“THE PATIENT SURVIVED DESPITE THE TREATMENT” A STUDY OF FINNISH HEALTH POLICY AND NEW PUBLIC MANAGEMENT Case: The Government Resolution on the Health 2015 public health programme Janina Vilén Political Science University of Turku Master’s Thesis August 2012 UNIVERSITY OF TURKU Faculty of Social Sciences VILÉN, JANINA: “THE PATIENT SURVIVED DESPITE THE TREATMENT” A study of Finnish health policy and New Public Manage- ment. Case: The Government Resolution on the Health 2015 public health programme. Master’s Thesis, 243 p. Political Science August 2012 Internationally, Finland has been among the most respected countries during several de- cades in terms of public health. WHO has had the most significant influence on Finnish health policy and the relationship has traditionally been warm. However, the situation has slightly changed in the last 10-20 years. The objectives of Finnish national health policy have been to secure the best possible health for the population and to minimise disparities in health between different population groups. Nevertheless, although the state of public health and welfare has steadily improved, the socioeconomic disparities in health have increased. This qualitative case study will demonstrate why health is political and why health mat- ters. It will also present some recommendations for research topics and administrative reforms. It will be argued that lack of political interest in health policy leads to absence of health policy visions and political commitment, which can be disastrous for public health. This study will investigate how Finnish health policy is defined and organised, and it will also shed light on Finnish health policy formation processes and actors. Health policy is understood as a broader societal construct covering the domains of different ministries, not just Ministry of Social Affairs and Health (MSAH). The influences of eco- nomic recession of the 1990s, state subsidy reform in 1993, globalisation and the Euro- pean Union will be addressed, as well. There is not much earlier Finnish research done on health policy from political science viewpoint. Therefore, this study is interdisciplinary and combines political science with administrative science, contemporary history and health policy research with a hint of epidemiology. As a method, literature review, semi-structured interviews and policy an- alysis will be utilised. Institutionalism, policy transfer, and corporatism are understood as the theoretical framework. According to the study, there are two health policies in Finland: the official health policy and health policy generated by industry, media and various interest organisations. The complex relationships between the Government and municipalities, and on the other hand, the MSAH and National Institute for Health and Welfare (THL) seemed significant in terms of Finnish health policy coordination. The study also showed that the Investi- gated case, Health 2015, does not fulfil all necessary criteria for a successful public health programme. There were also several features both in Health 2015 and Finnish health policy, which can be interpreted in NPM framework and seen having NPM influ- ences. Keywords: comparative political research, government, health policy, New Public Man- agement, non-governmental organizations, parliament, policy analysis, political parties, political systems LIST OF ABBREVIATIONS 5 1. INTRODUCTION 6 2. AIMS, STRUCTURE, METHODS, DATA, RELIABILITY, AND VALIDITY 14 2.1 The aims and structure of the study 14 2.2 Methods and data 16 2.2.1 Semi‐structured interviews 17 2.2.2 Policy analysis 19 2.2.3 Written data 22 2.3 Validity and reliability 22 3. THEORETICAL FRAMEWORK AND APPROACHES 25 3.1 Institutional theory and rational decision making 25 3.2 Policy transfer, organisational learning, and path dependency 29 3.3 Corporatism and public choice theory 32 4. PUBLIC ADMINISTRATION AND NEW PUBLIC MANAGEMENT 37 4.1 NPM in a nutshell 38 4.2 Finnish public administration and NPM 41 4.2.1 The 1990s recession and NPM 43 4.2.2 State vs. municipalities 45 4.3 Some relevant changes regarding NPM in Finland 47 4.4 Future considerations 49 5. HEALTH, POLICY, AND POLITICS 52 5.1 Health promotion and social determinants of health 56 5.2 Health and politics 58 5.3 Health policy and party politics 62 5.4 Evidence­based health policy making 63 5.5 Targets in health programmes 66 5.6 International actors influencing health 70 6. FINNISH HEALTH POLICY 74 6.1 Definition of Finnish health policy according to literature 74 3 6.2 Historical background and present day 75 6.3 International influence and interaction 84 6.4 Public health research, education, and funding 89 7. ACTORS IN FINNISH HEALTH POLICY 93 7.1 Ministry of Social Affairs and Health 93 7.2 The National Institute for Health and Welfare and other sector research institutes 105 7.3 Municipalities 111 7.4 Public health and nongovernmental organizations (NGOs) 120 7.5 Trade unions 126 7.6 Industry 134 7.7 Media 140 7.8 Parliament of Finland and political parties 144 8. CASE: