Health system reforms and the needs of the ageing population : an analysis of recent policy paths and reform trends in Finland and Sweden

This is a sel -a chi ed e sion o an o iginal a icle. This e sion may di e om he o iginal in pagina ion and ypog aphic de ails. Au ho (s): Ti le: Yea : Ve sion: Copy igh : Righ s: Righ s u l: Please ci e he o iginal e sion: CC BY 4.0 h ps://c ea i ecommons.o g/licenses/by/4.0/ Heal h sys em e o ms and he needs o he ageing popula ion : an analysis o ecen policy pa hs and e o m ends in Finland and Sweden © 2022 he Au ho s Published e sion Tynkkynen, Liina-Kaisa; Pulkki, Ju a; Te onen-Gonçal es, Leena; Schön, Pä ; Bu s öm, Bo; Keskimäki, Ilmo Tynkkynen, L.-K., Pulkki, J., Te onen-Gonçal es, L., Schön, P., Bu s öm, B., & Keskimäki, I. (2022). Heal h sys em e o ms and he needs o he ageing popula ion : an analysis o ecen policy pa hs and e o m ends in Finland and Sweden. Eu opean Jou nal o Ageing, 19(2), 221- 232. h ps://doi.o g/10.1007/s10433-022-00699-x 2022 Vol.:(0123456789) 1 3 Eu opean Jou nal o Ageing (2022) 19:221–232 h ps://doi.o g/10.1007/s10433-022-00699-x ORIGINAL INVESTIGATION Heal h sys em e o ms and heneeds o  heageing popula ion—an analysis o  ecen policy pa hs and e o m ends inFinland andSweden Liina‑KaisaTynkkynen1· Ju aPulkki1· LeenaTe onen‑Gonçal es2· Pä Schön3· BoBu s öm4· IlmoKeskimäki5 Accep ed: 17 Ma ch 2022 / Published online: 15 Ap il 2022 © The Au ho (s) 2022 Abs ac Popula ion ageing wi h an inc easing numbe o people expe iencing complex heal h and social ca e needs challenges heal h sys ems. We explo e whe he and how heal h sys em e o ms and policy measu es adop ed du ing he pas wo decades in Finland and Sweden e lec and add ess he needs o he olde people. We discuss heal h sys em cha ac e is ics ha a e impo an o mee he ca e needs o olde people and analyse how heal h policy agendas ha e highligh ed hese aspec s in Finland and Sweden. The analysis is based on “mos simila cases”. The wo coun ies ha e a he simila heal h sys ems and a e acing simila challenges. Howe e , he policy pa hs o add ess hese challenges a e di e en . The Swedish heal h sys em is be e esou ced, and he a o dabili y o ca e be e ensu ed, bu choice and ma ke -o ien ed compe i ion e o ms do no add ess he needs o he people wi h complex heal h and social ca e needs, a he i has led o inc eased agmen a- ion. In Finland, he le el o public unding is lowe which may ha e nega i e impac s on people who need mul iple se ices. Howe e , in e ms o in eg a ion and ca e coo dina ion, Finland seems o ollow a pa h which may pa e he way o imp o ed coo dina ion o ca e o people wi h mul iple ca e needs. In ensi ied moni o ing and analysis o pa e ns o heal h ca e u i- liza ion among olde people a e wa an ed in bo h coun ies o ensu e ha ca e is p o ided equi ably. Keywo ds Olde people· Mul iple ca e needs· Equi y· Heal h ca e e o ms· P ima y ca e· Heal h policy· Finland· Sweden In oduc ion Uni e sal heal h co e age means ha all people ha e access o he heal h se ices hey need, when and whe e hey need hem, wi hou inancial ha dship. Access o heal h ca e also links o he hi d goal o Uni ed Na ions Sus ainable De el- opmen Goals which is o “ensu e heal hy li es and p omo - ing well-being o all a all ages” (UN 2021). A he same ime, heal h inequali ies and unequal access o ca e a e chal- lenges aced by mos o he heal h sys ems a ound he wo ld (GBD 2018), including he No dic coun ies (Keskimäki e al. 2019; Bu s öm 2009; Mackenbach 2020). To educe inequali ies be ween and wi hin di e en socie al g oups, heal h ca e policies need o be sensi i e o he e ogenous needs o di e en popula ion g oups. The e is cu en ly no empi ical consensus on he impac o inc easing longe i y on he need o heal h ca e (G ee e al. 2021). Acco ding o medicaliza ion heo y, longe - i y inc eases he numbe o people in need o ca e. Due o he popula ion ageing and epidemiological ansi ion, he numbe o olde people expe iencing ch onic condi ions wi h co-mo bidi ies is inc easing. Olde people inc eas- ingly su i e hei diseases, bu o en wi h ch onic heal h p oblems and inc eased ca e needs (Pa ke and Tho slund 2007). Ano he heo e ical app oach, comp ession heo y, Responsible Edi o : Ma hias Kliegel. * Liina-Kaisa Tynkkynen [email p o ec ed] 1 Facul y o Social Sciences, Heal h Sciences, Tampe e Uni e si y, Tampe e, Finland 2 Depa men o Social Sciences andPhilosophy, Uni e si y o Jy äskylä, Jy äskylä, Finland 3 Aging Resea ch Cen e , Ka olinska Ins i u e andS ockholm Uni e si y, S ockholm, Sweden 4 Depa men o Global Public Heal h, Equi y andHeal h Policy Resea ch G oup, Ka olinska Ins i u e , S ockholm, Sweden 5 Finnish Ins i u e o Heal h andWel a e, Helsinki, Finland 222 Eu opean Jou nal