Pharmacy Practice and Education in Finland

The Pharmacy Education in Europe (PHARMINE) project studies pharmacy practice and education in the European Union (EU) member states. The work was carried out using an electronic survey sent to chosen pharmacy representatives. The surveys of the individual member states are now being published as reference documents for students and staff interested in research on pharmacy education in the EU, and in mobility. This paper presents the results of the PHARMINE survey on pharmacy practice and education in Finland. Pharmacies have a monopoly on the dispensation of medicines. They can also provide diagnostic services. Proviisori act as pharmacy owners and managers. They follow a five-year (M.Sc. Pharm.) degree course with a six-month traineeship. Farmaseutti, who follow a three-year (B.Sc. Pharm.) degree course (also with a six-month traineeship), can dispense medicines and counsel patients in Finland. The B.Sc. and the first three years of the M.Sc. involve the same course. The current pharmacy curriculum (revised in 2014) is based on five strands: (1) pharmacy as a multidisciplinary science with numerous opportunities in the working life, (2) basics of pharmaceutical sciences, (3) patient and medication, (4) optional studies and selected study paths, and (5) drug development and use. The learning outcomes of the pharmacy graduates include (1) basics of natural sciences: chemistry, physics, technology, biosciences required for all the students (B.Sc. and M.Sc.), (2) medicine and medication: compounding of medicines, holism of medication, pharmacology and biopharmaceutics (side-effects and interactions), patient counseling, efficacy and safety of medicines and medication, (3) comprehensive and supportive interactions of the various disciplines of pharmacy education and research: the role and significance of pharmacy as a discipline in society, the necessary skills and knowledge in scientific thinking and pharmaceutical research, and (4) basics of economics and management, multidisciplinarity, hospital pharmacy, scientific writing skills, management skills. In addition, teaching and learning of “general skills”, such as the pharmacist’s professional identity and the role in society as a part of the healthcare system, critical and creative thinking, problem-solving skills, personal learning skills and life-long learning, attitude and sense of responsibility, and communication skills are developed in direct association with subject-specific courses. Professional specialization studies in industrial pharmacy, and community and hospital pharmacy are given at the post-graduate level at the University of Helsinki.


Introduction
The Pharmacy Education in Europe (PHARMINE) consortium surveyed pharmacy practice and education in the member states of the European Union (EU), including Finland, between 2008 and In 2015, the total healthcare expenditure in Finland was €19.8 billion, with an annual growth of 1.2%. This means 9.4% of gross domestic product. Specialized medical care costs were €6.9 billion and basic medical care costs were €3.7 billion. Drug costs and medical supplies were €2.5 billion (+4.0% compared to 2014). Public funding covered 74.6% (−1% compared to 2014) and private funding covered 25.4% of healthcare costs in Finland in 2016 [5]. Pharmaceutical care is an integral part of social and healthcare. The Ministry of Social Affairs and Health is responsible for the development of pharmaceutical care and preparing legislation concerning pharmaceuticals. The aim is to have an efficient, safe, appropriate, and cost-effective system of medical treatment available to all who need it. The proper availability and professionally competent distribution of pharmaceuticals is safeguarded at all times.

Design
Information was obtained from academics and practicising pharmcists (the authors) and from internet sources (university websites) on the following: • pharmacy: practice (community, hospital, and industrial); legislation; education and training; • harmonization with the EU sectoral directive on pharmacy [2] and with the Bologna recommendations [6].
Electronic survey methodology was used; data were collected in 2010 and revised in 2017-2018. Sampling was performed by sending the survey to all pharmacy departments, pharmacy orders and chambers, associations of industrial, hospital, and other specialization pharmacists, and associations of pharmacy students. Collection of data in any specific country took between six and 12 months. Data collection was performed electronically using standard survey platforms. We attempted at all times to collect objective, if possible, numerical data.
The information is presented in the form of tables in order to facilitate legibility. This presentation was developed in association with the Pharmacy journal editorial board; it is based on the organization of the PHARMINE survey [1], and was described in detail in a previous publication [7]. This format will ease the comparison of different EU countries by students and staff envisaging exchange programs, and by researchers in pharmacy education and practice.

