Leena Forma (Laurea University of Applied Sciences and Tampere University)

Emilia Leinonen (University of Jyväskylä)

The long-term care (LTC) system in Finland is characterised by a universal public LTC system with needs-based access to publicly organised services. The need for services is evaluated through an assessment with the client, their close relations and one or more professionals. The new wellbeing service counties are responsible for organising LTC and are the main providers, although some services are outsourced from private providers. Direct private purchasing of services by individuals is possible but relatively rare. LTC is mainly organised in private homes and the coverage of round-the-clock (residential) care has decreased. The role of families in providing LTC has increased in recent decades [1]. LTC is mainly funded publicly, but there are out-of-pocket payments. Total spending on LTC as a share of GDP was about 2.3% in 2021, sixth highest in the European Union-27 [2].

In Finland the legislative responsibility for LTC at national level is with Ministry of Social Affairs and Health (MSAH). Wellbeing services counties (=21) and the city of Helsinki are responsible for organising health and social services for all citizens, including older people. These counties were established at the beginning of 2023, mainly building on the existing counties which are responsible for development and planning. Previously, the responsibility for organising health and social services was with the municipalities (n=309 in 2022). Health and social services are integrated both at legislative and organisational level, but at the practical level there may be silos and e.g., difficulties in exchange of information.

Long-term care is mainly financed by taxes (about 84%) and user fees/out-of-pocket payments (about 16%) [3]. Publicly funded services are financed by national taxes, and the wellbeing services counties do not have a right to levy taxes.

The public system coverage is universal for all citizens of Finland. However, some older people complement the public services by purchasing private services, but there is no data on the extent to which this happens. Private LTC insurance is not available in Finland, but private health insurance has a role in financing of private health care. The counties set out-of-pocket payments, although there are national rules on the maximum possible payments. In practice out-of-pocket payments are mainly dependent on income, need for care and size of household, but there are also co-payments that are the same for all, such as those for support services.

The Ministry of Social and Health Affairs and the Association of Finnish Local and Regional Authorities have given a quality recommendation for services for older people [4]. The aim of the recommendation is to guarantee good quality of life and effective services for older people. The recommendation contains guidelines for developing service structures, housing and care environments as well as staff numbers, skills and management [5].

The national Supervisory Authority for Welfare and Health (Valvira) is responsible for supervising appropriateness of social and health care, including LTC [6]. Regional State Administrative Agencies coordinate and monitor health and social services providers and grant licences to private service providers [7].

The Finnish public LTC system is oriented towards community-based care, and residential-based care is offered only for those with the highest needs.

In the first instance, older people living at home are offered support services such as safety services, meals on wheels and cleaning services. Home care is an integrated service that includes home help (social care) and home nursing (health care). Day centre care is typically offered once a week, to support living at home, maintain social contacts or to provide leave to family and other unpaid carers. Reablement services are not offered regularly but have been piloted in multiple areas. Remote home care has been developed in recent years.

Home care is mostly provided by public providers, but about 11% of services were outsourced to private providers in 2019 [8]. Individuals may receive vouchers that can be used to purchasing private home care. In addition, older people may purchase services directly from private providers [9]. Home care is mainly funded by taxes, but care users pay a client fee, covering about 18% of the total costs in 2020. These fees may be high for those with low incomes and result in under-utilization of services that are needed [10].

In addition to unpaid care and home care, there is a small but growing type of home-like care called adult foster care that is meant for older people who have care needs but do not require 24-hour assistance (see below in the new models of care section).

Family carers are mostly spouses of older people and thus, they are also old and may have care needs themselves. Children and children-in-law also act as family carers, and they may have difficulties in combining work life and care responsibilities. Family members who provide care for older people may have a contract and support from wellbeing services counties. 5% of people aged 70 years, 6% of people aged 75 years and 7% of people aged 80 years receive informal care within the contract [4]. In addition, a large number of older people receive informal care without this formal support. Support for family carers with a contract includes services for the care receiver, care allowance, leave and support services for the care giver.

Residential care in nursing homes and health centres (LTC in primary care hospitals) has decreased remarkably in recent decades. Residential care is mainly provided in sheltered housing with 24-hour assistance [11]. Ordinary sheltered housing (without 24-hour assistance) is relatively rare, and there are plans to replace it with communal housing, which is described further in the new models of care and innovations section below. Half of all sheltered housing is provided publicly, and half by private providers, outsourced by wellbeing services counties. Private providers are mainly large multinational chains, that have purchased smaller providers, but there are still small providers, such as non-profit organisations.