o Ageing (2022) 19:221–232 1 3 assumes ha he popula ion li es longe in good heal h due o heal hie li es yles and li ing en i onmen s, and se ice needs accumula e o a sho e pe iod o he end o li e. In mos cases, people wi h mul iple ca e needs and unc ional and cogni i e di icul ies a e aged 80 and olde . This age g oup is g owing mos apidly in many coun ies (S a Fin 2021; S a is ics Sweden 2018). I is, howe e , unclea how well he con en and sugges ed measu es o heal h sys em e o ms e lec he needs o olde people. I has been a gued ha heal h policies a e designed o he “younge old” bu applied o he “oldes old”, whose ca e needs a e he g ea es (Gillea d and Higgs 1998). In his a icle, we explo e whe he and how heal h sys em e o ms and policy measu es adop ed du ing he pas wo decades in Finland and Sweden e lec and add ess he needs o he olde people. The analysis builds on “ he mos simila cases” d awing on he idea ha he No dic coun ies ep e- sen na ional con ex s ha ely on he p inciple o uni e sal- ism, public unding, (mainly) public p o ision and se ices o high quali y. Finland and Sweden o m an in e es ing pai o compa e as hei popula ion is ageing as e han ha in o he No dic coun ies. Finland and Sweden ha e also been shown o be simila when conside ing he supply side esou ces, public–p i a e mix, access egula ion, p ima y ca e o ien a ion and heal h sys em pe o mance managemen (Reibling e al. 2019) o he deg ee o decen aliza ion o heal h ca e se ices (La sen e al. 2020). Taking his as a s a ing poin , we e lec heal h ca e policy de elopmen s agains he cha ac e is ics o heal h sys ems we ha e iden i- ied om he schola ly li e a u e o be impo an in add ess- ing he needs o he olde people. Olde people’s ca e needs and ela ed ca e sys em cha ac e is ics To mee he needs o olde people independen o hei soci- oeconomic s a us, a o dabili y o heal h ca e is o majo impo ance. Socio-economic di e ences in heal h a e e i- den a olde age: indi iduals wi h highe educa ion usu- ally ha e be e le el o heal h and unc ioning han hose wi h basic educa ion (En o h e al. 2019). In addi ion, peo- ple in he lowes income g oup epo mo e o en o ha e a need o isi a medical doc o compa ed o hose in he highes income g oup (Hannikainen 2018). Howe e , he abili y o isi a doc o may depend on he income le el as people in he lowe socioeconomic g oups may e ain isi ing a doc o because o inancial easons (Hannikainen 2018; Mola ius e al. 2014). Fo olde people, use ees and o he ou o pocke paymen s (OOP), including paymen s o ea men s and medica ion, may cause p oblems in e ms o a o dabili y and hus accessibili y o heal h ca e. The esea ch indica es ha inancial ha dship is mo e likely o occu when public spending on heal h is low ela i e o g oss domes ic p oduc (GDP) and OOPs accoun o a ela i ely high sha e o o al spending on heal h (Te ola e al. 2021). This sugges s he need o s eng hen he mechanisms o inancial p o ec ion o olde people wi h ch onic diseases and mul iple ca e needs. Bo h mul imo bidi y and dec eased unc ional abili y inc ease he need o di e en ypes o ca e and equi e join e o s om a ange o ca e p o ide s (Hujala e al. 2017). Demen ia and o he memo y diso de s o m g ea challenges o heal h and ca e sys ems wo ldwide (Bane jee 2013). In Finland and Sweden, demen ia is he domina ing cause o admission o esiden ial long e m (Sköldunge e al. 2019; Kehusmaa e al. 2018). Howe e , mos people wi h memo y diso de s li e and a e ca ed o a home. A key heal h sys em cha ac e is ic in his espec is ca e in eg a ion and coo - dina ion ac oss he ca e con inuum. Coo dina ed and in e- g a ed in e en ions ha e shown o be impo an especially o people wi h mul imo bidi y and mul iple ca e needs (Eklund 2009). Fo many olde people, coo dina ion o ca e is impo an also because o he cogni i e impai men s ha make hem incapable o na iga e in o en complex se ice sys ems. Memo y diso de s inc ease wi h age (Jylhä e al. 2019) and he absolu e numbe o people wi h demen ia has inc eased due o longe i y (ibid.; Bane jee 2013). Demen ia and o he memo y diso de s o m g ea challenges o heal h and ca e sys ems wo ldwide (Bane jee 2013). Fo example, bo h in Finland and Sweden, demen ia is he domina ing cause o admission o esiden ial long e m (Sköldunge e al. 2019; Kehusmaa e al. 2018). Howe e , mos people wi h memo y diso de s li e and a e ca ed o a home. One o he keys o success ul coo dina ion and con inu- i y o ca e is he exis ence o a s ong p ima y ca e sys- em which can ake esponsibili y o coo dina ion o ca e. S eng hening and imp o ing p ima y ca e sys ems ha e become a key s a egy o espond o changing popula ion needs (Kuhlmann e al. 2017). Composi ion o o ganiza ion o p ima y ca e a ies coun y by coun y bu