Routine register data was used in this study. As dentists' remuneration in the PDS is partly based on these data and private patients' reimbursements by the NHI are fully based on recorded treatment, data on utilisation of dental services can be considered to be comprehensive in both sectors. One limitation was that because fewer than half of the adults treated in the private sector who were entitled to reimbursements only for reimbursable treatments, the total number of patients treated in the private sector had to be estimated. In 2000, fewer than half of the adults were entitled to such reimbursements whereas in 2004, all adults were entitled to reimbursements (except those who received a prosthetic care in the private sector). However, as few adults were likely to have received prosthesis without prior clinical examination or other treatments, which were eligible for partial reimbursement, a very small number would not have been recorded in the registers in 2004. A further potential complication in our estimates was that the PDS does not separate costs for the treatment of children and those for adults.
The oral health care reform was considered politically so important that the Parliament passed the changes more rapidly than proposed by the Ministry of Social Affairs and Health which supervises the health care provision system. In a period of two years (2001 to 2002) 2.1 million adults (40.9% of the population), who had previously not been eligible, became eligible for Public Dental Services or subsidised private care. During the four years covered in this study, there was little guidance for the PDS on how to proceed with the implementation of the reform. According to the chief dentists in the PDS, the main priorities were recruiting new dentists and hygienists and delegating to dental hygienists tasks previously done mainly by dentists [17
]. However, the PDS had difficult recruiting dentists because in Finland the dental student intake was reduced in 1994 and two of the four undergraduate dental schools had been closed down. This and the large numbers of dentists reaching retirement age meant that the number of practising dentists has decreased in recent years. Furthermore, in the private sector the managers of larger dental companies complained of recruitment difficulties [11
]. Although one dental school was reopened in 2000 and some recruitment has taken place from other European Union countries, there were many unfilled vacancies for dentists during the study period.
This study shows that there was a small increase in the supply of oral care services between 2000 and 2004. However, the mean number of patients seen in one year by a dentist in the PDS decreased from 863 to 840. On the other hand, the numbers of dental hygienists increased and they provided a greater proportion of children's treatments in the PDS than before [18
]. In the private sector, the total number of patients remained at the same level as before the reform, but as the number of dentists decreased, the mean number of patients per year seen by a dentist increased from 480 (2000) to 525 (2004). The mean number of clinical working hours was similar in both the PDS and the private sector at about 30 hours per week in the PDS and about 28 hours per week in the private sector [19
]. In Finland almost 70% of the dentists are women, which together with the freedom to set fees at any level in the private sector may in part explain the relatively low output in this care sector.
The chief dentists in the PDS complained that their dental staff did not support the speed of the reform. In particular, the changes required in work routines were often opposed locally [17
]. There was no formal guidance for the private sector, which to a great extent continued to work as before. In the study period, in commercial terms, the inflation-adjusted growth of the private dental care industry revenue was high, and there was therefore no need to make any changes in marketing or pricing in spite of the fact that it now had to compete with the public sector [11
A special survey conducted on treatments provided in the PDS in 2003 showed that a third of the adult patients had made emergency visits to a dentist [21
]. This may have been because Parliamentary Ombudsman had taken a stand during the initial reform implementation and stated that emergency services were to be given maximum priority in the PDS in situations where it was not possible to offer care to all patients who sought care and treatment. Apart from this, in the initial phase of the reform, little change occurred in treatment provided by the PDS [18
] or in the private sector [22
The reform considerably increased the total running costs of oral health care. However, it should be noted that reducing costs and increasing efficiency were not primary goals of the reform. In 2004, the public sector saw 842 947 children and 964 214 adults (inclusive of the special needs groups) at a lower cost than the private sector which saw just over one million adults. The traditional distribution of the patients (i.e
. the public sector catering for children, younger adults and special needs groups and the private sector for well-off middle-aged or older adults [2
]), probably in part explains the differences in costs between the two sectors as the middle aged and older adults were more likely to receive treatment involving costs of crowns, bridges and dentures made at laboratories as well as clinical work. Overall, our study indicates that oral health care in the public sector (PDS) was less expensive than in the private sector.
The average rise in prices in the private sector between 2000 and 2004 was about 20% and the total NHI support for basic care provided by the private sector rose by 26% [5
]. Thus, in practice, part of the cost of reimbursing private care and treatment was due to higher prices.
In most OECD countries, considerable inequities exist in general health care [23
]. The Finnish oral health care reform aimed to reduce inequity and increase the fairness of the care provision system. The initial results showed some progress towards these goals. To speed up the reform process, in 2005, after the present study, the government introduced legislation to guarantee care in the PDS within "a reasonable period of time" but there have been no attempts to encourage the private sector to do more.