based on the recommendations from THL, the MSAH decides on the national vaccination programme. Currently the programme includes free-of-charge vaccinations for children against 11 different diseases, and HPV vaccinations for girls. The 11 diseases are: rotavirus and pneumococcal infections, diphtheria, tetanus, pertussis, polio-encephalitis, Haemophilus influenzae type b infections, measles, mumps, rubella, and chicken pox. Also, children receive influenza vaccinations annually from 6 months to 6 years of age. The MSAH is currently evaluating the administration of HPV vaccinations to boys according to THL recommendations. Adults receive a booster against diphtheria and tetanus every 20 years, influenza vaccinations for those aged over 65 years, and other supplementary vaccinations when needed or if they belong to specific risk groups (e.g. health and social care personnel, migrants, people living in areas with tick-borne encephalitis). All vaccinations are voluntary. THL has recently started a nationwide registry on vaccinations that collects information on vaccination status directly from patients’ records.
The 2017 Government Decree on Infectious Diseases, based on the 2016 Infectious Diseases Act (1227/2016), redefined the classification of hazardous and monitored infectious diseases. It also aims to improve the collaboration and information exchange between physicians and authorities.
In terms of noncommunicable diseases, THL runs specific programmes to decrease the burden of chronic conditions and mental health problems. These include, for example, an online service that supports the planning and management of municipal and regional health promotion services (TEAviisari, https://teaviisari.fi/teaviisari/en/). THL regularly conducts a number of surveys, including the National Health, Well-being and Service Survey, FinSote.
According to the Occupational Health Care Act (1383/2001), the aim of occupational health care is to prevent work-related diseases and accidents, and to preserve the health and functional capacity of employees. According to this Act, every employee is entitled to occupational health care, regardless of the nature and duration of the employment relationship. Occupational health care is a service provided and paid for by the employer for the purpose of supporting the ability of employees to work. All employers are required to organize regular health examinations for their employees if the work involves special health risk factors defined in legislation (e.g. noise, flour dust or solvents) or is otherwise hazardous. Employees may ask for an opinion from occupational health care for health issues, and when confronted with, for example, physical or psychosocial overload at work. Besides early intervention when work capacity is compromised, occupational health care can assess the remaining work capacity of employees. Occupational health promotion is arranged by employers through their own, municipal or private service providers. Municipalities are obliged to organize occupational health services locally for employers who request them.
Maternal and child health care has a strong tradition in Finland and these services form a comprehensive network covering all municipalities and include services that involve the well-being of the entire family. Maternity clinics provide family support, monitor the progress of pregnancy and offer screening tests and consultations when necessary. Expectant mothers normally meet with a nurse and doctor 11–15 times during pregnancy. Attending a maternity clinic is one of the preconditions for eligibility for maternity benefit. Both parents are expected to take part in family and childbirth preparation sessions. Child health clinics provide support to families by organizing home visits by public health nurses prior to and after birth. These clinics assess the physical, mental and social state of children below school age, provide vaccinations and support parents. A 2011 Government Decree (338/2011) requires all children below school age to have 15 visits at the child health clinic, five of them under the supervision of a physician. One of the main functions of the clinics is to promote healthy growing environments for children and to encourage healthy family lifestyles. Children below 18 years of age receive publicly funded free-of-charge preventive dental care.
Sexual and reproductive health is promoted by a national action plan (currently covering the period 2014–2020), which emphasizes sex education, good care at birth, an understanding of multiculturalism, as well as male sexual and reproductive health (Klemetti & Raussi-Lehto, 2013). In practice, municipalities provide family planning and related services free of charge. The largest cities have separate clinics for treatment of sexually transmitted diseases, but otherwise treatment is provided as part of the general services of health centres. Comprehensive family planning services and health education targeting young people have resulted in the lowest number of pregnancy terminations in the Nordic countries. THL gathers and publishes data on sexual and reproductive health, including statistics on abortions and perinatal health in the Nordic countries and surveys on schoolchildren’s health behaviour (School Health Promotion, every other year).
Taxation of harmful products, such as alcohol, tobacco and soft drinks, is the primary means of controlling the use of these substances in Finland. The sale of alcohol is a state monopoly (Alko Ltd) and only products that contain less than 4.7% of ethyl alcohol were available for sale outside the monopoly alcohol shops since the early 1990s until 2018. After a heated debate, the Alcohol Act was reformed in 2017 (1102/2017), with changes entering into force in the beginning of 2018. The main changes were that retail stores can sell all kinds of alcoholic beverages that contain up to 5.5% alcohol by volume and restaurants’ and bars’ opening hours are deregulated (but not the serving hours). The reform maintains Alko’s retail monopoly and the existing licensing system. THL and a special committee of the MSAH continue to monitor the public health consequences of these changes. Valvira and the RSAAs perform the licensing, supervisory and guidance activities as stipulated in the Alcohol Act.
Bans on tobacco advertising and gradually increasing restrictions on smoking in public places have been implemented in Finland since 1976. In 2007, restrictions were imposed on smoking in restaurants. The Tobacco Act was reinforced in 2016 (549/2016) to adhere to the EU Tobacco Product Directive and national objectives. The changes include a ban on cigarettes with characterizing flavours, such as menthol, restrictions on smoking on balconies in private apartment buildings and in vehicles transporting children, and certain safety and quality requirements for e-cigarettes containing nicotine. The sale of tobacco to children under 18 years is prohibited in Finland and products are not openly available in shops. Advertising of tobacco and strong alcohol products is banned. Other measures used to attain the goal of a completely smoke-free Finland by 2030 are education, research and the use of nicotine replacement therapy. The latter was made available outside of pharmacies in 2006.
The latest nutrition recommendations by the National Nutrition Council, an expert body under the Ministry of Agriculture and Forestry, were published in 2014 (National Nutrition Council, 2014). They follow the Nordic recommendations but allow for less intake of salt. Dedicated recommendations have also been issued for specific population groups, such as schoolchildren, young adults, older people and pregnant and breastfeeding women (Finnish Food Authority, 2019). As the Finnish adults are more often overweight than their Nordic counterparts, THL has launched a nationwide programme for 2016–2018 to decrease the prevalence of obesity (Box5.1). In addition, the MSAH has introduced a national strategy for physical activity that emphasizes the dangers of sedentary lifestyles (MSAH, 2013). Special attention has been paid to the nutrition and physical activity in older people and to the prevention of obesity in children. The Ministry of Education and Culture is responsible for creating favourable conditions for sports and physical activity.
Municipalities are obliged by a 2011 Government Decree (Governmental Decree on Screening 336/2011) to provide the following screening tests for their residents: 1) breast cancer screening for all women between the ages of 50 and 69 years, or for those born in 1947 or after, every 20 to 26 months; 2) cervical cancer screening for women aged between 30 and 60 years every five years; 3) ultrasound examinations and screening for chromosomal abnormalities for pregnant women. In addition, there is newborn screening for hypothyreosis and specific inherited metabolic disorders. Municipalities may also offer other screening services, but are obliged to assess cost–effectiveness and ethical considerations. Screening for colorectal cancer was started in some municipalities in the beginning of 2019 and will become a nationwide programme in the 2020s.