ega dless o how he se ices a e o ganized p ima y ca e o en is he i s poin o con ac in a heal h sys em. Inc easing numbe o olde people unde sco es he need o p o ide se ices ha can deal wi h he needs o he popula ion, making he p ima y ca e a ocal poin o heal h policy. (G oenewegen e al. 2015.) P ima y ca e is gene alis ca e, which ocuses on he pe son as an in eg al whole (K ingos e al. 2015). This is c ucial especially o olde people wi h mul iple ch onic diseases which also make polypha macy ( he use o i e o mo e d ugs concu en ly) common among olde people (Midao e al. 2018; Johnell and Fas bom 2012). The p e alence o polypha macy has also inc eased o e ime (G ansjön-C a man e al. 2016; Pulkki e al. 2019). Olde people’s ex ensi e use o d ugs and high p e alence o como bidi ies subs an ially inc ease he isk o ad e se 223Eu opean Jou nal o Ageing (2022) 19:221–232 1 3 d ug eac ions, hospi aliza ions, and mo ali y (Johnell and Fas bom 2012). A well- unc ioning p ima y ca e may alle i- a e hese isks. Me hods andma e ials Ou empi ical analysis d aws on a e iew o he scien i ic li e a u e as well as “g ey” li e a u e, policy documen s and desc ip i e s a is ics. The imeline o he analysis is 2000–2020. Compa a i e me hod has signi ied di e en hings a di - e en imes (Alla d 2004). In a gi en si ua ion whe e socie- ies a e ageing ac oss he de eloped wo ld a an un o esee- able a e, i is o ele ance o compa e how socie ies ha e esponded o economic, social and human challenges ela ed o ageing. By sc u inizing policy ini ia i es, s a egies and ecommenda ions as well as “ ailed” e o m p oposals, we can make inc emen al changes ha a e o en le ou side he adi ional, mo e s uc u al o s a is ically o ien ed analysis isible. By compa ing wo socie ies and hei heal h ca e policy esponses o ageing ou esea ch ep esen s indi idualiz- ing compa isons (Tilly 1984). Tilly w i es how his ype o compa ison con as s a small numbe o cases o g asp he peculia i ies o each case (ibid., 82). This s and o compa a- i e esea ch in ol es disco e ing how di e en wo cases a e. So does ou s udy. In he con ex o compa ing cul u - ally, economically and poli ically simila socie ies and hei esponses o ageing, i makes sense o ocus on di e ences a he han simila i ies. In e ms o empi ical analysis, ou esea ch consis s o h ee pa s. Fi s , we iden i ied he co e cha ac e is ics o good ca e o he elde ly om he p e ious esea ch li e a- u e (see abo e). These we e 1) heal h ca e sys em capaci y, esou cing, and a o dabili y o heal h ca e, 2) in eg a ed ca e and ca e coo dina ion, and 3) s eng hening p ima y ca e. Second, we analysed heal h ca e sys em capaci y, esou c- ing, and a o dabili y o heal h ca e by e iewing he key heal h sys em indica o s and he esea ch li e a u e. The analysis hus s a ed by mapping he con ex and sys em cha ac e is ics by p o iding desc ip i e s a is ics ob ained om OECD Coun y Heal h P o iles 2019 o Finland and Sweden (OECD 2019a, b), OECD Heal h a Glance publi- ca ions (OECD 2020, 2021), S a is ics Sweden, S a is ics Finland and No dic Wel a e Da abase. Thi d, we ocused on in eg a ed ca e and s eng hening p ima y ca e and sea ched how hese aspec s a e mani es ed in he selec ed policy documen s. In he sea ch and selec ion o he key policies, we used Heal h Sys ems in T ansi ion epo s o Sweden and Finland (Anell e al. 2012; Keskimäki e al. 2019) and Imme gu e al. (2021) which p o ides he desc ip ion o he majo heal h e o ms also in Sweden and Finland. In addi ion, we used pu posi e sampling o include a ew o he ini ia i es ha we e no included in he a o e- men ioned publica ions bu which he au ho s knew o be ele an especially om he poin o iew o olde people o which we e so ecen ha hey we e no included in he publica ions. By analysing documen s, ou esea ch mainly ocuses on analysis o policy agendas. The a ional-linea concep ualiza ions o policy-making p ocess see agenda- se ing only as a i s s age o he p ocess, which is hen ollowed by implemen a ion and e alua ion. We ollow a cons uc i is pe cep ion o policy-making and a gue ha while e ms and concep s appea on agendas, hey play an essen ial ole in cons i u ing he eali y by de e mining how he issue ge s de ined, amed, and unde s ood. (Te onen- Gonçal es 2013.) The analysed documen s we e di ided in o (1) legisla i e documen s, (2) na ional le el p og ams, and (3) na ional guidelines and ecommenda ions (compa e o ins ance Wadman e al. 2009). Also, e o m p oposals (4) a e included i hey ha e had a majo impac in heal h policy de elopmen s in a coun y. The laws, p og ams and documen s a e lis ed in Tables3 and 4. Because, he needs o olde people a e o en complex, and hey equi e se ices om a ious sec o s we e e , when ele an , also