The organisation and responsibility for care for older people in Denmark, Finland and Sweden: outline and comparison of care systems.

AIM: To outline the organisation and responsibility for health and social care provided to older people in Denmark, Finland and Sweden. METHODS: Non-quantifiable data on the care systems were collated from the literature and expert consultations. The responsibilities for primary healthcare, specialised healthcare, prevention and health promotion, rehabilitation, and social care were presented in relation to policy guidance, funding and organisation. RESULTS: In all three countries, the state issues policy and to some extent co-funds the largely decentralised systems; in Denmark and Sweden the regions and municipalities organise the provision of care services - a system that is also about to be implemented in Finland to improve care coordination and make access more equal. Care for older citizens focuses to a large extent on enabling them to live independently in their own homes. CONCLUSIONS: Decentralised care systems are challenged by considerable local variations, possibly jeopardising care equity. State-level decision and policy makers need to be aware of these challenges and monitor developments to prevent further health and social care disparities in the ageing population.

Performing up to Nordic principles? Geographic and socioeconomic equity in ambulatory care sensitive conditions among older adults in capital areas of Denmark, Finland and Sweden in 2000-2015.

BACKGROUND: Denmark, Finland and Sweden pursue equity in health for their citizens through universal health care. However, it is unclear if these services reach the older adult population equally across different socioeconomic positions or living areas. Thus, we assessed geographic and socioeconomic equity in primary health care (PHC) performance among the older adults in the capital areas of Denmark (Copenhagen), Finland (Helsinki) and Sweden (Stockholm) in 2000-2015. Hospitalisations for ambulatory care sensitive conditions (ACSC) were applied as a proxy for PHC performance. METHODS: We acquired individual level ACSCs for those aged ≥ 45 in 2000-2015 from national hospitalisation registers. To identify whether the disparities varied by age, we applied three age groups (those aged 45-64, 65-75 and ≥ 75). Socioeconomic disparities in ACSCs were described with incidence rate ratios (IRR) and annual rates by education, income and living-alone; and then analysed with biennial concentration indices by income. Geographic disparities were described with biennial ACSC rates by small areas and analysed with two-level Poisson multilevel models. These models provided small area estimates of IRRs of ACSCs in 2000 and their slopes for development over time, between which Pearson correlations were calculated within each capital area. Finally, these models were adjusted for income to distinguish between geographic and socioeconomic disparities. RESULTS: Copenhagen had the highest IRR of ACSCs among those aged 45-64, and Helsinki among those aged ≥ 75. Over time IRRs decreased among those aged ≥ 45, but only in Helsinki among those aged ≥ 75. All concentration indices slightly favoured the affluent population but in Stockholm were mainly non-significant. Among those aged ≥ 75, Pearson correlations were low in Copenhagen (-0.14; p = 0.424) but high in both Helsinki (-0.74; < 0.001) and Stockholm (-0.62; < 0.001) - with only little change when adjusted for income. Among those aged ≥ 45 the respective correlations were rather similar, except for a strong correlation in Copenhagen (-0.51, 0.001) after income adjustment. CONCLUSIONS: While socioeconomic disparities in PHC performance persisted among older adults in the three Nordic capital areas, geographic disparities narrowed in both Helsinki and Stockholm but persisted in Copenhagen. Our findings suggest that the Danish PHC incorporated the negative effects of socio-economic segregation to a lesser degree.

"Local cooperation has been the cornerstone": facilitators and barriers to resilience in a decentralized health system during COVID-19 in Finland.

