Decentralisation and equity of healthcare provision in Finland

Editorials by Leys and Diderichsen Finland has a comparatively sparse population of 5.1 million in an area of 338 145 km2. Although 66% of the population live in towns, a substantial proportion still lives in rural areas.1 The nation is divided into 452 municipalities, which have a long tradition of local democracy and local elections. The population and area of the municipalities varies from a few hundred inhabitants to large cities with over 100 000 inhabitants, the median population being 6000. Municipalities have a mandate to raise taxes and responsibilities for providing services, and they can form federations covering larger populations. Central government has traditionally guided this process through legislation and state subsidies earmarked for specific services (figure). These subsidies were particularly important when basic services were being provided in remoter and poorer areas, where the maintenance of services is expensive and resources are scarce. In 1993 an act of parliament changed the basis of state subsidies from earmarked to block grants, giving municipalities more independence in using resources. Finance and provision of public health services in Finland excluding care provided by national health insurance and employers. Adapted from Martikainen and Uusilkyla2 #### Summary points In Finland the provision of health services is decentralised and the responsibility of municipalities In practice, central government has traditionally supported these responsibilities through specially allocated funding In the 1990s central government changed to block grants and municipalities have become more independent in providing services Municipalities have tax powers, but in the 1990s they have been increasingly collecting funds through user fees In practice local governance as such may not guarantee equitable access to services or the rights of the most vulnerable groups without legal provision, supervision, and subsidies for poorer areas The Finnish healthcare system has always been comparatively decentralised. Municipalities not only …