The development of digital services in LTC has been a central policy goal in recent governmental programmes. The aim has been to increase the use of electronic patient recording (EPR) systems, robots, Artificial Intelligence and different digital services such as remote surveillance services in both home care and sheltered housing to improve care providers’ operational efficiency and support care recipients’ independent living and lower the need for physical visits in home care [12]. In 2018, 50% of the public home care and ordinary service housing units were using different kinds of assistive technology (including videoconferencing, alarm/safety bracelets, and robots). Out of all public home care units, 40% were using remote/virtual care in 2018 [13,14].

In care for older people, practical nurses (lähihoitaja) are the most common professionals. They have undertaken vocational education lasting 2 to 3 years. Registered nurses (sairaanhoitaja) also work in care for older people, they are educated in universities on applied sciences, and their studies last for 3.5 years. Care assistants (hoiva-avustaja) are a new professional group in Finnish care for older people, and they have a 3-month education. On average Finnish home care workers have longer education compared to colleagues in other Nordic countries [15].

It is assessed that there is a lack of more than 16,600 nurses and 8,000 practical nurses in Finland (all sectors, not only care for older people) [16]. One reason for the shortage is that large generations are retiring, and the sector is not considered very attractive by younger people. Many nurses have left to work in other sectors, and the main reasons for quitting job in home care have been e.g., mismatch between needs and resources, and ethical burden [17]. Measures adopted to increase workforce include extending work careers of nurses approaching retirement age and increasing the hiring of nurses from other countries. However, in a report of Ministry of Economic Affairs and Employment [18] it was concluded that hiring foreign nurses is not an answer to the acute lack of nurses. Entering the Finnish labour market in the health care sector is slow due to language skill requirements and need to duly legalise the professionals. The National Supervisory Authority for Welfare and Health (Valvira) grants the right to practise a health care profession on application to persons trained in Finland and abroad [19].

The Resident Assessment Instrument (RAI) has been used in many care services for a while, e.g., in home care, 40% of clients were assessed using RAI in 2020. From the beginning of 2023 RAI assessments became mandatory in all care services for older people, both in home care and residential care.

Information on care use is available in national registers maintained by the Finnish Institute for Health and Welfare (THL). The data are available for research purposes under tight data protection conditions. THL provides statistical reports on care on a yearly basis, mainly on care use, not on performance of the care services.

The THL also started to collect data on client satisfaction in care for older people in 2022. The first results were published in autumn 2022, and there were 42,000 responses from clients of home care and care homes. In future, the survey will be mandatory, and it will be carried out every two years [20]. There has been critique towards the methods of collecting the data, i.e., that professional carers are collecting data about care provided by themselves.

There is a new and growing type of service offering adult foster care, where people live in ordinary homes with foster carers who are not related to them and who provide care. These foster carers are not formally employed by the public sector but have a commission arrangement with the wellbeing services county [21]. In 2022, more than 2,000 older persons received care in adult foster care, either short-term or long-term [8] . Adult foster care is similar to UK’s Shared Lives Scheme.

The Finnish government is currently proposing reforms to the Social Welfare Act that aim to strengthen and expand home-based care, including widening the services on offer and adopting measures to secure sufficient staff [22]. The housing services under the Social Welfare Act will be communal housing, 24-hour service housing, temporary housing and supported housing. Communal housing will replace the current ordinary service housing. Communal housing includes suitable housing for clients and services that promote social interaction. 24-hour service housing and services will be organised in the same way as in the current service housing with 24-hour assistance. Personnel must be available around the clock, and the statutory staffing levels will be complied with in services for older people.

Of people aged 75+ years, 11% received regular home care and 9% round-the-clock care in 2018. For people aged 85+ years these figures were 22% and 19% respectively [4]. The coverage of residential care for older people has decreased in recent decades, and the coverage of home care has not increased [23]. Thus, the total coverage has decreased, and access to care is relatively poor. This can be seen in other health services, as older people who cannot cope at home have to seek for help from first aid clinics repeatedly [24]. 17-26% of older people living at home were found to face care poverty in 2010 and 2015 [25]. In addition, thousands of clients of home care do not receive all the care they need because they cannot afford it [26]. A place in residential care is hard to get. Half of municipalities could not offer immediate residential care for those who needed it in 2022 [27].

The out-of-pocket payments in Finland are higher than in other Nordic countries [1], and as mentioned earlier, some older people cannot afford all the care they need. In principle wellbeing services counties are obliged to moderate the payments if the client is not able to pay them, but there is no information about how often this happens. 