PURPOSE: The purpose of this study was to elucidate facilitators and barriers to health system resilience and resilient responses at local and regional levels during the first year of the COVID-19 pandemic in Finland. DESIGN/METHODOLOGY/APPROACH: The authors utilized a qualitative research approach and conducted semi-structured interviews (n = 32) with study participants representing five different regions in Finland. Study participants were recruited using purposive and snowball sampling. All study participants had been in management and civil servant positions during the first year of the pandemic, representing municipalities, municipalities' social and healthcare services, hospital districts and regional state administrative agencies. All interviews were completed remotely from April to December 2021 and the recordings transcribed verbatim. The authors coded the transcripts in ATLAS.ti 9.1 using directed content analysis. FINDINGS: The findings highlighted a wide range of localized responses to the pandemic in Finland. Facilitators to health system resilience included active networks of cooperation, crisis anticipation, transitioning into crisis leadership mode, learning how to incorporate new modes of operation, as well as relying on the competencies and motivation of health workforce. The authors found several barriers to health system resilience, including fragmented organization and management particularly in settings where integrated health care systems were not in place, insufficient preparedness to a prolonged crisis, lack of reliable information regarding COVID-19, not having plans in place for crisis communication, pandemic fatigue, and outflux of health workforce to other positions with better compensation and working conditions. ORIGINALITY/VALUE: Factors affecting health system resilience are often studied at the aggregate level of a nation. This study offers insights into what resilient responses look like from the perspective of local and regional actors in a decentralized health system. The results highlight that local capacities and context matter greatly for resilience. The authors call for more nuanced analyses on health systems and health system resilience at the sub-national level.

Explaining regional variation in elective hip and knee arthroplasties in Finland 2010 - 2017-a register-based cohort study.

BACKGROUND: A persistent research finding in industrialised countries has been regional variation in medical practices including elective primary hip and knee arthroplasty. The aim of the study was to examine regional variations in elective total hip and knee arthroplasties over time, and the proportions of these variations which can be explained by individual level or area-level differences in need. METHODS: We obtained secondary data from the Care Register for Health Care to study elective primary hip and knee arthroplasties in total Finnish population aged 25 + years between 2010 and 2017. Two-level Poisson regression models - individuals and hospital regions - were used to study regional differences in the incidence of elective hip and knee arthroplasties in two time periods: 2010 - 2013 and 2014 - 2017. The impact of several individual level explanatory factors (age, socioeconomic position, comorbidities) and area-level factors (need and supply of operations) was measured with the proportional change in variance. Predictions of incidence were measured with incidence rate ratios. The relative differences in risk of the procedures in regions were described with median rate ratios. RESULTS: We found small and over time relatively stable regional variation in hip arthroplasties in Finland, while the variation was larger in knee arthroplasties and decreased during the study period. In 2010 - 2013 individual socioeconomic variables explained 10% of variation in hip and 4% in knee arthroplasties, an effect that did not emerge in 2014 - 2017. The area-level musculoskeletal disorder index reflecting the need for care explained a further 44% of the variation in hip arthroplasties in 2010 - 2013, but only 5% in 2014 - 2017 and respectively 22% and 25% in knee arthroplasties. However, our final models explained the regional differences only partially. CONCLUSIONS: Our results suggest that eligibility criteria in total hip and knee arthroplasty are increasingly consistent between Finnish hospital districts. Factors related to individual level and regional level need both had an important role in explaining regional variations. Further study is needed on the effect of health policy on equity in access to care in these operations.

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

Population ageing with an increasing number of people experiencing complex health and social care needs challenges health systems. We explore whether and how health system reforms and policy measures adopted during the past two decades in Finland and Sweden reflect and address the needs of the older people. We discuss health system characteristics that are important to meet the care needs of older people and analyse how health policy agendas have highlighted these aspects in Finland and Sweden. The analysis is based on "most similar cases". The two countries have rather similar health systems and are facing similar challenges. However, the policy paths to address these challenges are different. The Swedish health system is better resourced, and the affordability of care better ensured, but choice and market-oriented competition reforms do not address the needs of the people with complex health and social care needs, rather it has led to increased fragmentation. In Finland, the level of public funding is lower which may have negative impacts on people who need multiple services. However, in terms of integration and care coordination, Finland seems to follow a path which may pave the way for improved coordination of care for people with multiple care needs. Intensified monitoring and analysis of patterns of health care utilization among older people are warranted in both countries to ensure that care is provided equitably.

