Final day: Private and Hospital Pharmacy

The final day of the course, we visited Yliopiston apteekki and also the Pharmacy of the University Hospital. Drugs expenditure in Finland is highly regulated. Over-the-counter drugs are always sold with the assistance of a pharmacist, and prices are fixed and regulated by the Authority. Since bio-equivalence studies are compulsory, the pharmacist have to provide the cheaper alternative to the patient, every time it is possible. On the other hand, the hospital pharmacy is also highly regulated and must supply primary care centers and other related health institutions inside its district.
All of this is excellent, because ensure fair prices and prevents abusive practices against patients. Also, the quality of medicines that are provided is ensured. In my country, the pharmacy sector is a business with very poor regulation, with several well-reported cases of collusion between big chains of pharmacies. Also, in Chile, most of the medicines are not covered by the standard health insurances, and this expenses explain more than one third of out-of-pocket payment. I think we need more control over this system.

Helsinki day 2: THL registers, infectious diseases and care of homeless people.

In our second and last day in Helsinki, we attended a lecture in the THL about the Finnish research registers and informatical systems; then we had another lecture about the THL infectious
diseases surveillance registry and finally we went to the Helsinki city service center for
homeless people.
In the first place we could see the very well organized (and at the same time very complex and intrincate) database system, that contains information related with identification of the citizens, social and health system, among others. There are three points I would like to highlight: The first, is that information is decentralized and databases reside in different places, and nobody have access to everything at the same time, which improves security; the second point, is that researchers have access to all the information and, at the same time, there is a very strict control with the aim of protecting the identity of particular persons; and the third one, is about the high confidence people have in their authorities, and in the government in general. Information of good quality is the key for making research in public health and for designing and monitoring health interventions. This is one of the strengths of the Finnish System, and also of the Chilean one, compared with other Latin-American countries.
Also, we went to a lecture about control of infectious diseases. Very good hygienic conditions explain the low prevalence of many food transmitted diseases. Control of the Health Authority and reporting from the centers in the periphery are also very good.

Finally, we went to the center for homeless people. Here, I could notice that people who were in that situation, usually shared three interrelated problems: alcoholism, unemplyment and lack of social relationships. In Finland any person can apply for municipal social support, including a place to live and a stipend. Thus, the causes of this are not only economical and maybe are far more complex, maybe of psychological origin. On the other hand, in Chile, the problem is related with extreme material poverty and lack of opportunities, in a society characterized by huge inequities of many different kinds.

Helsinki day 1: Many places.

Our days in Helsinki were the longest in the whole course, with many different activities and rushing from one place to the other. The first day in the Capital of Finland, we went to the Finnish Medical Association (the National Medical Trade Union), then to the Helsinki University Hospital to see the central clinical laboratory corresponding to the whole Helsinki University Hospital District and finally we had a very interesting lunch-meeting, invited by Dr. Turunen, from the Duodecim (The Finnish Medical Scientific Association). It is difficult to talk about everything we did in too little words, so I will refer to the most important from my own point of view.

In the Finnish medical association I could notice how strong this Medical Trade Union is. They have a huge political power from the fact that almost all doctors practicing in Finland are members. Other interesting fact is the quality of the information they have regarding to the medical professionals: they have very accurate statistics about salaries, occupation and working conditions which allows them to know very well the situation of Physicians in Finland, facilitating the task of safeguarding their professional and economical interests, as stated in its declaration of aims and principles. In our country trade unions in general are very weak, and the medical one is not the exception. Enrollment is far from being universal, and its political power is not very strong.

Next, we went to the clinical laboratory of the Helsinki University Hospital. They have a very high level of technology, specially regarding to automatisation of the processes. Of course it is necessary because of the high number of people that are served by this lab only. Again, technology is the same as you can find in my country, but usually coverage is not as good as here, because of inequities. Again, the private sector have better availability of services than the public one, limiting the access for people of lower income.
Finally, the discussion with the person from the Duodecim was particulary interesting for me, because I am interested in working in some kind of collaborative study with people from other countries in the issue of the burden of caregivers of people with dementias. I think that international collaboration is important, because talking to people who comes from other settings and realities allows you to view the seme problems from a different perspective and to figure out different solutions. Collaborating is always interesting, you learn a lot from people who came from other backgrounds!

Care of the Children and Obstetrics

This happened to be the last day of the week... before the Midsummer Holiday. We went to a Children's Day Care Center and then we came back to the University Hospital to see the work of Finnish midwives, in the Obstetrics Department. We also see some newborns with their mothers.