In 2019 there was a care crisis, as multiple quality problems came into the spotlight. These occurred mainly in private care homes, which were obliged to close or were transferred to public providers. Following this, the monitoring of care homes was strengthened [28].

There is very scarce evidence on effectiveness of care. Only some small-scale studies have been conducted.

During the COVID-19 pandemic, care for older people is considered to have continued to work quite well. However, social isolation increased as visits to people living in care homes were not allowed, and it has been suggested that the restrictions were too tight [29].

As in many other countries, the Finnish Government recommended that all persons aged 70 years or over should stay in quarantine-like conditions from March 2020 to June 2020. According to Aaltonen et al (2021) [30], the situation of older persons living at home and receiving family care and support was more difficult compared to those living in sheltered housing: to receive the care or support they needed, they could not follow the social distancing recommendation and were in that sense more vulnerable to the virus and possible infection. Aaltonen et al (2021) further argue that older persons who received help, care and support from their families were forgotten in the crisis preparation and management plans. During the pandemic, there were governmental budget allocations to services for older people but most of the allocations were related to health care services: support was given to hospital districts to fund equipment costs, and municipalities received additional subsidies for arranging basic services [31]. According to a report [32], the impacts of the pandemic on the situation of family carers were also quite severe. Finnish family carers suffered from a lack of services for themselves and those they cared for, a lack of contact with other people, and an overall lack of support measures such as protective masks that were only available to professional care workers.

From epidemiological perspective, Finland has come out of the crisis quite well compared to other countries, partly because of the high level of trust in institutions and official communications. However, there is a serious backlog in social and health care services, especially in mental health services and oral health services but also in primary and special health care. For instance, the number of diagnoses of chronic illnesses has dropped significantly during the pandemic [33]. The shortage of personnel nevertheless remains a significant issue. In February 2022, nearly a third of service providers rated the adequacy of personnel as ‘concerning’ or worse [34]. Furthermore, it seems that the negative consequences of the pandemic have impacted the most vulnerable groups such as older persons [33].

In 2023 a major reform of social welfare and health care was adopted. The responsibility to organise health and social services was transferred from municipalities to wellbeing services counties. The financing system was not changed in that reform, but that may happen in the next set of reforms.

A new amendment to the Employment Contracts Act called Carer’s leave (Omaishoitovapaa) came into force on 1st August 2022. According to this new amendment, an employee has a right to have up to five days off during a calendar year if the employee’s immediate presence is needed because their relative or someone else close to them needs a considerable amount of support or assistance because of serious illness or injury.

An Act on client fees in health and social services came into force in 2021, which also regulated the fees for sheltered housing. Before that, there were extensive variations between regions and care providers in determining of client fees.

The Act on care services for older people is under reform, currently the required minimum number of nurses per client in 24-hour sheltered housing (staff/client ratio) is 0.65 and this should be 0.7 from the beginning of 2028 [35]. However, the implementation of a required minimum number of nurses has been postponed since there are not enough available nurses. Some care providers have stated that they would need to close their care homes, because they are not able to fulfil the requirement. Many are also afraid that the nursing ratio requirement in residential care is creating a shortage of nurses in home care. 

Forma L. and Leinonen E. (2024) Long-term care system profile: Finland. Global Observatory of Long-Term Care, Care Policy & Evaluation Centre, London School of Economics and Political Science. https://goltc.org/system-profile/finland

Forma L, Aaltonen M, Teräväinen P, Pulkki J (2023) Mikä maksaa ja kuka maksaa? Ikääntyneiden hoidon kustannukset ja rahoitus -pilottitutkimus. [What pays and who pays? Costs and financing of care for older people – a pilot study.] Kunnallisalan kehittämissäätiön julkaisuja [Publications of the Foundation for Municipal Development] 56/2023.

Saske S, Karttunen T, Kehusmaa S, Alastalo H, Josefsson K 2023: Vanhuspalvelujen tila 2022. Kolmasosa ympärivuorokautisen palveluasumisen yksiköistä täytti 0,7 mitoituksen jo marraskuussa 2022. [The state of services for older people in 2022. A third of the 24-hour service housing units already met the 0.7 ratio in November 2022] Finnish Institute for Health and Welfare, Statistical report 12/2023.

