does not noticeably influence the attitude of the patient. Ambulatory care is more costly for the patient despite the fact that health insurance has been designed to alleviate this problem. In practice, prac titioners and polyclinics admit patients to hospitals where ambulatory care would be preferable on medical considerations alone.

The charges by hospitals, polyclinics and corresponding services are fixed by the government and are the same in the whole country, Inflation and increases in the level of income have only partly been reflected in charges. Consequently, services are becoming relatively cheaper each year. All maternity services, child health services, school health including dental services, preventive and curative services for infectious diseases including tuberculosis, ambulatory care for mental diseases, nad services by PH-nurses (by law at least one per 4.000 of population) are provided without charge. Hospital treatment is subsidized by local and central taxation to such an extent that the patient's share is only $1.75-$2.50 per patient day. Welfare authorities assume this responsibility for those members of society who cannot pay even this subsidized price. Charges to individuals using the local G.P. or private practitioner are of about the same magnitude. Health insurance compensates most of the charges of private practitioners as well as travel expenses and drugs used at home. For polyclinics (mainly outpatient services of hospitals) the charge is about $2.00. The charge for a patient day in a hospital corresponds to the legal minimum wages for three hours.

The financing system is not optimal in all aspects, especially the balance between hospital and ambulatory care. The system is also too costly for small local authorities. Health insurance has achieved its aim to a great extent, which was to equalize financial access to have ambulatory care, prescribed drugs for home use, etc. for all citizens.

SPECIAL ASPECT OF THE STRUCTURE OF THE MEDICAL CARE SYSTEM

Clearcut responsibilities which are given geographic units are typi cal of Finnish society. The geographic units differ in size but are always composed of one or more local authority areas (communes, municipalities) which have legal responsibility for the provision of services but have the right to delegate practical execution to jointly organized bodies. Autonomy of these units is relatively great and their administrative powers are quite sweeping. On the other hand, the central government has carefully retained the right to control and to inspect. The government has a legal right to obtain information concerning any service supported by tax money. There are special statutes which put medical and health manpower under an obligation to provide information to the National Board of Health. In this respect. the government has great freedom. It is possible to control services on the basis of statistical indicators. At present a great deal of such in formation is centralized and based on individual event or person-based reports, but traditional annual reports are still the most common source of information.

Because Finland has a long tradition of collecting comprehensive statistics, cooperation between information providers and consumers has traditionally been quite good. Planning as a device to enable society to solve social problems and to implement social values has

always been accepted. The Diet and government are seen as the responsible organizers. Because of this, they hold a central position in the planning and decisionmaking process.

DISTRIBUTIONAL RESPONSIBILITY AND REGIONALIZATION: EQUITY

Among the generally accepted moral concepts of Finnish society social justice has a very central position. One of the elements of this concept is "distributional justice," which relates to equitable distribution of social benefits and resources. If this idea is implemented, one of the consequences is an attempt to minimize existing inequalities among areas. In principle there are two approaches to achieving this: (a) Centralization of the administration of a system and provision of enough power and resources to central authority.

(b) Regionalization of authority, because theoretically regional authorities are in the best position to observe local needs.

In Finland, recent trends support the regional, decentralized concept. The aim is to form suitable collectives which can be managed and to which society can give responsibilities. Theoretically, collectives could form on the basis of occupational groupings, social classes, religion, nationality or language instead of geography. Some form of "regionalization" exists in all societies and it is specially true in relation to services in which society is either especially interested (e.g. taxation) or has taken the role of responsible organizer or provider of services.

Health services are a subsystem which can be organized with or without society's responsibility for the distribution of services. This distributional responsibility (DR) is a typical "non-material" variable describing the attitudinal relationships of society and the service system. The DR varies and it is quite possible to organize services without such a responsibility. In theory the DR is not dependent upon the resources/needs ratio. It is possible to optimize the distribution of limited services. But if the question is considered more practically, one of the expressions of DR in the system is a reasonable scale. This is especially true when the balance between the special branches of services are considered, e.g. if they are balanced with regard to existing needs. The quality of services might provide an opportunity to draw conclusions concerning the DR. It can hardly be considered to be effective if services organized for less prosperous segments of society are not up to medically acceptable standards. If the DR is really applied, the effect of distances, financial difficulties and other limitations are minimized-or at least the system attempts to do so. A properly planned information subsystem is a prerequisite if society takes on such a responsibility.