o se - ices, such as home ca e and esiden ial long- e m ca e, ha a e o ganized unde social se ices in Finland and Sweden bu a e o special a en ion o ano he pape in his special issue (Ros gaa d e al. 2022). Desc ibing hecon ex The Finnish heal hca e sys em is buil on h ee pa ially pa allel sys ems (Keskimäki e al. 2019): he co e sys em is o med by a ax- unded sys em un by municipali ies and hospi al dis ic s. In addi ion, he e is an obliga o y social and heal h insu ance sys em eimbu sing, o ins ance, he use o p i a e heal h ca e and p esc ip ion medicine, and an occupa ional heal h ca e sys em o employed people. The co e sys em is inanced h ough municipal axa ion, s a e ans e s and use ees. Municipali ies (n = 297, mainland Finland) a e esponsible o bo h heal h ca e and social se - ices (including home ca e and long- e m ca e) and hey can o ganize he se ices by hemsel es, oge he wi h o he municipali ies o by pu chasing se ices om o he munici- pali ies o om p i a e p o ide s. Specialized medical ca e is also inanced by municipali ies, bu i is o ganized h ough 20 hospi al dis ic s which a e ede a ions o municipali ies. (Keskimäki e al. 2019.) In Sweden, he sys em is di ided in o local and egional le els, heal h ca e being he esponsibili y o he 21 egions and social ca e he esponsibili y o 290 municipali ies. Bo h heal h and social ca e a e ax unded, wi h egions and municipali ies collec ing axes which a e complemen ed by 224 Eu opean Jou nal o Ageing (2022) 19:221–232 1 3 s a e g an s and use ees. The se ice p o ision is mainly public bu especially in p ima y ca e and in la ge ci ies, he numbe o p i a e p o ide s has inc eased in ecen yea s (Ekonimi ak a 2021; Bu s öm 2017; S all o s and Tyll- s öm 2018; Anell e al. 2012). Heal h ca e sys em capaci y, esou cing, anda o dabili y o heal h ca e The main di e ences and simila i ies conce ning he capac- i y and esou cing o he heal h and ca e sys ems a e p o- ided in Tables1 and 2. The le el o public heal h ca e inancing is lowe in Finland when measu ed as p opo ion o GDP o in pe capi a heal h ca e cos s. Also, he sha e o public unding is lowe in Finland. The di e ences a e la ge also in e ms o long- e m ca e cos s, wi h pe capi a cos s in Sweden being wice as high as in Finland al hough he p opo ion aged 80 + yea s is he same in bo h coun ies. Ou -o -pocke expendi u es (OOPs) o social and heal h ca e se ices and medica ion a e ela i ely high in Finland compa ed o Sweden when measu ed in e ms o annual paymen caps (Table2). This is an impo an ea u e which may esul in inequali ies in access and ca as ophic cos s especially among olde people in lowe socio-economic g oups (Te ola and Heino 2020; Ilma inen e al. 2020). In Finland, la ge sha e o people epo s ca as ophic heal h spending compa ed o Sweden Table 1 Finland has mo e doc o s wo king in p ima y ca e han Sweden, bo h as a p opo ion o all doc o s and pe 100,000 popula ion (Sou ce: La sen, Clausen, Höjgaa d. VIVE epo 2020) Numbe o gene al p ac i ione s (GPs) GPs pe 100,000 popula ion GPs as p opo ion (%) o all doc o s Finland (2016) 3,950 72.1 19 Sweden (2017) 6,028 58.4 14.9 Table 2 Key heal h sys em indica o s o Finland and Sweden. The numbe s desc ibe mos ly yea 2019 o nea es a ailable yea . Mone a y uni o heal h ca e expendi u e and use ees is Eu o. (Sou ces: OECD 2019a, OECD 2019b, 2020, OECD 2021, Nomesco Repo 2017) Finland Sweden P opo ion aged 65 + yea s (%) 20.2 19.7 P opo ion aged 80 + yea s (%) 5.1 5.1 Pe cen in ins i u ions, se ice housing, o wi h home ca e se ices In ins i u ions 80 + yea s (%) 14.2 14.1 In ins i u ions 65 + yea s (%) 5.1 4.7 Home ca e 80 + yea s (%) 16.4 24.0 Home ca e 75–79yea s (%) 5.0 7.0 P ac icing doc o s pe 1 000 popula ion 3.2 4.3 Pe cen (%) o GDP o heal h 9.2 11.0 Heal h expendi u e om public sou ces as a sha e (%) o o al 80 85 Heal h expendi u e om public sou ces as a sha e (%) o o al go e n- men expendi u e 14 19 Heal h ca e cos pe capi a (eu o) 3036 3872 Ou pa ien ca e 1117 (37%) 1303 (34%) Inpa ien ca e 751 (25%) 848 (22%) Long- e m ca e 578 (19%) 1024 (27%) Pha maceu icals and de ices 443 (15%) 478 (12%) P e en ion 117 (4%) 126 (3%) Use ees (caps, eu o) Visi s 683 109 Pha maceu icals 572 218 T anspo 300 N/A Sha e o households wi h ca as ophic heal h spending 3.8 1.8 Popula ion epo ing unme needs o medical ca e (%) 4.7 1.4 225Eu opean Jou nal o Ageing (2022) 19:221–232 1 3 (Table2). One o he ools o cos con ainmen in Finland has been o dec ease he public eimbu semen le els and o inc ease use ees in se ices despi e he ela i ely high p opo ion o OOPs al eady. Se e al e o ms ha e aimed o cu b public spending on medicines (Te ola e al. 2021) which ha e also included e o ms dec easing he eim- bu semen le