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Articles 13, 17 and 30 of the Convention. With reference to its observation, the Committee notes the observations attached to the Government’s report for the period ending 31 May 2007, in which the Central Organization of Finnish Trade Unions (SAK), The Finnish Confederation of Salaried Employees (STTK) and the Confederation of Unions for Academic Professionals (AKAVA) state that the resources of municipalities for preventive and basic health care are inadequate, the public health service suffers from a shortage of doctors and nursing staff, access to health care is unequal and there are substantial differences in the health status of different socio-economic groups. The unions indicate that sickness insurance compensation for private health care has not been raised since 1989 and covers only about 30 per cent of the cost of care. They consider that endemic diseases, obesity, substance abuse, mental health, etc., require an extensive social welfare policy programme and better evaluation of health impacts.

The Government states that in the last decade there were significant changes in the funding of health-care services. In 1996, households accounted for 21.5 per cent of total health care expenditure, while the part of the central Government was 24.3 per cent, local authorities – 36.8 per cent, and Social Insurance Institution (sickness insurance) – 13.6 per cent. By 2007, the share of the central Government has dropped to less than 20 per cent, while the share of local governments has increased to 43 per cent. The share of fees charged directly to beneficiaries stayed at the level of 20 per cent. The charges payable by beneficiaries are laid down in the Act and Decree on Social Welfare and Health-care Charges. The Act on the status and rights of patients requires health care to be of good quality and empowers an appellate authority to take remedial measures, if necessary. Municipal health centres provide primary health care. Municipalities are also responsible for arranging specialized hospital care and ensuring that the level and quality of services meet their residents’ needs. They may arrange services independently or buy them from a service provider. The role of private service providers has increased and accounts for some 25 per cent of health spending. Part of the cost of health care given by private providers is compensated by sickness insurance: 60 per cent of doctors’ fees and 75 per cent of medical examination and treatment at rates approved by the Sickness Insurance Institution (SII). The approved rates for medical services in the private sector are fixed by the Government. For amounts paid in excess of these rates no compensation is provided by the SII. In 2006, the average compensation of doctors’ fees attained only 27.5 per cent (39.1 per cent in 1997) and of the cost of medical examination and treatment – 31.75 per cent (42.8 per cent in 1997). Although the real level of compensation has dropped below the 30 per cent level, according to the Government, this has not led to a fall in the demand for private health-care services or made it more difficult for lower-income classes to have access to them. The report further indicates that, as from 1 January 2005, an examination or treatment prescribed by a physician is compensated for a maximum of 15 times during a year (previously 15 times in three months). From 1 January 2006 medicines are compensated at a fixed percentage of the price, the basic compensation covering 42 per cent of the price of an approved medicine. From 1 January 2006 the funding of sickness insurance was revised. Sickness insurance was divided into earnings security insurance funded by the employers and the employees and medical care insurance funded by the insured and the state.

The Committee also notes that, in 2001, the Government adopted a public programme “Health 2015”. In 2002–07, two national development projects were implemented: the “National Health Care Project” and the “Development Project for Social Services”. In 2005, the nationwide immunization programme was revised. The Commission for Local Authority Employers (KT) points out that the number of health personnel, particularly of nurses, has increased faster than in any other area of administration in the municipal sector. The Committee observes that the measures highlighted in the Government’s report show that the Government assumes its responsibilities for the sound administration of health institutions and for the provision of the medical benefits (Article 30 of the Convention). With regard to the question of the effectiveness and sufficiency of these measures raised by the workers’ organizations, the Committee draws attention to Recommendation No. 1626 (2003) of the Parliamentary Assembly of the Council of Europe on the reform of health-care systems in Europe, which states that “the main criterion for judging the success of health systems reforms should be effective access to health care for all without discrimination, which is a basic human right. This also has the consequence of improving the general standard of health and welfare of the entire population.” On its part, the Convention also emphasizes that medical benefits should not be limited to curative medical care but aim at actually improving the health of the protected persons (Articles 8 and 9). Reforms of health care must be implemented in such a manner as to take into account the economic situation and avoid hardship to persons of small means (Article 17). Bearing this in mind, the Committee would like the Government to state the main indicators used to monitor the general standard of health and welfare of the population in Finland and trends in this standard in the last few years, paying particular attention to the situation of the low-income categories of the population. The Committee would also appreciate information on the measures taken or envisaged to ensure the financial sustainability of the sickness insurance system in the long term.