As may be expected, the socially oriented health services system in Finland emphasizes the principle of distributing services in such a way that the needs of the entire population are satisfied as well as possible. One practical consequence of this are clearly defined responsibilities for providers and for consumers of services. In Finland, geography is the only basis of DR, and this is reflected in the systematically applied regional concept. The small size of local authority units ensures that distance does not unduly limit the availability of services.

munes but the more specialized the service, the greater should be the

area.

Generally speaking, it is justifiable to conclude that in Finland the DR exists both theoretically and practically. In legislation the DR is not always specified in detail. It clearly exists in relation to infectious diseases and tuberculosis where prevention, casefinding, treatment and rehabilitation are provided for anyone free of charge and according to accepted norms. Lack of resources or skills does not relieve regional authorities from this responsibility. For instance, pri vate services must be used if there are no others available. There are examples where even services in neighboring countries have been used for certain necessary operations. The DR principle is not quite as clearly defined in legislation concerning mental health services. Laws about general hospitals define only the minimum numbers of hospital beds and the level of services. In jointly owned tertiary care (central) hospitals the beds are owned by individual local authorities but the patients are accepted solely on medical grounds. In order to achieve a correct distribution of services, the Chief Medical Officer of the hospital has the responsibility for ensuring that the most urgent cases are given preference when patients are selected for treatment.

In summary, the DR principle is quite prominent in the Finnish health services system and practical applications can be found on all administrative levels.

SOME CONCLUDING REMARKS

At present there are no markedly diverging opinions concerning the main organizational framework and goals of the health services system. This does not mean that there are no activities aimed at improv ing the organization or operation of the system.

The following list of problems, are under discussion or are generally perceived as weaknesses in the prevailing system at present. Of course, the extent of the problem varies and in some cases an outside expert most probably would recommend no changes. Still such a list provides an overview of prevailing attitudes.

-Both medical associations and laymen agree that there are too few physicians in the country (in 1970 there was one physician per 1,000 of the population). At present there are three medical schools The fourth in under construction. There are preliminary plans concerning a fifth one. In 1980 the balance between demand and supply should be achieved.

-Segmentation of services is a problem which needs correction. -Improvements concerning ambulatory care require legislative meaures. A proposal for new legislation is under discussion. -State subsidies do not sufficiently support the small and less prosperous communes.

-There is a gap between social and welfare services. On the national level these systems cooperate reasonably well. This is not always true on the local level.

-Services to the chronically ill are insufficient. A state committee has recently published a proposal for future measures.

-According to some, the hospital sector is too large in relation to ambulatory care, and costs are too high.

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-There still is a need to construct more high level "central hospitals." A national program in this respect is not yet completed.

-The great number of institutional beds for mental diseases is often criticized. There are not enough ambulatory facilities, day and night hospitals, and rehabilitation activities.

There is a shortage of pediatric mental health services.

-There is not enough interest in screening activities and prevention. This problem exists especially relative to the working age population.

Many would prefer completely free medical services. Interview surveys show that about 90% of population hold this opinion.

-The health education level is too low and needs special attention. -Pharmacies are based on an "archaic" system of regional privilege. Strong opinion favors reorganization and a state commission is presently planning a new system.

There are many other smaller problems, but this list gives the main areas which are presently under discussion. In most cases there are no diverging opinions concerning principles. Disagreements concern the order in which improvements should be implemented and the best way to organize them.

The same problems are seen in other countries. It should be noted that difficulties existing in other countries are of less severity in Finland. For example, there is no shortage of nurses. The relatively solid financial basis, à population affirmatively interested in health services, and an organizational structure which seems to correspond with the expectations of people will make it possible to solve most of the problems in this list in a relatively short period.