Balancing financial incentives during COVID-19: A comparison of provider payment adjustments across 20 countries.

Provider payment mechanisms were adjusted in many countries in response to the COVID-19 pandemic in 2020. Our objective was to review adjustments for hospitals and healthcare professionals across 20 countries. We developed an analytical framework distinguishing between payment adjustments compensating income loss and those covering extra costs related to COVID-19. Information was extracted from the Covid-19 Health System Response Monitor (HSRM) and classified according to the framework. We found that income loss was not a problem in countries where professionals were paid by salary or capitation and hospitals received global budgets. In countries where payment was based on activity, income loss was compensated through budgets and higher fees. New FFS payments were introduced to incentivize remote services. Payments for COVID-19 related costs included new fees for out- and inpatient services but also new PD and DRG tariffs for hospitals. Budgets covered the costs of adjusting wards, creating new (ICU) beds, and hiring staff. We conclude that public payers assumed most of the COVID-19-related financial risk. In view of future pandemics policymakers should work to increase resilience of payment systems by: (1) having systems in place to rapidly adjust payment systems; (2) being aware of the economic incentives created by these adjustments such as cost-containment or increasing the number of patients or services, that can result in unintended consequences such as risk selection or overprovision of care; and (3) periodically evaluating the effects of payment adjustments on access and quality of care.

COVID-19 pandemic in Finland - Preliminary analysis on health system response and economic consequences.

OBJECTIVES: The objective of this study was to describe and analyze the impact of the coronavirus disease COVID-19 on health policy, social- and health system, and economic and financing system to prevent, treat, contain and monitor the virus in Finland. METHODS: This study provides early outcomes of health policy measures, social- and health system capacity as well as economic challenges in COVID-19 pandemic in Finland. This paper is based available documents and reports of different ministries and social, health and economic authorities collected online. This was complemented by other relevant pandemic data from Finland. RESULTS: The impact of COVID-19 pandemic on the Finnish society has been unpredictable although it has not been as extensive and massive than in many other countries. As the situation evolved the Government took strict measures to stop the spread of the virus (e.g. Emergency Powers Act). Available information shows that the economic consequences will be drastic also in Finland, albeit perhaps less dramatic than in large industrial economies. CONCLUSIONS: Finland has transferred gradually to a "hybrid strategy", referring to a move from extensive restrictive measures to enhanced management of the epidemic. However, health system must be prepared for prospective setback. It is possible, that COVID-19 pandemic has accelerated the development of digital health services and telemedicine in Finnish healthcare system.

Cumulative social disadvantage and hospitalisations due to ambulatory care-sensitive conditions in Finland in 2011─2013: a register study.

OBJECTIVES: To study the interplay between several indicators of social disadvantage and hospitalisations due to ambulatory care-sensitive conditions (ACSC) in 2011─2013. To evaluate whether the accumulation of preceding social disadvantage in one point of time or prolongation of social disadvantage had an effect on hospitalisations due to ACSCs. Four common indicators of disadvantage are examined: living alone, low level of education, poverty and unemployment. DESIGN: A population-based register study. SETTING: Nationwide individual-level register data on hospitalisations due to ACSCs for the years 2011-2013 and preceding data on social and socioeconomic factors for the years 2006─2010. PARTICIPANTS: Finnish residents aged 45 or older on 1 January 2011. OUTCOME MEASURE: Hospitalisations due to ACSCs in 2011-2013. The effect of accumulation of preceding disadvantage in one point of time and its prolongation on ACSCs was studied using modified Poisson regression. RESULTS: People with preceding cumulative social disadvantage were more likely to be hospitalised due to ACSCs. The most hazardous combination was simultaneously living alone, low level of education and poverty among the middle-aged individuals (aged 45-64 years) and the elderly (over 64 years). Risk ratio (RR) of being hospitalised due to ACSC was 3.16 (95% CI 3.03-3.29) among middle-aged men and 3.54 (3.36-3.73) among middle-aged women compared with individuals without any of these risk factors when controlling for age and residential area. For the elderly, the RR was 1.61 (1.57-1.66) among men and 1.69 (1.64-1.74) among women. CONCLUSIONS: To improve social equity in healthcare, it is important to recognise not only patients with cumulative disadvantage but also-as this study shows-patients with particular combinations of disadvantage who may be more susceptible. The identification of these vulnerable patient groups is also necessary to reduce the use of more expensive treatment in specialised healthcare.