Article 27. The Committee recalls that the burial grant paid under the National Pension Act was abolished in 1996, but can be applied for under section 16 of the Accident Insurance Act. In 2007, the amount of the burial grant was 4,040 euros. The report also indicates that nearly all persons covered by compulsory insurance under this Act fall within the scope of the employees’ group life insurance, which the employer may be obliged to set up under the generally binding collective agreements. The Committee would like to point out that compensation paid by the group life insurance for the death of an employee could not be regarded as a funeral benefit in the sense of Article 27 of the Convention. The Committee would, therefore, like the Government to explain in its next report the extent of the personal coverage of the Accident Insurance Act and to show that the survivors of all persons protected in Finland in application of Article 19 of the Convention who were in receipt of, or qualified for, the sickness benefit shall be entitled to a funeral benefit guaranteed by Article 27. Please explain whether the current amount of the burial grant is sufficient to cover the real expenses of the funeral.

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With reference to its previous observation where it asked the Government to adopt legislation so as to extend coverage for dental care to the whole of the adult population, the Committee notes with satisfaction from the Government’s report that, since 1 December 2002, the entire population is covered by dental care under sickness insurance.

The Committee recalls that since the middle of 1990s the workers organizations of Finland – the Central Organization of Finnish Trade Unions (SAK), the Finnish Confederation of Professionals (STTK) and the Confederation of Unions for Professionals and Managerial Staff in Finland (AKAVA) – have been expressing their concern, in the light of Articles 13, 17 and 30 of the Convention, regarding the insufficient funding and staffing of the public health system, the lowering of the quality of the municipal health services, the reduction of the preventive health care and the consequent transfer of medical care to the more expensive private sector providers, accompanied by the reduction of the level of compensation and the increase of the patient’s own share in the cost of the necessary medical care. In their new observations attached to the Government’s latest report for the period ending 31 May 2007, these organizations maintain that: the resources of municipalities for preventive and basic health care are inadequate, the public health service suffers from a shortage of doctors and nursing staff, access to health care is unequal and there are substantial differences in the health conditions of different socio-economic groups. The Committee deals with the issues raised by the workers’ organizations in a request addressed directly to the Government.

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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.

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With reference to its previous comments concerning the application of Article 17 of the Convention, the Committee notes the information provided by the Government in its report of 1991-94 together with the comments made by the Confederation of Unions for Academic Professionals (AKAVA) and the Central Organization of Finnish Trade Unions (SAK).

Both organizations point out that, as part of the Government's saving programme, compensation for medical treatment has been reduced and the share of the cost borne by the patient has grown, in particular for physicians' fees, out-patient and in-patient fees and medicines. At the same time, the right to deduct medical costs from the taxable income has been discontinued. The savings programme has particularly affected access to dental care, which has not been extended to unprotected segments of the population, despite the promises given. According to the AKAVA, central and local government cost cutting also threatens to reduce medical services in the public sector. The SAK considers that the scope and availability of medical care services, as defined in Article 13 of the Convention, is problematic because of scarcity and of the economic difficulties of those in need of such services.

In its report, the Government confirms that, as part of the Government saving programme, sickness insurance benefits have been cut, more costs have been shifted to patients, and as from 1992 medical costs are no longer tax deductible. As a result of the sharp decline in public resources, it has been considered justifiable to assign some health care responsibilities to the private sector. The new state subsidy scheme which took effect in 1993 has contributed to reinforcing the significance of the private sector, side by side with public services, by giving local authorities the chance of buying the services they offer from the private sector through competitive bidding. Over 27 per cent of all physicians' services in the community care sector compensated under the sickness insurance scheme were provided by private physicians. In principle, 60 per cent of physicians' fees are compensated, but in practice this compensation averaged about 36 per cent in 1993, as a result of the lower fee scale introduced by the Government. For medical examination and treatment ordered by physicians, the compensation is fixed at 75 per cent of the part exceeding the patient's "own risk" per medical order in accordance with the confirmed fees. However, the average compensation for these services amounted to only about 38 per cent in 1993. As regards dental care, about half of all expenditure on these services was spent in the private sector. The compensation percentage for dental treatment is 90 per cent and for other care 60 per cent of the confirmed fees. In practice though, it amounted to about 55 per cent on average in 1993. Generally, those born before 1956 are not entitled to compensation for costs incurred from dental care. This has been considered a real shortcoming and the Government has in fact been preparing to extend the coverage to the whole population. However, this has been postponed until the beginning of 1996 in order to curb government spending.

