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.