The WHO review group scrutinized intensively Finland’s process of developing policy for health for all and the documents on strategy for health for all. Many of the group’s observations and conclusions were accurate. It repeatedly saw the policy process as being oriented much in accordance with Finland’s traditions: mainly within the health care sector, too much command-style process and no clear break-through to broader health policy-making shared by broader societal institutions and an active public. The revised strategy tried to address these challenges later.
Even though the 1986 document on policy for health for all restated many familiar themes in health planning and resource allocation, it disseminated the message outside the health care sector. Why did it not kindle much independent action outside the health care sector? The policy must be viewed based on the historical background and tradition of how Finland has operated in the past decades. All power and knowledge was concentrated in the national health care administration, which used resource allocation techniques to effec-tively reorient grassroots-level actors in accordance with national policies. Substantial human intelligence was used in thinking how to attract state subsidies to good causes in the municipal and regional health services. The heritage of the 1970s – the strong political interest in health and health care issues – was lost somewhere with
the fading of the general political radicalism that affected the entire spectrum of political parties.
The present situation in Finland has been shaken up by the realization that the era of asking for more money and human resources seems to be over. The most realistic structure of financial incentives of the new state subsidy system has caused a radical reorientation of thinking. This could constitute an interesting basis for another round of policy-making, which should now somehow grow from the roots to the top, keeping both the people and their nearest health-related authorities, the municipalities, very much in charge.
Recent developments in Finland could offer interesting policy lessons for other countries. Health professionals in many countries view public debate and consciousness about such issues as cost-containment, limits to care, setting priorities and rationing very negatively. In Finland, these issues must be at the top of the agenda. About 15% of all public services, including health services, are financed by the government borrowing more money (12). This is clearly unsustainable. Nevertheless, the representa-tives of the health care sector in Finland have had many timely and welcome reactions. The new search for efficiency, the most appropriate allocation of diminishing resources and new administrative and organizational arrangements would not have been possible in the spirit of the 1980s, when the only perceived limit to growth in health care was the lack of personnel.
Breaking the link between public financing and public provision of services did not lead to wide privatization. In fact, the net effect has been de-privatization, since the municipal decision-makers have been loyal to municipal staff and they have first cut back privately purchased services. Only in new types of semi-institutional services to elderly people and people with long-term mental disorders have small, often family-based, enterprises won new ground (13).
It has become much more difficult to implement national health policy strategies because of the new autonomy of the municipalities. Policy development could turn out to be difficult to light up and move in coherent directions. Health care professionals now spend much time and attention in contemplating health care reform and in defending the survival of their own institutions. Citizens’ initiatives diverge.
Some groups are trying to return to the “good old days” when everything was protected by national will and earmarked financing. Others seek solutions from alternative medicine. The most ominous develop-ment seems to be the silence of the really disadvantaged groups in the society and the passivity of political decision-makers when they are told that the people in greatest need have been the first to suffer.
References
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