Changes in the governance structures after the health system reform in Finland

Abstract Introduction A major structural reform reorganized both the administrative and financial structures of the public health and social service system in Finland as of 2023. Governance is one of the key health system functions and the purpose of this study was to describe changes in the governance structures after the initial phase of the reform. Methods The data was collected using semi-structured interviews conducted at two different time points in 2023-2024. Interviewees included the directors of the new wellbeing services counties and chairpersons of county boards (n = 38), as well as representatives of the key ministries (n = 8). Inductive thematic analysis was used to analyse the data. Findings The structural reform has meant a large change in the overall governance of the system. As a result of the reform, power balances and roles between and within different governance levels changed. Also, competition between national policy goals emerged especially in relation to financial and health and social policy goals. The wellbeing services counties also experienced limited ability to exercise self-governance which challenges their role as self-governing entities. Our analysis reveals that governance structures were still evolving two years post-reform, with numerous challenges emerging. These challenges suggest that not all aspects of governance were adequately prepared or addressed prior to the reform's implementation and some of the challenges occurred because of the changes in the contextual factors. Conclusions Our findings emphasize the need to pay closer attention to governance when health system reforms are designed and implemented. In the context of vast scale reforms governance model must be continuously evaluated, developed, and improved even after the initial implementation phase. It is also important to have policy capacity and willingness to adapt the implementation and the reformed structure to the potential changes in the circumstances.