From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

Finland’s response to the coronavirus pandemic – Update (May 2020)

Liina-Kaisa Tynkkynen, Tampere University/Faculty of Social Sciences/Health Sciences, liina-kaisa.tynkkynen@tuni.fi

Salla Atkins, Tampere University/Faculty of Social Sciences/Health Sciences

Ilmo Keskimäki, Finnish Institute for Health and Welfare & Professor, Tampere University/Faculty of Social Sciences/Health Sciences

Meri Koivusalo, Tampere University/Faculty of Social Sciences/Health Sciences

Pauli Rautiainen, Tampere University/Faculty of Management and Business

Timo Sinervo, Finnish Institute for Health and Welfare

Finland has been successful in slowing the coronavirus epidemic. Compared to many countries, the epidemic landed in Finland late. That allowed early implementation of restrictive measures which have also been obeyed well. Since early April 2020 the Government has introduced new restrictions but also measures to reopen the society.

On 30^th March the measures announced by the Government in mid-March were extended until 13^th May. These extensions were expanded by closing restaurants as of 4^th April until 31^st May except for take away and delivery. The lockdown of the Uusimaa region was taken down on 15^th April. On 22^nd April the Government decided that public events and gatherings of more than 500 people to continue to be banned until at least 31^st July.

On 4^th May the Government announced a roadmap for transition measures. Though the Government extended the application of the Emergency Powers Act, several restrictions were to be dismantled as of 14^th May. This included for example opening primary schools, early childhood education and outdoor recreational facilities and lifting some of the statutory restrictions in cross-border traffic. As of 1^st June, more restrictions will be lifted (e.g. opening of restaurants and public premises such as cultural venues, libraries, sports facilities, and several rehabilitative and preventive services). Also from 1^st June, restrictions on gatherings are eased from 10 to a maximum of 50 persons. Borrowing from libraries was to be immediately permitted as of 4^th May. The Government recommends that higher education institutions and secondary level schools continue distance teaching until the end of the semester. The recommendation on working from home is also continued. Residents aged over 70 years are advised to continue avoiding physical contacts. Also, the restrictions concerning visits to health and social care units will remain in force.

The spread of the epidemic has currently stalled in most areas of Finland which has opened a window for the discussion on easing the restrictions. Opening of the society and the economy has been called for especially by industry but also increasingly by health experts who frame it as a precondition to safeguard the financing of the welfare state. Discussion has also been had on the negative health and social effects of the restrictions (e.g. the effects of isolation on the elderly and on children) and risks for unmet service needs due to cancelled appointments.

The exit plan explained above was based on the report by an expert group led by the permanent secretary of the Ministry of Finance Martti Hetemäki. The Government calls their approach “the hybrid strategy”, which aims to curb the epidemic and to protect at-risk groups while minimising societal and economic costs and the impact on citizen rights. According to the Government the aim is to move from the general restrictions to targeted measures by using the “test, trace, isolate and treat” approach (TTIT). However, there are still few visible measures taken that would make the national TTIT strategy seem viable. Currently contact tracing, for instance, takes place through local action, whereas the national focus seems to be more on follow up, modelling and developing a mobile app to help in contact tracing. This reflects Finland’s decentralised health system and the lack of a national agency responsible for implementation of public health measures.

Many experts and the media have called for more open discussion on the assumptions behind the decisions made. The Government and the officials in the Ministries and Finnish Institute for Health and Welfare (THL) have, however, been reluctant to publish the epidemiological models and other evidence. Even the Constitutional Law Committee of the Parliament and an expert group appointed by the Government have stated that it has been difficult to attain all the information they would need. Scientific evidence has been underlined continuously by the Government, but because of the lack of openness it is unclear how this has applied to decisions in practice. The Hetemäki report, for instance, is based on an assumption that the epidemic should not be suppressed too heavily in order to avoid a large second wave to occur. However, all of this has been stated without reference to “the scientific evidence”.

Finland’s response has so far been generally well received. Most of the measures have not been a subject of any major political disagreements among the Government or between the Government and opposition. However, as the strategy now shifts to the next phase it has become more visible that the views on the ways forward range from aggressive suppression to moderate mitigation. There are also signs that the expertise represented by THL for instance has begun to be politicised in the media and on social media.

Finland’s Response to the Coronavirus Pandemic – Original post (April 2020)

Liina-Kaisa Tynkkynen, Assistant Professor, Tampere University/Faculty of Social Sciences/Health Sciences

Salla Atkins, Associate Professor, Tampere University/Faculty of Social Sciences/Health Sciences

Ilmo Keskimäki, Research Professor, Finnish Institute for Health and Welfare & Professor, Tampere University/Faculty of Social Sciences/Health Sciences

Meri Koivusalo, Professor, Tampere University/Faculty of Social Sciences/Health Sciences

Timo Sinervo, Research Professor, Finnish Institute for Health and Welfare

The first positively tested coronavirus case in Finland was of a Chinese tourist in a holiday resort in Lapland on January 29 2020. On February 13 2020 COVID-19 was included in the list of generally hazardous communicable diseases, following amendment of the Government Decree on Communicable Diseases. However, the situation with the spread of COVID-19 in Finland started quickly to evolve only in early March. This was probably aided by travel to the Alps during the winter holidays, which Finns enjoyed in February.

