Monday, March 25, 2013

Finland: Health Care De-centralisation.


Finland: an amazing country!

© 2012 Am Ang Zhang
It looks like we could be learning a lot from the rather catastrophic decline of the Finnish Health Care system that has been admired round the world for its efficiency especially with the low level of medical staffing. It looks as if de-centralisation is one of the main reasons for the failure. It looks as if England is copying such catastrophic decentralisation with its adoption of CCGs.

Recent History:
Many analysts would state that during the past 3–4 years, the Finnish health centres are either in a state of crisis or at least on a path that may lead into crisis if they now fail to attract enough young doctors and dentists and will later have severe difficulties in recruitment of nurses.
But why would a primary care system, which has been often admired internationally, drift into the difficulties that have been described here?


The beauty of a centralised health service:
Finland launched its health centre based primary care with rather idealistic goals at a time, when the country was much centrally steered. The government held the power through the instrument of tailoring the state subsidies to the local municipalities and thus also to the health centres.

When the national policy called for adding resources to health promotion, rehabilitation, mental health or similar lines of services, the local level complied, since the funding received in return was significant.

Decentralisation:
When the pendulum took its rapid swing from central steering to extreme decentralisation, the course of development changed within a few years. Services that could be characterized as being less attractive or appealing to the middle-aged and often middle-class local decision-makers, suffered. Substance abuse services, long-term care, rehabilitation and similar were easiest among those sectors that experienced cuts.

The Lesson:
This means that one main lesson from the Finnish experience could be that decentralization can lead to loss of coherent health policy making.

The local scenes are occupied by stakeholders who defend the local interests, fight for local jobs and behave in unsustainable ways if they see ways to make savings.


Failure:
But the government has not been able to prevent the turning of primary health care into a battleground on which the future of the Finnish municipal structures and also of the ways that municipal services operate will be settled.

In the name of integration, or creation of structural efficiency or building of networks or getting rid of disturbing borders, Finland now sees changes that are seriously threatening to dissolve the whole identity of primary health care as it has been known in the country for almost 40 years.

Moral dilemma:
Should primary health care remain loyal to its fundamental principles of prevention, health promotion and provision of equitable services, which would mean a special emphasis on those who are disadvantaged? Or should primary health care seek to please the general public and the decision-makers by offering whatever is in demand? It would be unwise to forget either side, but self-analysis is much needed.

The short history of Finnish primary health care shows a wave-like development where enthusiasm is followed by pessimistic visions. Unfortunately, it seems that many difficult years may now be ahead.
 
© Am Ang Zhang 2012
Material taken from: Integrated primary health care: Finnish solutions and experiences           Simo Kokko, MD

2 comments:

Anonymous said...

I think that from the point of politicians the main aim of healthcare is to please the lobbyists who want to make a profit for healthcare companies or insurers (depending on the healthcare system in a country). Poor and disadvantaged people aren't very profitable. Better to focus on the middle classes who have money to spend, whether it's just on extras or whether it's on the basics as well.

Cockroach Catcher said...

It is the same with schools and in England we did have a system that worked: Grammar Schools. Originally hospital were set up in poor areas so that the non paying patients provide for training of doctors that later treated the rich.