A Finnish Perspective on Health and Health Care

The health care systems in both the U.S. and Europe are undergoing re-evaluations and reforms. The Scandinavian health care systems have long been seen as the examples of excellent health care that takes into account medical, psychological, and social factors, and combines equality and freedom of choice. Finland has been able to balance the provision of universal coverage for a broad array of health services with effective cost control to a greater extent than many other countries.

A possibility to bridge the American and Finnish discussions on health care reforms is offered by Michael E. Porter and Elisabeth Olmsted Teisberg’s Redefining Health Care, Creating Value-Based Competition on Results (2006). One of their key messages is to move from an activity-based service system to a new approach where the patient is in the center and where his or her health outcomes are given the guiding role. Often economic-administrative reports tend to forget the importance of personal, developmental, and interactional-psychological factors in health-related issues, and focus on the misconception that health care, and not health, is the output. As Redefining Health Care rightly reminds us, from the patient perspective, care itself is not the goal but merely a means to achieve and maintain good health. Given

Page 437

a choice between more care and more health, a patient’s choice is obvious. However, health care systems around the world remain organized to deliver treatment, not to maximize health. Thus, I present some points of departures concerning the topics raised in a recent report, The Finnish Health Care System: A Value-Based Perspective (2009; Helsinki: Sitra), co-authored by Porter.

Well-being is not guaranteed by any extrinsic production of managed care and its cost computation. Neither do evidence-based medical procedures nor medical and information technologies as such allow enough attention to the experiential space and to the psychology and phenomenology of the patient-subject, which includes autobiographical and collective memory, the self-stories, and co-narrated and co-constructed meanings of being ill in a personal life-world. Even positive psychology and health psychology tend to evade the rich spectrum of human experience while stressing the need to keep to solely creative, happy, and successful life projects.

Current discrete health care interventions minimize patient involvement. For the patients, such systems are both fragmented and externally regulated. When patients see many clinicians across multiple sites, hardly any individual provider has the time or responsibility to ensure that patients understand what is expected of them. Because each provider meets different types of patients with different diseases, attention on patient engagement can be very limited.

In Finland, care delivery already has the exceptionally strong elements of integration. The reform should involve moving toward the true integration of primary, specialized, psychological and rehabilitative care, as well as social work within integrated practice and research units. The monopoly of the “medical” should also be reformed by the more interdisciplinary endeavors and bio-psycho-socio-cultural

Page 438

conceptions of personal-existential and interactional problems and conflicts.

One of the negative features in all technologically advanced health care systems is the tendency to patronize patients and bypass the active participation of patients in their health care. Patients are truly the co-producers of care, the subjects of their illnesses, and should not be subjugated to the medical professionals and their diagnosis, treatment, and administrative power. For example, patients with chronic conditions are often the best “experts” on their disease and its impact on their ability to function, even if they may also have limitations and resistances in accepting their precarious situation. Nevertheless, well-informed and emotionally involved, “empowered” patients will have better prerequisites for choosing treatment options, being motivated, and joining forces with clinicians and their teams in shaping a culture of personal care, cooperation, and mutual understanding.

Various surveys and interviews have shown that the socially marginalized suffer from ill health physically, mentally, and socially. Their health status is, in all measures, markedly poorer than that of the general population. In qualitative studies, the interviewees have described their situation as lonely, stressful, and filled with anxiety and/or depression. The mental well-being of the marginalized is strongly affected by negative childhood experiences, violence, abuse, and other traumatic or highly stressful experiences continuing into their adult lives, as well as by unbalanced relations to those nearest them and a general hopelessness regarding their situation.

Health-psychology research indicates a need for holistic and lifespan approaches, opposing fragmented self and other-representations and contributing to personal experiences of meaning and coping alongside health promotion ini-

Page 439

tiatives, in the social web of health care. The marginalized are not in our web of care, instead they are displaced, outside of our security system. Their life-storylines have been cut and their self-narratives are broken and silenced. The ongoing health care reform does not give insurance against marginalization or the reverberations of early negative experiences into the later life situations of the silenced and the abandoned.

The emotional concerns and conceptions of health and illness have their roots in childhood. Children’s health attitudes and behaviors are formed in their secure–insecure attachment relations and are linked to the values and activities of the adults who are raising them. Home and school are the most important environments in advising and educating the primary-school children. Health guidance at home and at school with mutual goals has a major preventive influence on the child’s health-related problems and risk behavior. Interactive, continuous collaboration between home and school is found to be essential for promoting children’s health learning. A development and research program “Schools for Health in Europe” is led in Finland by Professor Kerttu Tossavainen. The aims of that research are to: clarify the child’s health learning process in home and school community environments, explain what possibilities the health-related program of home-school partnership brings to support the child’s health learning, evaluate the progression and effectiveness of health-learning programs in families and in the school community, and to compare possible changes in partnership between school community and parents in experimental and control schools. Previously, education for health promotion practice has paid little attention to dealing, in adequate and context-sensitive ways, with psychological resistances and personal security concerns.

The question “Can we afford it?” is often posed. Concerning our health, the answer is evident: “If we cannot

Page 440

afford it, who else can?” We even have to afford others’ health care, because their health is ours too.

Page 441