THE GOVERNMENT RESOLUTION ON THE HEALTH 2015 PUBLIC HEALTH PROGRAMME (HEALTH 2015) 150 8.1 Programme­based policy making in Finland 150 8.2 Health 2015 and other policy programmes 153 8.3 Preparatory process 155 8.3.1 Some general observations 155 8.3.2 Participants 159 8.3.3 Objectives 164 8.3.4 Resources and communication 165 8.3.5 Structure, content, and preparatory schedule 166 8.4. Policy analysis on Health 2015 document 173 9. RESULTS 176 10. DISCUSSION 181 11. BIBLIOGRAPHY 198 FOOTNOTES 215 APPENDICES 1 ‐10 217 4 LIST OF ABBREVIATIONS ABPH The Advisory Board for Public Health CS Civil servant CVD Cardiovascular disease EBDM Evidence-based decision making EBM Evidence-based medicine EU The European Union FMA The Finnish Medical Association FSHS Finnish Student Health Service [YTHS] HFA Health for All Health 2015 The Government Resolution on the Health 2015 public health programme HiAP Health in All Policies KTL The National Public Health Institute MAF The Ministry of Agriculture and Forestry MEE The Ministry of Employment and the Economy MF The Ministry of Finance MFA The Ministry for Foreign Affairs MP Member of Parliament MSAH The Ministry of Social Affairs and Health NCD noncommunicable disease NGO nongovernmental organisation NPM New Public Management O Other R Researcher RAY Finland’s Slot Machine Association SDP Social Democratic Party SOSTE Finnish Society for Social and Health STAKES The National Research and Development Centre for Welfare and Health TEC Treaty establishing the European Community Tehy The Union of Health and Social Care Professionals TEU Treaty on European Union THL National Institute for Health and Welfare TK/TK21/TK2000 Health for All [Terveyttä kaikille] VALSU The national plan for organising social and health care [valtakunnallinen suunnitelma] WHO World Health Organisation 5 ”Medicine is a social science, and politics is nothing else but medi- cine on a large scale. Medicine, as a social science, as the science of human beings, has the obligation to point out problems and to at- tempt their theoretical solution: the politician, the practical anthro pologist, must find the means for their actual solution.” Rudolf Virchow (Virchow 1941, p. 93) “Public-health institutions, including international ones, too often ig- nore the analysis by one of the founders of public health, [Rudolf] Virchow, who noted that “medicine is not only a biological, but also a social intervention and politics is public health in the most profound sense.” Vicente Navarro (Navarro 1997, p. 1480) 1. INTRODUCTION These two quotes function extremely well as an introduction and rationale to the topic of my master’s thesis. I will investigate how the Finnish health policy is de- fined and organized and also shed light on Finnish health policy formation pro- cesses and actors. In this study, health policy is understood as a broader societal construct covering the domains of different ministries, not just Ministry of Social Affairs and Health MSAH (for a more detailed discussion, see Chapter 5). Thus, I will not investigate health care or Finnish healthcare system and this aspect may be good to keep in mind. I will examine more closely The Government Resolution on the Health 2015 pub- lic health programme [later: Health 2015] (Ministry of Social Affairs and Health 2001) as a case. Health 2015 has been chosen for this study because it is at the moment the only comprehensive and formal public health programme in force, and it was prepared in 1997-2001 – in the middle of a major turmoil in Finnish public administration. Health 2015 seemed to be an interesting case also for an- other reason; a mid-term evaluation (Muurinen, Perttilä & Ståhl 2008) showed 6 that it was not very well known in municipalities and respondents’ opinions were quite critical. In the 1990s, the operational environment changed due to economic recession, state subsidy reform in 1993, globalization, and joining the European Union (Melkas, Lehto, Saarinen & Santalahti 2005). Therefore, investigating this docu- ment and the preparatory process has offered me a rewarding window to this era but also given me a new understanding of how things and events may occur in institutional decision-making process. I have also learned how certain situations may look totally different from outside than how the actors in focus experience them. This journey has been much more fruitful than what I knew to expect. Anu Kan- tola has investigated political governance in the early 1990s recession in Finland in her doctoral dissertation and writes that there seemed to be things that no one wanted to say in public; she felt that she saw only the tip of the iceberg and she had to dive under the surface of the water to see where it started and how the iceberg was actually constructed (Kantola 2002, 19). That summarises quite well my feelings as well; I thought I was delving into health and health policy but soon I found out that I have to study the Finnish and Nordic welfare policy, the 1990s recession, the European Union, and WHO closer.