The Road to the Alcohol Act 2018 in Finland: A conflict between public health objectives and neoliberal goals.

Finnish alcohol policy has aimed for decades years to mitigate alcohol-related harm by using high taxation and restrictions on the physical availability of alcohol. The state monopoly on the retail of alcohol has played a central role in reducing the availability of alcohol. In 2011, preparations began for a comprehensive reform of the Alcohol Act 1994. Over time, the issue became highly politicised, lobbied and divisive. It took intense work of two consecutive governments to finalise the reform. The new Alcohol Act came into force in 2018. It expanded the rights of grocery stores to sell alcohol and reduced the administrative burden for on-premise sales. As a result, the state monopoly on the retail of alcohol was weakened, but it still has an important impact on the physical availability of alcohol. The Finnish public health community expected an increase in alcohol sales following the reform because of greater alcohol availability and expected price reductions related to greater competition of sales in grocery stores. However, prices decreased less than expected in 2018, partly due to a simultaneous increase in alcohol taxes. It is difficult to evaluate the impact of the reform at this early stage. However, after the reform, the 10-year (2008-2017) downward trend in the total per capita alcohol consumption was discontinued despite the tax increase. According to preliminary analyses, the change in the law may have slightly increased recorded alcohol sales but the effect was not statistically significant.

Employment Status and Personal Income Before and After Onset of a Severe Mental Disorder: A Case-Control Study.

OBJECTIVE: Individuals with severe mental disorders have an impaired ability to work and are likely to receive income transfer payments as their main source of income. However, the magnitude of this phenomenon remains unclear. Using longitudinal population cohort register data, the authors conducted a case-control study to examine the levels of employment and personal income before and after a first hospitalization for a serious mental disorder. METHODS: All individuals (N=50,551) who had been hospitalized for schizophrenia, other nonaffective psychosis, or bipolar disorder in Finland between 1988 and 2015 were identified and matched with five randomly selected participants who were the same sex and who had the same birth year and month. Employment status and earnings, income transfer payments, and total income in euros were measured annually from 1988 to 2015. RESULTS: Individuals with serious mental disorders had notably low levels of employment before, and especially after, the diagnosis of a severe mental disorder. Their total income was mostly constituted of transfer payments, and this was especially true for those diagnosed as having schizophrenia. More than half of all individuals with a serious mental disorder did not have any employment earnings after they received the diagnosis. CONCLUSIONS: The current study shows how most individuals in Finland depend solely on income transfer payments after an onset of a severe mental disorder.

Finland: Health System Review.

This analysis of the Finnish health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. Finland is a welfare state witha high standard of social and living conditions and a low poverty rate. Its health system has a highly decentralized administration, multiple funding sources, and three provision channels for statutory services in first-contact care: the municipal system, the national health insurance system, and occupational health care. The core health system is organized by the municipalities (i.e. local authorities) which are responsible for financing primary and specialized care. Health financing arrangements are fragmented, with municipalities, the health insurance system, employers and households all contributing substantial shares. The health system performs relatively well, as health services are fairly effective, but accessibility may be an issue due to long waiting times and relatively high levels of cost sharing. For over a decade, there has been broad agreement on the need to reform the Finnish health system, but reaching a feasible policy consensus has been challenging.