els o ou pa ien p esc ibed medicines. To adjus use ees, he new Ac on social and heal h ca e cli- en ees en e ed in o o ce in July 2021. I ex ended OOP- ee se ices and i also con ains long-awai ed s ipula ions o paymen s o se ice housing. (Val ioneu os o 2020.) Highe sha e o people epo s unme ca e needs in Finland compa ed o Sweden (Table2) bu in bo h coun- ies, inequali ies in access o ca e pe sis . Among pe sons 65yea s and olde in Finland, 10% in he lowes income g oup did no isi a doc o in 2013–2015 because o inan- cial easons, compa ed o 3% in he highes income g oup. (Hannikainen 2018.) In Sweden, only 2% o pe sons aged 65–84yea s e ain om seeking heal h ca e o economic easons (Mola ius e al. 2014). In Finland, he e a e di - e ences in access o heal h ca e be ween low-income and high-income g oups: low-income g oups use public se - ices wi h o en long wai ing imes, while high-income g oups use well-a ailable occupa ional heal h se ices o p i a e se ices (Keskimäki e al. 2019). E en hough a simila occupa ional heal h ca e se ices do no exis in Sweden, simila pa e n can be disce ned: socio-economic di e ences in mo bidi y and heal h ca e needs a e no e lec ed in co esponding demand and use o heal h ca e se ices (Bu s öm 2009). Howe e , he use o eme gency depa men ca e among olde pe sons is highe in low- income g oups (Doheny e al. 2019), la gely explained by hei g ea e needs. The co e p oblems in heal h sys em capaci y in Finland and in Sweden ha e been ela ed o une en dis ibu ion o esou ces be ween di e en heal h sys em unc ions and sec o s. Especially p ima y heal h ca e and elde ly ca e ha e been unde esou ced. In Finland, in compa ison wi h specialized heal h se ices, he e is inc easing imbal- ance in unding. In 2009–2019, he e was a 30% inc ease in municipal specialized heal h ca e spending, while no change in p ima y heal h ca e unding (THL 2021). Toge he wi h s a ing p oblems, his has esul ed in unme ca e needs (i.e. long wai ing imes) especially among olde people (OECD 2019a). In Sweden, in u n, he unding is alloca ed wi h a s onge emphasis o ins ance in long- e m ca e (OECD 2019b). Despi e in en ions a na ional le el o inc ease he capaci y in p ima y heal h ca e, he p opo ion o doc o s in p ima y heal h ca e is s ill less han 15% in Sweden (La sen e al. 2020) wi h highe p o- po ion o p ima y ca e doc o s in Finland han in Sweden (Table1). Howe e , in gene al, Finland has less doc o s pe capi a han Sweden (Table2). Mapping heheal h sys em e o ms andpolicy measu es inFinland andSweden In he ollowing, we desc ibe and compa e he policy measu es ha ha e been aken in Finland and Sweden in he a eas o 1) in eg a ed ca e and ca e coo dina ion, and 2) s eng hening p ima y ca e. Tables3 and 4 a e p o ided o sum up he e o ms in each a ea in 2000–2020. In eg a ed ca e andca e coo dina ion In Finland and Sweden, in eg a ed ca e and ca e coo di- na ion a e high on he agenda o na ional policy. How- e e , hese ha e been ad anced pa ly wi h di e ing ools and a ge s. In Finland, es uc u ing he sys em h ough adminis a i e in eg a ion, as well as de eloping se - ices and p ac ices, has been p omo ed h ough na ional p og ams and legisla i e ini ia i es. In Sweden, in u n, he in eg a ed ca e p ac ices ha e mainly been p omo ed h ough na ional le el p og ams. Concu en ly, choice-and ma ke -o ien ed compe i ion e o ms ha e been in oduced which ha e a leas pa ly unde mined ca e in eg a ion and inc eased sys em agmen a ions. In Finland, adminis a i e in eg a ion has been a he co e o na ional e o m a emp s on social and heal h ca e. While p ima y heal h ca e and social se ices a e o ganized in municipali ies, he long-las ing aim has been o adminis a i ely in eg a e heal h and social se ices a same o ganiza ional le el and unde he same budge (Tynkkynen e al. 2021). The na ional adminis a i e e o m will be implemen ed 2023 onwa ds, bu al eady be o e ha , smalle e o ms bo h a na ional and local le - els ha e been implemen ed o suppo he de elopmen o in eg a ed ca e p ac ices (Keskimäki e al. 2018; Tynk- kynen e al. 2019). In addi ion, he Heal h Ca e Ac (2010) aimed a s eng hening he in eg a ion be ween p ima y heal h ca e and specialized heal h ca e. Al hough a leg- isla i e basis o in eg a ion was c ea ed in his law, in p ac ice, i s in luence as a s ee ing de ice has been a he weak due o he lack o inancial o s uc u al elemen s included in he law. In eg a ion o ca e a clinical and p o essional le el and speci ically o olde popula ion has been p omo ed h ough special legisla ion o h ough amending laws in bo h coun ies. In Finland, he Ac Suppo ing he Func- ional Capaci y o he Olde Popula ion and on Social and Heal h ca e Se ices o Olde Pe sons (2013) aimed