In this case, the services seemed to similar to the corresponding ones in my country, but I could find very imortant differences to be ignored. Of course there were differences regarding the quality and quantity of available resources, but this was not the most important aspect to consider, in my opinion. The most interesting were located outside the health system: the social security as a whole, including the educational system for the children and the working conditions and warranties for the parents were very different. For example, mothers in Finland usually have a period of 18 months! (Even though I do not remember the exact figures, but it is more than in my country where mothers must

come back to work when their babies are only 3 months old!) Bonding is a very important process, whose interference can produce several kinds of undesirable consequences. Also, the social protection system provides a wide range of different option for the parents to decide the best kind of preschool education for their children. Everyone has access to the same options, without regard to the income level of the family.

Also, we can see this phenomenon from another point of view: people who provide this services to the children are also adults and they have their own children. In Finland the difference in net income are one of the lowest in the world (as shown by the GINI index). Teachers and health care personnel have fair salaries, dignity and social recognition. The working conditions are also very good (Pre-school teachers were in charge of small groups of students in charge per person, the opposite being the rule in my country). As any other worker, they have the same benefits in health, aducation, etc. I think that all this things together explain the good quality of the services delivered.

As a final anecdote: We and my classmates were waking through the mother's delivery place and neonatal wards, when we see a very beautiful young lady, with a smile in her face, feeding a newborn, very peaceful, with no hurry at all. We thought she was the child's mother, but actually she did not! She was a nurse doing her usual job in the Hospital. Then I begun to think about what would you need in order to have that working conditions, and again, the solution is not confined to change things only inside the health system: you should think about the health system as composed by people who, in turn, are members of the society and everything has an impact in everything.

Visit to the Tampere University Hospital: ER & Specialized Neonatal Care

On Wensday, June 23th, we went to the Tampere University Hospital, one of the five University Hospitals in Finland, corresponding to one of the administrative and territorial division of the Finnish Health System, each of them serving about 0.5 to 2 million people. The most complex medical interventions were performed in this clinical, academic and research institutions. First, we went trough the emergency room: It was very hard to find a single person in a bed... I couldn't find out whether this was always like that or it was an exceptional situation. But the most important point was the fact that they did not have the need to hospitalize people there because there are enough places to receive people in other clinical services of the hospital, in order to give the patient appropriate medical care (The opposite is the rule in the Public Health System in Chile, this is such a huge problem now!). On the other hand, we visited the Service of Neonatology. Here, not surprisingly, I could see a picture very similar to what you could see in my country: the very same technology, the very same division of spaces... maybe some little differences in specific protocols or practices (for instance, you do not feed newborns with donated human brest milk), but essentially, the picture is very, very similar.

Now some reflections. First, regarding to the difference in dealing with medical emergencies: Even though Finland do have many more resources (both in quality and in quantity compared to Chile), However, the Chilean private sector in Chile works pretty much like the Fin

nish one, even though it covers only the 20% of the whole population, more or less. Again, there is a problem with the distribution of the resources. Some people argues that more equity implies and slower rate of economical growing... but I think that we should provide a minimum to all people. The problem is that always someone must pay for that, and political willingness is needed. Also, providing more economical resources to the health systems or institutions not always improve the quality and quality of services that are provided... I do not know how t

o implement a solution, but I think it surely implies a set of interventions at different levels.

Second, regarding to the virtual "lack of differences" in the way neonatal care is provided: This was not surprising in any way, considering that Chile has maternal and perinatal indicators quite similar (or even better in some aspects) to the Finnish ones. This fact demon

strates that, frequently, the most important problems in health have more to do with finding the best mens and strategies to implement the right politics to generate the desired effects than with uncertainty respecting what to do. Sometimes the problem is a matter of lack of resources, it is true, but most of the time the

big problem is the tendency of the social systems to resist to the external change (It is not difficult to recognize self-perpetuating social dynamics of many kinds, sometimes with desirable and other times with not desirable consequences).

I think social change requires a great deal of creativity for findings ways to make people think and reflect about the system they are conserving by their particular actions. I think this is the origin of every successful and long lasting social in-tervention.

Elderly Care in Finland

This day we had a short lecture about the organization of the care for elder people in Finland. Also, in the morning, we visited a public elderly care center - Koukkuniemi, the oldest in the Nordic countries - and in the afternoon we went to a private one, "Viola-home". (The idea was to get a general overview about how society deals with the problem of aging, focusing on nursing home places for old people who are dependent in their daily living activities (ADL). In both cases, the quality of the "core" services seemed very similar to me: facilities and assistance in basic activities of daily living was of good quality, meeting required standards. Also, almost every person who needed to be institutionalized could get a place, being the responsibility of the social and health insurance system to provide the services either in the private or in the public sector (Again the implementation of this was managed at the municipal level, with (mostly) municipal founding). Taking this into account, differences existed mainly in relation to the number of employees per patient and also in the kind and quality of hosteling services, like the size of the rooms, furniture, beauty of common spaces, etc. Not surprisingly, the later aspects were better in the private one.