Finland moved to an epidemic stage in mid-March soon after the WHO had announced the COVID-19 outbreak as a pandemic. On March 16 2020 the national Government announced, in cooperation with the President of the Republic, that the country was in a state of emergency as a result of the coronavirus outbreak. This was followed by several Government-led actions implemented across the country.

The measures taken included closure of schools (except for grades 1-3) and universities, several physical distancing measures applied to the entire population (e.g. banning mass gatherings, closure of public sites, instructions to work from home if duties allow it, avoiding unnecessary travel and refraining from social contacts) and physical distancing of those over 70 years old, who were advised to self-isolate in quarantine-like conditions. Finland has also closed its borders (except for those in permanent employment across borders in the North-West border of Sweden and Norway) and decided to close bars, pubs and restaurants as of April 4 2020.

The epidemic centre is currently the capital region and its surroundings, namely the Uusimaa region. On March 28 2020 the Government restricted movement to and from the Uusimaa region until April 19 2020 to prevent the epidemic evolving too rapidly in the rest of the Finland, which has less ICU and testing capacity.

The Government has argued strongly for “evidence-based policy making” throughout its term 2019-2020. In the context of the COVID-19 epidemic the Government has emphasized the advice and recommendations from “the experts” referring namely to the Finnish Institute for Health and Welfare (THL) and Ministry of Social Affairs and Health (STM), but also that it takes “political responsibility” for the decisions made. However, the Government has not been explicit in terms of the strategy adopted to respond to the epidemic, which has led to an on-going discussion on several issues; to what extent are the measures based on scientific evidence, how much they reflect measures applied in other countries, and to what extent they are based on judgments made on the grounds of different modelling results or political pressure for visible action.

All in all, the strategy adopted by the Finnish Government to tackle the crisis seems to fall somewhere between suppression and mitigation. The Government and the national public health agency THL have repeatedly emphasized “flattening the curve” – thus mitigation– as the Finnish way to deal with the epidemic. However, there are also public health experts and academics who call for more aggressive suppression of the epidemic. Recently this approach has been reflected also in the statements by Government officials, STM and THL.

Discussion on social media, in the media, and among academics has centred around the perceived lack of testing in the country and models that seem more optimistic in terms of the deaths and need for ICU than those used in other countries. Possibly due to political pressure and emerging evidence, the testing capacity in Finland has been built up and increased as the situation has evolved. In terms of increasing testing, the bottlenecks have been both on the side of taking the tests but also in the capacity dedicated to tracing contacts and coordinating the tracing process, which also needs to be expanded. In addition, a lack of test materials and protective equipment and clothes has caused problems despite the deployment of equipment stored in the state emergency stockpiling.

It seems to be difficult to implement the “test-trace-isolate-treat”-strategy in the Finnish fragmented health system. While THL as a national public health agency provides support and guidance on how to respond to the epidemic, it is not a direct implementation agency. That is, the decisions on implementation and control are ultimately made by Regional State Administrative Agencies, local governments, cities, and hospital districts as long as the Government or legislation does not direct or require them to act. This has been reflected in different criteria and judgements about how broadly they have tested or traced people as well as how hospitals have been prepared. On the other hand, however, this gives ground for more bottom-up and regional approaches of control. However, so far, such bottom-up or regional strategies have not been evident even though the epidemic has not evolved similarly across the country.

According to the Government, the COVID-19 outbreak has been followed by the Finnish officials since the epidemic started in China. Finland has been active partner in global health security initiatives and is a Member of the WHO Executive Board. However, in official communications by the Government, STM and THL, the threat caused by the novel virus was not communicated to cause any major threat to Finland until the situation changed in the first weeks of March. It seems that problems in communication between different authorities have resulted in delays – e.g. in quarantining incoming plane passengers. The national pandemic preparedness plan on which initial approaches were based was focused on healthcare, and less thought was given at that stage to the multisectoral coordination that communicable disease control requires.

Finland’s preparedness measures are, to a large extent, based on the National preparedness plan for an influenza pandemic, which was updated in 2010-2012. That means that the preparedness to a pandemic has been, to a large extent, in the context of influenza, making it difficult to adapt to an epidemic that could not only be modelled and followed, but needed also to be controlled. The preparedness in the context of regulation is, in turn, based on the Emergency Powers Act that has been prepared in case of a war or a nuclear accident, rather than a public health crisis. Already at this point it can be said that after the acute crisis the preparedness both at the level of governance and regulation must be improved.

The epidemic is currently in very different stages in different parts of the country and there are a number of areas in which only a handful of tested cases are positive. While the stage of the epidemic varies, so does the regional competence to face the situation in terms of physical infrastructure, testing capacity, and human resources. The epidemic has yet to fully arrive in those parts of Finland that have a relatively large number of older people and higher morbidity in the population. In addition, in the sparsely populated areas, the distance to hospital can be measured in tens, even hundreds of kilometres, raising the question of access to intensive care in an emergency situation. The Finnish approach has been so far to treat all regions the same (e.g. closure of schools and restaurants) as the Uusimaa capital region, regardless of their epidemiological situation. It remains to be seen whether this approach is justified.

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