o imp o e olde pe sons igh s o access o social and heal h ca e se ices in acco dance wi h hei needs. The Ac en ails an obliga ion o social and heal h ca e au ho i- ies o make indi idual ca e plans in co-ope a ion wi h he 226 Eu opean Jou nal o Ageing (2022) 19:221–232 1 3 clien s and wi h hei amily membe s. The Ac also s ipu- la es ha heal h ca e p o essionals should in o m social ca e p o essionals when discha ging an olde pe son om a hospi al. In addi ion, i e na ional ecommenda ions o he quali y o ca e o olde people ha e been issued o suppo municipali ies (STM & Kun alii o 2001; 2008; 2013; 2017; 2020) and wo s a egic p og ams on aging ha e been published (STM 2004, 2020a). In Sweden, simila de elopmen s ha e aken place h ough amendmen s in he Heal h and Medical Se ices Ac and he Social Se ices Ac in 2010. The amendmen s ocused on people who need help om bo h heal h and Table 3 Heal h sys em e o ms in he a ea o in eg a ed ca e and ca e coo dina ion in Sweden and Finland in 2000–2020 In eg a ed ca e and ca e coo dina ion Legisla ion P og am Recommenda ion Re o m p oposal Sweden P esc ibed d ug egis e (2005) Amendmen in he Heal h and Medical Se ices Ac and he Social Se ices Ac , s a ing ha people who need help om bo h heal h and social ca e should be o e ed a join indi idual ca e plan (2010) Regula ed igh o annual d ug e iew o pe sons 75 + , p esc ibed i e o mo e d ugs (2012) Ac on Coo dina ed Discha ge om Hospi al Ca e (Lag om sam e kan id u sk i ning ån slu en hälso-och sjuk å d) (2018) Go e nmen al p og amme on ca e coo dina ion o olde people wi h complex heal h p oblems (2010–2015) Finland Heal h Ca e Ac (2010) Ac suppo ing he capaci y o olde popula ion and on social and social ca e se ices o olde pe sons (Vanhuspal elu- laki) (2013) Kan a-Se ices (The Na ional Pa ien Da a Reposi o y) (2016) Suppo ing in eg a ed se ice concep s and ca e coo dina- ion h ough na ional p og ams (Kas e-ohjelma 2010–2015) Na ional s a egic p og ams on aging (1998, 2001, 2020) Fu u e Heal h and Social Se ices Cen es P og amme 2020–2022 Na ional Quali y Recommenda- ions on de eloping se ices o olde people (2001, 2008, 2013, 2017, 2020) Adminis a i e in eg a- ion in na ional e o m a emp s (SOTE) and local/ egional e o ms (2007–2018) Table 4 Heal h sys em e o ms in he a ea o s eng hening p ima y ca e in Sweden and Finland in 2000–2020 S engh ening p ima y ca e Legisla ion P og am Recommenda ion Re o m p oposal Sweden Speci ica ion o Wai ing ime gua an ee (2005) Law on choice in heal h and social ca e (LOV) (2009) Na ional Choice Re o m in P ima y Ca e (Vå d alssys em i p imä å den) (2010) (New) Pa ien Ac (2015) Finland Ca e gua an ee (2009) Heal h Ca e Ac (`) Ac Suppo ing he Func ional Capaci y o he Olde Popula ion and on Social and Heal h ca e Se ices o Olde Pe sons (2013) Na ional de elopmen p og ams in social and heal h ca e (Kas e 2008– 2015) Med75 + da abase (2015) Na ional Quali y Recommenda ions on de eloping se ices o olde people (2013, 2017, 2020) 227Eu opean Jou nal o Ageing (2022) 19:221–232 1 3 social ca e and s a ed ha hey should be o e ed a join indi idual ca e plan o ensu e he se ice con inui y and pa ien sa e y (Samo dnad Indi iduell Plan, SIP). The Ac on Coo dina ed Discha ge (2018) om hospi al ca e also s ipula ed ha pa ien s who need social and heal h ca e a e discha ge om hospi al should be p o ided wi h an indi- idual ca e plan. In addi ion o legisla i e ools, he de elopmen o in e- g a ed p ac ices in bo h coun ies has happened h ough na ional p og ams which ha e also included inancial sup- po h ough s a e g an s. In Finland, he Na ional De el- opmen P og amme o Social Wel a e and Heal h Ca e KASTE2008-2015 (STM2008; 2012) s i ed o p omo e in eg a ion h ough in e sec o al coope a ion and in eg a ion by suppo ing he de elopmen o indi idual ca e and se - ice plans, ch onic ca e models, and desc ip ions o se ice chains. These p ac ices ha e been adop ed in many munici- pali ies and i can be said ha mos o he de elopmen s in e ms o in eg a ion ha e aken place h ough bo om-up de elopmen s o in eg a ed p ac ices (Sine o e al. 2016). Fu u e Heal h and Social Se ices Cen es P og amme, launched in 2020, wo ks owa ds simila goals by de elop- ing in eg a ed p ac ices a p ima y ca e le el by unding egional de elopmen wo k and p o iding na ional suppo (STM 2020b). Simila de elopmen s ha e aken place in Sweden whe e se e al na ional p og ams ha e been in oduced o imp o e in eg a ion o se ices and ca e coo dina ion. In 2010–2015, he go e nmen ini ia ed a p og amme o imp o e ca e coo - dina ion o olde people wi h complex heal h p oblems by in oducing inancial incen i es o enhance he use o quali y egis e s and o educe hospi al admissions, eadmissions