Evaluation and Assessment
In order to follow the terminology of Finnish pharmacy degrees, three major personnel categories can be separated from each other as follows: Pharmacy personnel in Finland M.Sc. Pharm. (Proviisori) = Pharmacists who dispense medicine and counsel patients; the degree is a requirement for pharmacy owners and managers-a five-year university education.
B.Sc. Pharm. (Farmaseutti) = Pharmacists who dispense medicine and counsel patients in pharmacies but cannot own a pharmacy or be a head manager in a pharmacy-a three-year university education.
Pharmacy technician (Lääketeknikko) = Supporting personnel in pharmacies taking care of medicine storage, logistics, invoicing, and cash services-a 2-3-year upper secondary vocational education. Table 1 provides details of the numbers and activities of community pharmacists and pharmacies in Finland. Items are expounded in the "comments" column.

Competences and roles of community pharmacists
Pharmacists work as the following: • dispensing staff members • pharmacy owners, managers, • specialist pharmacists (after professional post-gradute studies).
Competences include administrative issues, customer service, medication review, marketing, education of pharmacy staff, and multidisciplinary co-operation with other healthcare professionals.
Pharmacists provide services to help patients monitor the therapeutic control of blood sugar or blood pressure.

Ownership limited to pharmacists? Yes
A license to own a pharmacy is granted to a person having a 5-year degree in pharmacy with a 6-month traineeship (M.Sc. Pharm.).
Are there rules governing the geographical distribution of community pharmacies? [8] Yes The location of community pharmacies is based on the decision made by the Finnish Medicine's Agency (FIMEA) (https://www.fimea.fi/web/en). FIMEA evaluates if there is a need for one (or multiple) community pharmacies in some particular area and specifies also the area where the pharmacy or pharmacies should be located. Within that specific area, pharmacies are free to choose their exact location. This system assures equal accessibility to medicines and pharmacy services for the whole population.
Are drugs and healthcare products available to the general public by other channels?

No
In Finland, medicines are sold to the public only from pharmacies, with the exception that nicotine replacement therapy (NRT) products may also be available in grocery shops. However, many pharmacies offer internet shop alternatives for healthcare products and over-the-counter drugs. Veterinary drugs are also available from veterinarians.
Using the data in Reference [1] and Table 2, it can be calculated that, compared to the EU linear regression estimation (for definition and calculation, see Reference [1]), the ratio of the number of community pharmacists in Finland to the population compared to the linear regression estimation = 0.40. Thus, the number of pharmacists per population is lower than the EU norm. The same comparison for community pharmacies produces a ratio of 0.5, lower than the EU norm. This may reflect the separate activities of pharmacists compared to other healthcare professionals.
The activities and occupations of pharmacists in Finland are similar to those of community pharmacists in other EU member states [1]. Table 2 provides details of the numbers and activities of persons other than pharmacists working in pharmacies in Finland.
Finland is one of the rare if not the only country in the EU which follows the Bologna principles to the letter. Thus, there are separate three-(B.Sc. Pharm.) and five-year (M.Sc. Pharm.) degrees each with a job profile following graduation. This topic is discussed in detail later. Competences and roles Pharmacy technicians: Their main task is to take care of medicine storage and logistics in the community pharmacy. They also take care, for example, of invoicing and operating of pharmacy IT systems. Table 3 provides the numbers and activities of hospital pharmacists in Finland.