Trajectory modelling of ambulatory care sensitive conditions in Finland in 1996-2013: assessing the development of equity in primary health care through clustering of geographic areas - an observational retrospective study.

BACKGROUND: Due to stagnating resources and an increase in staff workload, the quality of Finnish primary health care (PHC) is claimed to have deteriorated slowly. With a decentralised PHC organisation and lack of national stewardship, it is likely that municipalities have adopted different coping strategies, predisposing them to geographic disparities. To assess whether these disparities emerge, we analysed health centre area trajectories in hospitalisations due to ambulatory care sensitive conditions (ACSCs). METHODS: ACSCs, a proxy for PHC quality, comprises conditions in which hospitalisation could be avoided by timely care. We obtained ACSCs of the total Finnish population aged ≥20 for the years 1996-2013 from the Finnish Hospital Discharge Register, and divided them into subgroups of acute, chronic and vaccine-preventable causes, and calculated annual age-standardised ACSC rates by gender in health centre areas. Using these rates, we conducted trajectory analyses for identifying health centre area clusters using group-based trajectory modelling. Further, we applied area-level factors to describe the distribution of health centre areas on these trajectories. RESULTS: Three trajectories - and thus separate clusters of health centre areas - emerged with different levels and trends of ACSC rates. During the study period, chronic ACSC rates decreased (40-63%) within each of the clusters, acute ACSC rates remained stable and vaccine-preventable ACSC rates increased (1-41%). While disparities in rate differences in chronic ACSC rates between trajectories narrowed, in the two other ACSC subgroups they increased. Disparities in standardised rate ratios increased in vaccine-preventable and acute ACSC rates between northern cluster and the two other clusters. Compared to the south-western cluster, 13-16% of health centre areas, in rural northern cluster, had 47-92% higher ACSC rates - but also the highest level of morbidity, most limitations on activities of daily living and highest PHC inpatient ward usage as well as the lowest education levels and private health and dental care usage. CONCLUSIONS: We identified three differing trajectories of time trends for ACSC rates, suggesting that the quality of care, particularly in northern Finland health centre areas, may have lagged behind the general improvements. This calls for further investments to strengthen rural area PHC.

Refugee crisis in Finland: Challenges to safeguarding the right to health for asylum seekers.

In 2015 Finland received an unprecedented number of asylum seekers, ten times more than in any previous year. This surge took place at a time the Finnish Government was busily undergoing a wide-range health and social care reform amid growing nationalist and populist sentiments. Our aim is to explore the governance of a parallel health system for asylum seekers with a right-to-health approach. We concentrated on three right to health features most related to the governance of asylum seeker health care, namely Formal recognition of the right to health, Standards and Coordination mechanisms. Through our qualitative review, we identified three major hurdles in the governance of the system for asylum seekers: 1) Ineffectual and reactive national level coordination and stewardship; 2) Inadequate legislative and supervisory frameworks leading to ineffective governance; 3) Discrepancies between constitutional rights to health, legal entitlements to services and guidance available. This first-time large-scale implementation of the policies exposed weaknesses in the legal framework and the parallel health system. We recommend the removal of the parallel system and the integration of asylum seekers' health services to the national public health care system.

The transposition of the Patients' Rights Directive in Finland-Difficulties encountered.

The Directive on the application on patient rights' in cross-border healthcare (2011/24/EC) was transposed in Finland by the Act on Cross-Border Health Care (1201/2013), which entered into force on 1 January 2014. A new reimbursement model for cross-border health care costs was designed. The Finnish legislator considered the chosen reimbursement model to correspond both with the aims of the Directive as well as to the functioning of the national health care scheme. The European Commission, however, initiated the first infringement procedure against Finland already in January 2014. In spring 2015, the Government launched a Regional government, health and social services reform, which would fundamentally transform the organizing, production and financing of health care services in Finland. Consequently a Government bill (HE 68/2017 vp) to change the existing reimbursement model for cross-border health care costs was delivered to the Parliament on 1 June 2017. In this article, Finland's implementation process of the Directive is reviewed. Special attention is drawn to the argumentation concerning the reimbursements of cross-border health care costs. The differences of views on reimbursements can generally illustrate the conflicting objectives to expand access to cross-border health care services and to ensure financial sustainability of states thereof.