and o educe inapp op ia e d ug use among olde people. This p og amme aimed a imp o ing coo dina ion be ween egional heal h ca e se ices and municipal social se ices o olde people (Hagman e al. 2014). The ini ia i e was esou ced h ough s a e g an s o egions and municipali- ies o de elop he se ices in i e a eas: a p e en i e way o wo king; good ca e o demen ia; good ca e a he end o li e; good pha maceu ical ea men o olde people; and coo dina ed heal h and social ca e. In Finland, isks ela ed o polypha macy and he use o inapp op ia e medicines ha e been aimed o educe h ough ee-accessed Meds75 + da abase o medica ion o olde pe sons. The pu pose o he da abase is o sup- po he clinical decision-making on he pha maco he apy o pa ien s o e 75yea s o age and o imp o e medica- ion sa e y especially in p ima y heal h ca e. (Fimea 2021.) The Meds75 + da abase has been main ained by he Finnish Medicines Agency, Fimea since yea 2015 (Fimea 2016). Also, majo de elopmen in e ms o suppo ing in eg a ion o in o ma ion sys ems has been implemen ed in he o m o he Na ional Pa ien Da a Reposi o y called Kan a Se ices, which is an elec onic pa ien eco d co e ing en i e popula- ion. I includes all public and p i a e heal h ca e p o ide s, enables elec onic p esc ip ion o medicines, and p o ides clinical in o ma ion no only o medical p o essionals bu also o pa ien s. (La sen e al. 2020, 80). Du ing he 2000s, se e al p e en ion policies ega ding polypha macy we e de eloped and implemen ed also in Sweden. One example was an in e en ion o imp o e d ug he apy o olde people. In 2005, he Swedish p esc ibed d ug egis e was ini ia ed, which include da a on all p e- sc ip ion d ugs dispensed o he Swedish popula ion. One aim wi h he egis y was o e alua e he quali y in d ug ea men among olde people (Johansson and Schön 2017). E alua ions ha e shown signi ican imp o emen s, o exam- ple an almos 40% educ ion in d ug use be ween 2005 and 2013. These esul s ha e led o egula ions on d ug e iews. People 65yea s and olde who a e p esc ibed i e o mo e d ugs ha e he igh o a d ug e iew (Fas bom and Johnell 2015). S eng hening p ima y ca e Imp o ing access o p ima y ca e se ices has been high on he agenda du ing he analysed pe iod in Finland and Swe- den. Howe e , he coun ies ha e adop ed di e ing pa hs. In bo h coun ies, ca e gua an ee legisla ion has been used o imp o e access o p ima y ca e. In Finland, maximum wai ing imes o p ima y and specialized heal h ca e we e in oduced h ough na ional ca e gua an ee ha ini ially en e ed in o o ce in 2005. I heal h cen es canno p o ide he se ice in due ime, hey mus ob ain he se ice om o he se ice p o ide s, such as p i a e p o ide s wi hou any addi ional cos o he pa ien . Howe e , in Finland, he wai ing imes se by ca e gua an ee a e ela i ely long wi h maximum wai ing ime o non-u gen ca e a p ima y ca e being h ee mon hs (Heal h Ca e Ac 2010). In Sweden, wai ing- ime gua an ee was in oduced al eady in 1992, and i was u he speci ied in 2005. The legisla ion was u he p omo ed h ough he “Queue-billion (Kömilja den)” ini ia- i e s a ing om 2008. The aim o he ini ia i e was o p o- ide inancial incen i es o he egions o mee he a ge s se in he ca e gua an ee. These incen i es we e discon inued in 2014 bu in 2019 e i ed again by he na ional go e nmen . To s eng hen p ima y heal h ca e, Sweden has also in oduced o he legisla ion o inc ease he supply o p i- ma y heal h ca e se ices, h ough p i a iza ion and ma - ke -o ien ed e o ms, which ha e been in oduced o e a longe ime, by di e en mechanisms and small changes in legisla ion (S all o s and Tylls öm 2018; Dahlg en 2018; Wingbo g 2017). The law on choice in heal h and social ca e (LOV) came in o o ce in 2009 wi h a pu pose o enable es ablishmen o new p i a e p o ide s and acili a e choice in social and ca e se ices. Applying he law is olun a y 228 Eu opean Jou nal o Ageing (2022) 19:221–232 1 3 o municipali ies, bu he law pa ed he way o he subse- quen manda o y law on Choice in P ima y Ca e. In 2010, an amendmen was made o he Heal h and Medical Se ices Ac , manda ing he egions and coun y councils o allow ci izens o choose hei PHC p o ide , and o allow p i a e p o ide s o eely es ablish p ac ices i hey me ce ain p e-de ined c i e ia. All egions had o change hei sys em o p o ide choice in p ima y ca e. In e ec , bo h pieces o legisla ion mean a ouche sys em, whe e esiden s ha ing he igh o he se ice can choose he p o ide hey wan , and he municipali y ( o social se ice) and he egion ( o p ima y ca e) a e esponsible o acc edi ing he p i a e p o- ide s and o paying o hem. In 2019, a go e nmen bill, “Close ca e” (Nä a å d), p o- posed ha p ima y ca e mus be s eng hened o be he ocal poin o ca e, and he link