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1. The Committee notes the information provided by the Government in its report for the period 1994-98 together with the new comments made by the Central Organization of Finish Trade Unions (SAK) and the Confederation of Unions for Academic Professionals (AKAVA). It recalls that in its previous observation dealing with the Government's report for the period 1991-94 and the comments of the same organizations, concern was expressed, in the light of Articles 13, 17 and 30 of the Convention, over the fact that continuous cuts in government health spending led to the weakening of the public medical services, the significant transfer of medical care to the more expensive private sector providers, accompanied by the general reduction of the level of compensation and the consequent increase of the patient's own share in the cost of the necessary medical care. The Government was asked in particular to reconsider these questions, reinforce public health care facilities and ensure that the level of compensation for medical care prescribed in the legislation is applied in practice.

In their new comments, both trade union organizations point out that the problems relating to the availability, coverage and compensation of health care services mentioned in their comments of 1994, remain largely the same and that the overall situation has not improved. The AKAVA states that cost-cutting in the public health system has led to the reduction of the preventive and basic health care services and staff, with the remaining staff showing signs of burn-out. One result of such measures has been an increase in spending on specialized medical care and impractical placements of patients. The SAK adds that, as a result of the public management reform, local authorities' financial situation and growing autonomy, public health care staff resources are not gauged to meet the need, and waiting lists for various public health services, such as operations, have got longer. Supervision and monitoring of municipal health services, which are the responsibility of the local state offices, have deteriorated and are often not performed in practice because of lack of competence or the data needed to carry it out. On the other hand, the cost of private physicians' services puts them beyond the reach of many. Concerning the level of compensation of medicines, the SAK states that, because of the way medicinal products are priced, the deductible part payable by low-income people is becoming unreasonable. According to the AKAVA, the proportion of medicine costs paid by patients has risen greatly in the last five years and now accounts for over half of the total. This, in turn, has reduced the chance that people get all the treatment they really need. Finally, the SAK stresses that social decisions on health care systems and compensation should be taken with a long-term perspective in view.

With regard to public health care facilities, the Government points in the report to an increase in the number of visits to public services, part of which could be attributed to a real increase in visits, while another part is due mostly to the fact that, as a result of the state subsidy reform of 1993, hospitals obtain their revenues now primarily on the basis of patients treated and have therefore introduced more exact registers of visits by type of treatment. In reality, the structural changes in the public health care system in the reporting period have resulted in the decrease in institutional care and the increase in outpatient (open care) specialist medical care. An estimated 50 per cent of the population are currently covered by the "personal physician system", which has reduced waiting periods in the public sector so that it is now usually possible to get treatment within a few days. Waiting lists for operations at public hospitals have shortened, though for certain treatments the trend was the reverse. In Finland, organization of such types of health services as medical care, dental care, school health care and occupational health care falls under the responsibility of the local authorities, which are free to fix the amount of charges taken for each service. In practice, while the actual charges taken by different local authorities may vary greatly, most local authorities charge the maximum allowed by the Decree on social welfare and health care charges. If the charges perceived cause certain categories of low-income people unreasonable financial hardship, the local authority can decide to reduce the charge or to grant income support to cover the cost of medical care.

Generally, according to the report, households accounted for 21.5 per cent of total health care expenditure in 1996, while the public funding was distributed as follows: central government 24.3 per cent, local authorities 36.8 per cent and Social Insurance Institution (sickness insurance) 13.6 per cent. The Government further indicates that, with the improving economic situation, use of private health services has increased. The level of compensation for these services is prescribed by the Sickness Insurance Act as follows: for physicians' fees it is 60 per cent of the rates approved by the Social Insurance Institution (any part of the fee above the approved rate is not compensated); for medical examinations and treatment ordered by physicians it is 75 per cent of the part of the approved fees per medical order after deducting FIM70 per treatment constituting the patient's "own risk"; for medicines prescribed by physicians the basic compensation is 50 per cent per purchase over and above the deductible sum of FIM50. The detailed statistics supplied by the Government for the period 1994-97 show, however, that in practice the average level of compensation, having slightly increased, is still far below the prescribed rates of compensation for the abovementioned types of health services, attaining respectively only 39.1 per cent of physicians' fees, 42.8 per cent of the cost of medical examinations and treatment, and 39.7 per cent of the cost of medicines. Since the beginning of 1996, in principle 75 per cent (previously 90 per cent) of dental check-up and treatment costs and 60 per cent of other costs at approved rates have to be covered in the case of those born in and after 1956. In practice though, it amounted to only 49 per cent in 1997, down from 55.6 per cent in 1994. While referring to legislative measures taken at the end of 1997 to restrain rising costs of medicines, the Government states also that, from January 1999, basic compensation paid is to be limited and subjected to specific clarification in case of certain diseases and expensive medicines. Finally, the maximum amount of compensation in excess of which medicine costs are compensated in full has been raised to FIM3,240.43 in 1998.