[1] Szebehely M, Meagher G 2018: Nordic eldercare – Weak universalism becoming weaker? Journal of European Social Policy 28, 294–308. https://doi.org/10.1177/0958928717735062

[2] European Commission, Directorate-General for Employment, Social Affairs and Inclusion, Long-term care report: trends, challenges and opportunities in an ageing society. Volume I, Publications Office, 2021, https://data.europa.eu/doi/10.2767/677726

[3] Official Statistics of Finland 2023: Terveydenhuollon menot ja rahoitus 2020. [Health care expenditure and financing in 2020]. Statistical report 18/2023. Helsinki, Finnish Institute for Health and Welfare.

[4] Ministry of Social Affairs and Health and Association of Finnish Local and Regional Authorities 2020: Quality recommendation to guarantee a good quality of life and improved services for older persons 2020–2023. The Aim is an Age-friendly Finland. Publications of the Ministry of Social Affairs and Health 2020:29

[5] Quality and development of services for older people. https://stm.fi/en/older-people-services/quality-recommendations

[6] Healthcare and social welfare. https://valvira.fi/en/healthcare-and-social-welfare

[7] Social and health care services. https://avi.fi/en/about-us/our-services/social-welfare-and-health-care

[8] Sotkanet 2023: Statistical information on welfare and health, home help visits in households with older people (group id 126). Finnish Institute for Health and Welfare. https://sotkanet.fi/sotkanet/en/index

[9] Puhenparambil JM, Kröger T, van Aerschot L 2015: Users of home care services in a Nordic welfare state under marketisation: the rich, the poor and the sick. Health and Social Care in the Community 25, 54-64. https://onlinelibrary.wiley.com/doi/10.1111/hsc.12245

[10] Ilmarinen K, van Aerchot L, Kröger T 2022: Not free at all: Home care user fees in a Nordic care system. Social Policy and Society. Published online 2022:1-16. doi:10.1017/S1474746422000240

[11] Forma L, Aaltonen M, Pulkki J, Raitanen J, Rissanen P, Seinelä L, Valvanne J, Jylhä M 2018: Pitkäaikaishoito viimeisenä elinvuotena suurissa kaupungeissa ja muualla Suomessa 2002–2013 – rekisteritutkimus (Long-term care in the last year of life in large cities and the rest of Finland in 2002-2023 – A register study). Suomen Lääkärilehti (Finnish Medical Journal) 73, 2086–2091.

[12] Rantala, E., Taipale, S., Oinas, T., and Karhinen, J. 2022: Digital skills and application use among Finnish home care workers in the eldercare sector. In: Hirvonen, H., Tammelin, M., Riitta Hänninen and Wouters, E. J.M. (eds.) Digital Transformations in Care for Older People: Critical Perspectives. Routledge

[13] EPTA report 2019: Technologies in Care for Older People. Available at: https://eptanetwork.org/images/documents/minutes/EPTA_report_2019.pdf

[14] THL (2018) Kotihoidon ja ympärivuorokautisen hoidon toimintatavat 2018. Vanhuspalvelujen tila 2018-tutkimusaineisto. Helsinki: Terveyden ja hyvinvoinnin laitos. Available at: https://www.slideshare.net/THLfi/kotihoidon-ja-ymprivuorokautisen-hoidon-toimintatavat-2018-118997643

[15] Kröger T, Vuorensyrjä M 2008: Suomalainen hoivatyö pohjoismaisessa vertailussa. Vanhuspalvelujen koti- ja laitospalvelujen piirteitä ja ongelmia. (Care work in Finland in a comparative Nordic context: Characteristics and problems of care work in home care and institutional care for older people.) Yhteiskuntapolitiikka 73, 250-266.

[16] Keva 2023: Kuntasektorin työvoimaennuste. (The labor force forecast on municipalities) https://www.keva.fi/contentassets/de5752333bfb4e0a8194a8797ed24935/analyysi-kuntien-tyovoimatarpeista-2023.pdf Accesses 26th February 2024.

[17] Ring M, Ristolainen H & Tiilikainen E 2024: From Restricted Resources to Ethical Burden—Former Home Care Workers’ Reasons for Leaving Their Jobs. Journal of Applied Gerontology. https://doi.org/10.1177/07334648241231404

[18] Larja L, Peltonen J 2023: Työvoiman saatavuus, työvoimapula ja kohtaanto-ongelmat vuonna 2022 Työvoimatiekartat -hankkeen loppuraportti. TEM-analyyseja 113/2023. Ministry of Economic Affairs and Employment.

[19] Health care professional trained outside the EU/EEA. https://valvira.fi/en/.rights-to-practise/health-care-professional-trained-outside-the-eu/eea Accessed 26th February 2024

[20] Kehusmaa S, Leppäaho S, Havakka P, Karttunen T 2022: Vanhuspalvelujen asiakastyytyväisyyskyselyn tulokset – Kerro palvelustasi -kysely 2022. Tutkimuksesta tiiviisti 57/2022. Finnish Institute for Health and Welfare.