o o he specialis ca e (Swed- ish go e nmen 2019). Howe e , no majo changes ha e ye occu ed. In a ollow-up, he Na ional Boa d o Heal h and Wel a e concluded ha he COVID-19 pandemic had been a hind ance o implemen ing he e o m, along wi h di icul- ies o ec ui s a , especially o u al a eas. Howe e , some egions and municipali ies we e epo ed o ha e inc eased hei collabo a ion and he e was an inc eased use o e-heal h se ices. Indica o s o ollow up he implemen a ion o he e o m and hei impac will be de eloped (Na ional Boa d o Heal h and Wel a e 2021). To s eng hen he supply o p ima y ca e se ices, he “Swedish ype” choice and compe i ion model was also p o- posed in Finland in 2016–2018 (Tynkkynen 2021) bu Fin- land has adop ed a sligh ly di e en pa hway o s eng hen he se ices a p ima y le el. The Heal h Ca e Ac (2010) is he main piece o legisla ion egula ing bo h p ima y heal h ca e, specialized heal h ca e and p omo ion o heal h and well-being. When enac ed, he explici aim was o s eng hen p ima y heal h ca e. Finland has a wide ne wo k o munic- ipal le el p ima y ca e uni s which p o ide p ima y ca e se ices. In many places also social se ices a e ope a ing in he same cen e. In eg a ing la ge se o se ices unde he same uni has indeed been one o he local s a egies o s eng hen p ima y heal h ca e in gene al (Sine o e al. 2016) and hese ini ia i es ha e been suppo ed by se - e al na ional p og ammes, especially Kas e P og amme I (2008–2011) and Kas e P og amme II (2012–2015), which especially ocused on e o ming he s uc u e and con en o se ices a ge ed o olde people. In p ac ice, his mainly mean p omo ing di e en solu ions ha suppo ed li ing a home. The mos ecen na ional p og amme o s eng hen p ima y ca e is The Fu u e Heal h Ca e and Social Se ices Cen es-p og amme (STM 2020b). The p og amme aims a shi ing he ocus o se ices om specialized heal h ca e o p ima y heal h ca e and o p e en ion. Apa om being pa o he social and heal h ca e e o m agendas in Finland, p ima y heal h ca e has been implici ly on he agenda o old-age ca e policy oo. All ecommen- da ions o he quali y o ca e o he olde people (2001, 2008, 2013, 2017, 2020) and abo e-men ioned s a egic p o- g ams on ageing (2004, 2020) as well as Ac Suppo ing he Func ional Capaci y o he Olde Popula ion and on Social and Heal h ca e Se ices o Olde Pe sons (2013) seek o inc ease he p opo ion o olde people li ing a home wi h adequa e home ca e and o educe he numbe o hose aged o e 75yea s li ing a esiden ial long- e m ca e. Implici ly, his applies also o p ima y heal h ca e and home heal h ca e as pa o i . Despi e he desi e o shi he balance o ca e om ins i u ion o home ca e, he p opo ion o peo- ple ecei ing home ca e o amily suppo is s ill below he na ional a ge . I has also been a gued ha se ice s uc u es o egula home ca e ha e no achie ed he quali y ecom- menda ions ha a e ou lined in he Ac Suppo ing he Func- ional Capaci y o he Olde Popula ion and on Social and Heal h ca e Se ices o Olde Pe sons. (Rissanen 2020, 37). Discussion Ou analysis shows ha he e a e simila i ies bu also se e al di e ences in e ms o esou cing and capaci y o heal h sys ems and in he policies made in a eas o p ima y heal h ca e and ca e in eg a ion in he wo coun ies. Simila i ies ela e especially o na ional le el s ee ing h ough p og ams ha aim a suppo ing se ice de elopmen a local le el and which o en include inancial incen i es. Also, na ional ca e gua an ees ha e been used o imp o e access o p ima y ca e, bu which ha e no been alone su icien o imp o e he access o ca e. Bo h Finland and Sweden ha e a high deg ee o decen aliza ion and ela i ely weak na ional go e nance. This may explain why ce ain ini ia i es, e en egula ions, emain in en ions and do no ma e ialize as in ended i inan- cial incen i es a e no included in he e o m. The di e ences be ween he coun ies ela e bo h o he elemen s o he cu en sys em (capaci ies and a o dabil- i y) and o he gene al policy de elopmen s ha ha e aken place. When i comes o cu en sys ems, we can obse e ha Sweden in es s in heal h and ca e sys ems mo e han Finland does, and he le el o OOPs is also highe in Finland han in Sweden. In Finland, people also epo mo e unme ca e needs and ca as ophic heal h spending compa ed o Sweden. Wha is also ema kable is ha in Finland, cos con ainmen has been high on he na ional policy agenda despi e he al eady lowe le el o spending and highe OOPs (Tynkkynen e al. 2021). In e ms o cos con ainmen , bo h coun ies ha e emphasized ou pa ien ca e and communi y li ing (“ageing in place”) bu in Sweden, he esou cing in long- e m ca e emains highe han ha in Finland. One o he easons o unde esou ced p ima y heal h ca e in Finland may s em om he exis ence o dual p ac ice