1. Equity concerns in the Finnish Primary Health Care Simo Kokko 01/12/2015 Simo Kokko, Nordic Congress of General Practice, Copenhagen 15 May 20091

2. The whole Finnish framework of health services raises equity concerns First line of health services is made up of three alternative routes –1) Municipal health centers (covering the whole country) –2) Occupational health services (which have expanded far beyond the usual preventive tasks towards usual GP and nurse care) –3) Open access private services (out of pocket payment with reimbursement from the mandatory national sickness insurance) – typically clinical specialists 01/12/2015 Presentation name / Author2

3. The three alternatives can create a multi-tier system If the public health centers would function as designed, there would be less demand for the other two alternatives and they would remain as choices and opportunities for second opinions, but with –The historically difficult access to usual daytime services, many urban Finns bypass the health centers for reasons of convenience –With the shortage of (experienced) GPs, there is also a perception of differences in quality of service –Since residents of rural communities have less choice, this could constitute inequity – but does it have to? 01/12/2015 Presentation name / Author3

4. The answer in the debates has been Try to improve the public health centers’ service and maintain it on as high level as possible Do not interfere with the rights to alternative routes to services; these routes are said to have their rationale and they certainly have political and public opinion support These debates keep popping up at regular intervals; international evaluators (WHO, OECD etc.) criticize the Finnish health system for inequity due to these structures New proposal to a law allowing free use of service vouchers is right now in the middle of debates 01/12/2015 Presentation name / Author4

5. Shortage of primary care doctors and dentists There are about 3600 GP positions in the health centers (about 1500 per one doctor) Due to a number of developments, the entry to health center positions has been reduced –Cutbacks in numbers to be trained (a consequence of the 1990’s recession) –High demand of medical workforce in the specialist level services –The advent of medical workforce rental companies, which attract the younger graduates –“Changes in personal values” of younger doctors 01/12/2015 Presentation name / Author5

6. Equity consequences of the shortages Rural health centers can have very serious difficulties in recruiting - > people will have longer distances to services or they will have to live with reduced supplies of services and impaired access Some urban health centers, or some units in socially challenging neighborhoods are experiencing similar shortages - > very clear equity consequences Orientation to work (among both doctors and nurses) may divide PHC activities into more and less attractive - > with the ongoing fragmentation of services, the least attractive services are left with the least resources 01/12/2015 Presentation name / Author6