Finland: health system review

This analysis of the Finnish health system reviews developments in its organization and governance, financing, provision of services, health reforms and health system performance. Finland is a welfare state with a high standard of social and living conditions and a low poverty rate. Its health system has a highly decentralized administration, multiple funding sources, and three provision channels for statutory services in first-contact care: the municipal system, the national health insurance system, and occupational health care. The core health system is organized by the municipalities (i.e. local authorities) which are responsible for financing primary and specialized care. Health financing arrangements are fragmented, with municipalities, the health insurance system, employers and households all contributing substantial shares. The health system performs relatively well, as health services are fairly effective, but accessibility may be an issue due to long waiting times and relatively high levels of cost sharing. For over a decade, there has been broad agreement on the need to reform the Finnish health system, but reaching a feasiblepolicy consensus has been challenging.

Trends of socioeconomic equality in mortality amenable to healthcare and health policy in 1992-2013 in Finland: a population-based register study.

OBJECTIVE: To study trends in socioeconomic equality in mortality amenable to healthcare and health policy interventions. DESIGN: A population-based register study. SETTING: Nationwide data on mortality from the Causes of Death statistics for the years 1992-2013. PARTICIPANTS: All deaths of Finnish inhabitants aged 25-74. OUTCOME MEASURES: Yearly age-standardised rates of mortality amenable to healthcare interventions, alcohol-related mortality, ischaemic heart disease mortality and mortality due to all the other causes by income. Concentration index (C) was used to evaluate the magnitude and changes in income group differences. RESULTS: Significant socioeconomic inequalities favouring the better-off were observed in each mortality category among younger (25-64) and older (65-74) age groups. Inequality was highest in alcohol-related mortality, C was -0.58 (95% CI -0.62 to -0.54) among younger men in 2008 and -0.62 (-0.72 to -0.53) among younger women in 2013. Socioeconomic inequality increased significantly during the study period except for alcohol-related mortality among older women. CONCLUSIONS: The increase in socioeconomic inequality in mortality amenable to healthcare and health policy interventions between 1992 and 2013 suggests that either the means or the implementation of the health policies have been inadequate.

The role of the 2011 patients' rights in cross-border health care directive in shaping seven national health systems: Looking beyond patient mobility.

Reports on the implementation of the Directive on the application of Patients' Rights in Cross-border Healthcare indicate that it had little impact on the numbers of patients seeking care abroad. We set out to explore the effects of this directive on health systems in seven EU Member States. Key informants in Belgium, Estonia, Finland, Germany, Malta, Poland and The Netherlands filled out a structured questionnaire. Findings indicate that the impact of the directive varied between countries and was smaller in countries where a large degree of adaptation had already taken place in response to the European Court of Justice Rulings. The main reforms reported include a heightened emphasis on patient rights and the adoption of explicit benefits packages and tariffs. Countries may be facing increased pressure to treat patients within a medically justifiable time limit. The implementation of professional liability insurance, in countries where this did not previously exist, may also bring benefits for patients. Lowering of reimbursement tariffs to dissuade patients from seeking treatment abroad has been reported in Poland. The issue of discrimination against non-contracted domestic private providers in Estonia, Finland, Malta and The Netherlands remains largely unresolved. We conclude that evidence showing that patients using domestic health systems have actually benefitted from the directive remains scarce and further monitoring over a longer period of time is recommended.

Trends of relative and absolute socioeconomic equity in access to coronary revascularisations in 1995-2010 in Finland: a register study.