The Committee notes from the above information that, due to economic difficulties and the need to curb government expenses, the accessibility of medical care has been influenced in recent years, on the one side, by the continuous reduction of the level of compensation and the increase of the patient's own share in the cost of such care, and on the other side, by the significant shift in the provision of medical services from public to private sector to the extent that the above-mentioned occupational organizations have expressed concern with the "scarcity" of public medical services. At the same time, according to the figures given by the Government, compensation for care provided in the private sector by physicians and on their orders, as well as for dental care, attained in practice on average only 36, 38 and 55 per cent respectively of total cost, the rest of which has to be borne by the patient himself. In this situation, the Committee wishes once again 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. It also draws the Government's attention to Article 30 according to which the State shall accept general responsibility for the provision of benefits due under the Convention and in particular for medical benefit provided for under Article 13. The Committee therefore hopes that in view of the situation the Government will reconsider its policy in light of Articles 13, 17 and 30 and reinforce public health care facilities, and will take the measures necessary to ensure that the level of compensation for medical care prescribed in the legislation actually is being applied in practice. In this respect, it asks the Government to continue to furnish in its next report the recent statistical data on the volume and proportion of medical care provided by each of the public and private sectors and on the average level of compensation by type of medical care provided by the private sector. Finally, as regards access to dental care, the Committee hopes that the Government will report on the progress made in extending coverage for dental care to the whole of the adult population, in accordance with its stated intentions.

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Article 17 of the Convention. In its previous comments, the Committee noted the comments transmitted by the Central Organisation of Finnish Trade Unions (SAK) to the effect that, because the communities did not have enough capacity to provide basic municipal health care, insured persons had been forced to resort to private health services; some 30 per cent of the costs incurred were refunded. The Committee consequently pointed out that, under Article 17 of the Convention, 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 its reply, the Government states that medical care is the responsibility of the municipalities, particularly in the case of emergency treatment. It states that, if a patient also resorts for any reason to the care of a private physician, such care is reimbursed at 60 per cent of the rate approved by the Ministry of Social Affairs and Health, on the basis of the sickness insurance scheme. The same applies to examinations and treatment given at private hospitals or in special categories of municipal establishments.

The Committee has noted this information with interest. It would be grateful if the Government would indicate whether and, if so, for what reasons and under what conditions (for example owing to a possible inadequacy of the medical or hospital infrastructure at municipal level) insured persons may find it necessary in practice to resort to the services of private physicians or to undergo treatment in private hospital establishments. In this connection it asks the Government to supply statistics on the number of insured persons resorting to private medicine (whether for out-patient or in-patient care) in proportion to the total demand for care. Furthermore the Committee would also like the Government to indicate whether and how far the rates of reimbursement applied to consultations with private physicians and hospital care by the sickness insurance scheme correspond to the actual fees of physicians or hospitals.

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Article 17 of the Convention. The Committee notes the information supplied by the Government in its report. It notes with interest the adoption of new regulations concerning the reimbursement of cost sharing for medicine and transport when the total of the cost sharing for the year reaches respectively FIM 2,833 for medicines and FIM 500 for transport.

The Committee also notes the comments transmitted by the Central Organisation of Finnish Trade Unions (SAK), which are contained in the report. In the opinion of the SAK, because the communities do not have enough capacity to provide basic municipal health care, people have been forced to resort to private health services; some 30 per cent of the costs incurred are refunded. The Committee would be grateful if the Government would supply detailed information on the impact of this situation on the implementation of the Convention, taking into account the requirements of Article 17, which provides that the rules concerning cost sharing by the beneficiary or his breadwinner in the cost of medical care shall be so designed as to avoid hardship and not to prejudice the effectiveness of medical and social protection. Please also state the rules that are in force respecting the reimbursement of the cost of medical care that is provided by private practitioners.

[The Government is asked to report in detail for the period ending 30 June 1991.]