However, as statistics show, informal care by relatives or friends of the patient is, in practice, the main way for giving support to the elder population dependent on ADL, and the trend for this is to increase even more in the future, both because population is aging and because providing services at this level is cheaper for the health system than providing institutionalized care (and also has a more positive social impact on health). I think this has been understood well in Finland, since today the political and technical focus is giving economical, psychological and

technical support to informal caregivers (they receive instruction regarding to how to take care for dependent people and also receive an stipend).

In Chile, (different from the situation of our primary care, that is comparable to the Finnish one), we do not have any organized way to provide services for the elderly. IN my opinion this is a burning problem, since most of the care is provided by relatives: this makes difficult to see and assess the real impact of this condition. Taking care of other person is very demanding in the physical and social aspects (many of the caregivers report fact like having to left their jobs because of the need of providing care and also a detriment in their social and health-related quality of life) and also very expensive. Because of that, I think this constitutes a inequity-perpetuating mechanism because the cost of this condition is not being shared by the society as a whole, and usually women (and specially the poorer ones) are more affected (becaus

e, in my country they are most of the caregivers), not being difficult to imagine the social consequences of that (There are recently published studies in Chile that show some this facts, but we lack of comprehensive research on this topic).

Finally, I would like to talk about other thing that impressed me: In both institutions there were saunas for the elderly. In my country, that would be interpreted as something luxurious and unnecessary, and someone could easily think of the Finnish as lavish and extravagant people.

However, I could appreciate by myself that this places are very important in the social life (In fact I went there many times with friends). That let me remember the importance of grasping the whole context to understand the function of every component or particular aspect of a system. Given this explanation, is easy to understand the "why"... but I wonder how many time one makes judgments or proposes interventions without taking time to see the global picture. I'm sure this was one of the most important things I learned in this course.

Primary Health Care in Finland

Primary Health Care (PHC) is the foundation of any Health System, and in Finland, it is provided mainly by municipal health centers, with global coverage. Interestingly for me, the provision of services is highly decentralized: the central level only gives general recommendations, but the actual implementation of this guidelines is carried out by each municipality, with great flexibility and autonomy. On the other hand, almost all medical doctors must spend at least one or two years in primary health centers in order to get their medical license in specialized care, they are relatively well paid and also they have access to many diagnostic tools at the local level, decreasing the needing to make referrals to specialized care. Also, in the afternoon, we could visit a private occupational health insurance company and compare the quality of the occupational health services provided in both, the public and the private system.

What surprised me the most was to realize that a very decentralized system can work very well. In my country, we used to have a centralized system, and during the '80s there was a reform in order to give the responsibility of providing PHC to the municipalities. Despite of many similarities concerning high levels of coverage and decent overall health indicators, we have a stronger separation between the administration of the services and the technical stewardship, because the later is still very centralized. The National Ministry of Health dictates technical norms regarding how services must be provided and it has several mechanisms for enforcing them, with great success. However, it has not been very effective reducing inequities, because income levels are very different throughout the country and the quality and access to services is unequal. Another important difference, in my opinion a critical factor that explains why the Finnish system works that well, is the presence of very qualified technicians and politicians at the local level of government. Unfortunately, that is not the rule in Chile, because there are very few incentives for qualified people to work at that level. In one hand, bureaucracy makes very difficult to implement new solutions to unsolved problems and, in the other, the salaries are relatively low. Also, it is not attractive for medical doctors to work there, because resources are scarce. Also, specialization programs are paid by the student, not receiving any salary during his or her formation. All this things together constitute pervasive incentives for not working in PHC.

I think that one important thing we could do is to bring qualified people to the PHC and, specially, good administrators with technical skills. Improve salaries and/or bring more resources to allow professionals at this level to clinical resoluteness. However, we must remember that the most important determinants of health are mostly social, politic and economical in origin. If we think that the objective of the PHC is to improve the health level and quality of life of the population, mostly by preventing disease before its onset, we can see that the most important tool to achieve this is by means of educating people in healthy habits of life, task that cannot be performed by the health professionals alone. Municipalities should be able to implement prevention program in many areas, including the management of the physical and social environment. Obiously, we can not forget the need of increasing the general income level of the population along with reducing inequities. The solution is complex only to the extent that there is not political agreement at different levels on the importance of this factors. IN this context, is important to take into account the mechanisms by which this problems can perpetuate themselves.