BACKGROUND: Resources for coronary revascularisations have increased substantially since the early 1990s in Finland. At the same time, ischaemic heart disease (IHD) mortality has decreased markedly. This study aims to examine how these changes have influenced trends in absolute and relative differences between socioeconomic groups in revascularisations and age group differences in them using IHD mortality as a proxy for need. METHODS: Hospital Discharge Register data on revascularisations among Finns aged 45-84 in 1995-2010 were individually linked to population registers to obtain socio-demographic data. We measured absolute and relative income group differences in revascularisation and IHD mortality with slope index of inequality (SII) and concentration index (C), and relative equity taking need for care into account with horizontal inequity index (HII). RESULTS: The supply of procedures doubled during the years. Socioeconomic distribution of revascularisations was in absolute and relative terms equal in 1995 (Men: SII = -12, C = -0.00; Women, SII = -30, C = -0.03), but differences favouring low-income groups emerged by 2010 (M: SII = -340, C = -0.08; W: SII = -195, C = -0.14). IHD mortality decreased markedly, but absolute and relative differences favouring the better-off existed throughout study years. Absolute differences decreased somewhat (M: SII = -760 in 1995, SII = -681 in 2010; W: SII = -318 in 1995, SII = -211 in 2010), but relative differences increased significantly (M: C = -0.14 in 1995, C = -0.26 in 2010; W: C = -0.15 in 1995, C = -0.25 in 2010). HII was greater than zero in each year indicating inequity favouring the better-off. HII increased from 0.15 to 0.18 among men and from 0.10 to 0.12 among women. We found significant and increasing age group differences in HII. CONCLUSIONS: Despite large increase in supply of revascularisations and decrease in IHD mortality, there is still marked socioeconomic inequity in revascularisations in Finland. However, since changes in absolute distributions of both supply and need for coronary care have favoured low-income groups, absolute inequity can be claimed to have decreased although it cannot be quantified numerically.

Comparative observational study of mortality amenable by health policy and care between rural and urban Finland: no excess segregation of mortality in the capital despite its increasing residential differentiation.

BACKGROUND: Large cities are often claimed to display more distinct geographical and socioeconomic health inequalities than other areas due to increasing residential differentiation. Our aim was to assess whether geographical inequalities in mortality within the capital (City of Helsinki) both exceeded that in other types of geographical areas in Finland, and whether those differences were dependent on socioeconomic inequalities. METHODS: We analysed the inequality of distribution separately for overall, ischemic heart disease and alcohol-related mortality, and mortality amenable (AM) to health care interventions in 1992-2008 in three types of geographical areas in Finland: City of Helsinki, other large cities, and small towns and rural areas. Mortality data were acquired as secondary data from the Causes of Death statistics from Statistics Finland. The assessment of changing geographical differences over time, that is geographical inequalities, was performed using Gini coefficients. As some of these differences might arise from socioeconomic factors, we assessed socioeconomic differences with concentration indices in parallel to an analysis of geographical differences. To conclude the analysis, we compared the changes over time of these inequalities between the three geographical areas. RESULTS: While mortality rates mainly decreased, alcohol-related mortality in the lowest income quintile increased. Statistically significant differences over time were found in all mortality groups, varying between geographical areas. Socioeconomic differences existed in all mortality groups and geographical areas. In the study period, geographical differences in mortality remained relatively stable but income differences increased substantially. For instance, the values of concentration indices for AM changed by 54 % in men (p < 0.027) and by 62 % in women (p < 0.016). Only slight differences existed in the time trends of Gini or in the concentration indices between the geographical areas. CONCLUSIONS: No geographical or income-related differences in the distribution of mortality existed between Helsinki and other urban or rural areas of Finland. This suggests that the effect of increasing residential differentiation in the capital may have been mitigated by the policies of positive discrimination and social mixing. One of the main reasons for the increase in health inequalities was growth of alcohol-related mortality, especially among those with the lowest incomes.