The Committee notes this information together with the statistical data on the volume of medical care provided by the public and the private sectors. It notes that no significant sign of the improvement of the public health services could be observed from this information and data, and that, moreover, the Government does not make any attempt in its report to contest the allegations made by the trade union organizations concerning progressive decline of the public health system in the country with the concurrent increase in the cost of the private medical services. The information and data provided in the report with regard to the actual level of compensation for private medical services show that it has not improved over the last years and remains far below the percentage prescribed in the legislation. With regard more particularly to the level of compensation of the cost of prescribed medicines, the Committee notes that, according to the trade union organizations, the part paid by the beneficiary of the cost of medicines is becoming unreasonable for the low-income categories of the population, reducing their chance for getting all the necessary treatment. In this respect, the Committee once again wishes to draw the Government's attention to the principle laid down in Article 17 of the Convention, according to which the rules concerning sharing by the beneficiary or his breadwinner in the cost of medical care should be so designed as to avoid hardship and not to prejudice the effectiveness of medical and social protection. In the light of this provision of the Convention and the abovementioned allegations of the trade union organizations, the Committee would like the Government to explain in detail in its next report, with the help of appropriate statistical information if possible, what measures are being taken or contemplated, including by the different local authorities to which the Government refers in its report, to alleviate hardship that might be caused to the low-income categories of the population by the inadequate level of actual compensation of private medical care and medicines.

The Committee further notes that the trade union organizations stress in their comments the fact that reduction in the quantity and quality of the preventive and basic health care services and staff due to financial cuts goes hand in hand with the non-fulfilment by the State and the local authorities of their supervisory functions in this area due to lack of competent staff and corresponding data. This situation leads to the growing ineffectiveness of the health care system as a whole, manifested in the impractical placement of patients, longer waiting lists, staff overstrain and the shift of burden from general to specialized medical care. It may be further aggravated by the fact that important decisions on health care systems and compensation are decentralized to the local authorities and taken, according to SAK, without a proper long-term perspective and more under short-term budgetary and electoral pressures. The Committee would like the Government to address these concerns in its next report in the light of any long-term policy concerning the development of the national health care and compensation system which may have been established. In this connection, it wishes to remind the Government of its general responsibility under Article 30 of the Convention, for the due provision of the medical benefits of the quantity and quality specified in Article 13, as well as for the proper administration and supervision of the institutions and services concerned. The fulfilment of both these responsibilities, which provide the best existing safeguards against ineffectiveness and decline of the social security schemes, calls for the adoption of special long-term planning measures, including periodic actuarial studies and calculations concerning financial equilibrium, taking into account all the resources allocated by the state and local authorities for these purposes. The Committee would be grateful if the Government's next report would contain detailed information, supported by corresponding studies and statistical data on the comparative development of the public and private health care services, on any such measures taken by the state and local authorities to discharge their general responsibilities under Article 30 of the Convention with respect to medical care. Please indicate also the number of inspections and supervisory visits in health services carried out by the responsible authorities and their outcomes.

2. Extending coverage of dental care to all adult population. The Government states that, following an amendment of the Sickness Insurance Act which took effect on 1 October 1997, those born before 1956 can claim compensation once every three years for dental check-ups and preventive care. This amendment is for a fixed period and is only effective until 31 December 1999. Because of problems with public finances, a decision on a planned amendment concerning payment of dental care compensation to the entire population without any age limits has been postponed until the end of 1999. The Committee once again hopes that the Government will be able to adopt the said amendment in the near future, so as to extend coverage for dental care to the whole of the adult population, and will not fail to indicate the progress made in this respect in its next report.

3. Articles 18 and 26, paragraph 3, of the Convention. The Government indicates in its report that the grounds for granting the daily sickness allowance were changed at the beginning of 1996. The minimum amount of the daily allowance was abolished and the allowance is no longer paid at all if earnings are lower than the statutory limit (FIM5,170 in 1998). However, it can be paid to those who have no, or only a small, income on a discretionary basis, if the disability caused by the illness lasts over 60 calendar days without interruption. The 60-day waiting period is not applied in the case of discretionary rehabilitation allowance.

The Committee notes this information and would like the Government to provide a copy of the legislative provisions in question. It also notes that the above statutory limit of earnings, below which no daily sickness allowance is payable, appears to be rather high compared to the average monthly pay of an industrial employee which, according to the report, amounted to FIM9,952 in the last quarter of 1996, and might result in substantial numbers of low-paid or partially employed persons being refused this allowance. The Committee would like to recall in this respect that, according to Article 18 of the Convention, sickness benefit shall be paid to all persons protected covered by Article 19 in case of their incapacity for work resulting from sickness and involving suspension of earnings, as defined by national legislation. With respect to the 60-day waiting period before the daily allowance could be paid on a discretionary basis, it also recalls that Article 26, paragraph 3, of the Convention stipulates that, where the national legislation provides that sickness benefit is not payable for the initial period of suspension of earnings, such period shall not exceed three days. The Committee would therefore ask the Government to indicate in its next report how the protection guaranteed by these provisions of the Convention is ensured in respect of persons protected whose wages are below the said statutory limit.

4. Article 27. The Committee notes that, according to the report, the burial grant paid under the National Pension Act was abolished in 1996. However, it can now be applied for under the Accident Insurance Act; in other cases, the local authority can grant income support for burial costs. The Committee would like the Government to indicate the relevant provisions of the Accident Insurance Act and to explain whether they are sufficient to guarantee payment of a funeral benefit in all cases covered by this Article of the Convention.