[21] Leinonen, E. 2020: Caring in space: The boundaries between public and private spaces in Finnish adult foster care homes. Ageing and Society, 1-18. DOI: https://doi.org/10.1017/S0144686X19001831

[22] Ministry of Social Affairs and Health 2022: Legislative reform develops services provided at home and housing services for older people https://stm.fi/en/-/legislative-reform-develops-services-provided-at-home-and-housing-services-for-older-people

[23] Forma L, Pulkki J, Raitanen J, Jylhä M, Aaltonen M 2023: Miten ikääntyneiden sosiaali- ja terveyspalvelujen käyttö muuttui koronapandemian alkuvaiheessa? Yhteiskuntapolitiikka 88, 420–429.

[24] Yle News 2023: Lääkärit: Tässä on syy päivystysten kriisiin – sairaalat ovat täynnä vanhuksia, jotka eivät saa apua muualta. (Doctors: Here’s the reason for the emergency room crisis – hospitals are full of elderly people who can’t get help elsewhere.) https://yle.fi/a/3-12578664 Accessed 4th March 2024.

[25] Kröger T, Puthenparambil JM, & Van Aerschot L 2019: Care poverty: unmet care needs in a Nordic welfare state. International Journal of Care and Caring 3, 485-500. Retrieved Feb 26, 2024, from https://doi.org/10.1332/239788219X15641291564296

[26] Kehusmaa S, Leppäaho S, Havakka P, Karttunen T 2022: Vanhuspalvelujen asiakastyytyväisyyskyselyn tulokset – Kerro palvelustasi -kysely 2022. Tutkimuksesta tiiviisti 57/2022. Finnish Institute for Health and Welfare.

[27] Yle News 2022: Vanhus saattaa jonottaa kiireellistä hoivapaikkaa yli viikon – iso osa kunnista ei pysty lakisääteiseen aikaan. (An older person may wait more than a week for an urgent care place – a large number of municipalities cannot meet the statutory time limit.) https://yle.fi/a/74-20008532 Accessed 4th March 2024.

[28] Toivonen Virve-Maria, Muukkonen Matti, Mäki-Petäjä-Leinonen Anna 2021: Vanhuspalvelujen laatu ja valvonta – käytäntöä ja uudistamistarpeita. [Quality and monitoring of services for older people – practice and needs for reform.] Oikeus [Justice] 2/2021, pp. 209–227. https://www.edilex.fi/oikeus/235240004

[29] Forma L, Aaltonen M, Pulkki J 2020: COVID-19 and clients of long-term care in Finland – impact and measures to control the virus. LTCcovid, International Long-Term Care Policy Network, CPEC-LSE, 12 June 2020.

[30] Aaltonen, M., Pulkki, J., Teräväinen, P., and Forma, L. (2021) ‘Ikääntyneiden kokemukset hoivan ja avun saamisesta koronapandemian aikana’ [‘Older persons’ experiences on receiving care and help during the Covid-19 pandemic’], Gerontologia, 35(4): 326–341.

[31] Mesiäislehto, M., Elomäki, A., Närvi, J., Simanainen, M., Sutela, H. and Räsänen, T. (2022) The gendered impacts of the Covid-19 crisis in Finland and the effectiveness of the policy responses. Findings of the project “The impact of the Covid-19 crisis in Finland”. Helsinki: Finnish Institute of Health and Welfare.

[32] Sihto, T., Leinonen, E. and Kröger, T. (2022) Omaishoito ja COVID-19-pandemia: omaishoitajien arki, elämänlaatu ja palveluiden saatavuus koronapandemian aikana [Family care and the COVID-19 pandemic. Family carers everyday life, quality of life and access to services during the pandemic]. Jyväskylä: University of Jyväskylä. https://jyx.jyu.fi/handle/123456789/80448

[33] Varanka et al. 2022: https://julkaisut.valtioneuvosto.fi/bitstream/handle/10024/163983/VN_2022_14.pdf

[34] Kestilä et al. 2022: https://www.julkari.fi/bitstream/handle/10024/144268/THL_Rap4_2022_Covid-seuranta_kevat_2022_web.pdf?sequence=4&isAllowed=y[–]

[35] Government proposes to gradually increase minimum staffing level in services for older people https://stm.fi/en/-/government-proposes-to-gradually-increase-minimum-staffing-level-in-services-for-older-people-

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