Competences and roles of hospital pharmacists
In most hospitals, the hospital pharmacy or the medicine center is one of the medical service departments. The manager of a hospital pharmacy is required to have an M.Sc. in pharmacy, while the manager of a medicine centre is required to have an M.Sc. or B.Sc. in pharmacy. A manager of a hospital pharmacy or a dispensary is usually authorized by the medical director of the hospital. B.Sc. and M.Sc. hospital pharmacists used to have a logistic role in hospitals and healthcare centers. The role is now starting to change, and some pharmacists are working in the wards. A professional post-graduate specialization program for hospital pharmacists started in 2010 to ensure stronger competencies for the hospital pharmacists to work as clinical specialists (see more details of the specialized education in Table 7).
The number of pharmacists working in hospitals is lower than the EU average. The ratio of the actual number compared to the linear regression estimation is 1.94, (for definition and calculation, see Reference [1]). The duties of hospital pharmacists are similar to those elsewhere in the EU [1].
Turning to pharmacists in industry and in other sectors, Table 4 provides such information on these sectors in Finland. Teaching, research, administration, management, and leadership Varying roles and competencies: specialist pharmacists (pharmacists specialized in some specific issues, for example, marketing authorizations, pricing and re-imbursement of medical products, IT-issues such as e-prescriptions and databases, medicine information), researchers, managers Table 5 provides information on professional associations for pharmacists in terms of number, territorial distribution, and ethical and professional attributes in Finland.

Item
Reply Comments

Registration of pharmacists
Yes.
There are circa 2000 registered pharmacists in Finland.
Issued by Valvira (National supervisory authority for Welfare and Health) [11].
Creation of community pharmacies and control of territorial distribution Yes Issued by Finnish Medicines Agency (FIMEA) [8]. From the FIMEA website: Under Section 40 of the Medicines Act, the operation of a pharmacy business requires a licence (pharmacy licence) issued by FIMEA.
The conditions under which a pharmacy licence may be granted according to the Section 43 of the Medicines Act are as follows: "A pharmacy licence may be granted to citizen of a European Economic Area state who is a certified Master of Pharmacy and who has not been declared bankrupt or legally incompetent or who has not been assigned a person to supervise his or her interests. If there is more than one applicant, a pharmacy licence is granted to the applicant who can be considered to have the overall best potential for operating a pharmacy business. In assessing the potential, the applicant's work in pharmacies and other pharmaceutical services and studies, managerial skills, and other activities pertinent to operating a pharmacy business must be taken into account." Ethical considerations and role of pharmacists in healthcare

Yes
There is an advisory board on ethical issues in pharmacies based on the co-operation between Pharmacy Owners' Association (AFP [12]) and Finnish Pharmacists' Association (SFL [13]). Additionally, there exists a national ethical code of conduct produced by abovementioned organizations. In order to strengthen the role of community pharmacies in healthcare and to support the professional development, the Association of Finnish Pharmacists established a national strategy in 1997 that concerned pharmacy services and pharmacy role in healthcare. This strategy highlighted the importance of medication counseling in community pharmacies: whenever medicines are dispensed, information should also be provided. National long-term programs focusing on chronic diseases (asthma, diabetes, and heart diseases) were organized to encourage local co-operation between pharmacies and other healthcare professionals and to develop the competency and counseling skills of pharmacy staff.
Quality assurance and validation of higher-education institution (HEI) courses for pharmacists

No
The universities providing pharmacy education have their own quality handbooks and quality assurance procedures.
In the University of Helsinki, for example, feedback is collected from students and internal and external/international audits are made regularly. Table 6 provides detailed numbers and activities of pharmacy higher-education institutions (HEIs), staff, and students in Finland.  A comparison to the EU average for staff shows that Finland has a high ratio 2.1 [1], and the number of pharmacy HEIs is also high compared to the EU norm at 1.5. Concerning teaching, it is interesting to note that Finnish pharmacy HEIs offer an implemented Bologna style B.Sc. Pharm. degree. Table 7 below contains details of specialization electives. What are the student numbers in each specialization?

20
In both specialization programs, the yearly intake of Bachelors and Masters is altogether 20.
Post-graduate specialized education is offered in industrial pharmacy and in community and hospital pharmacy. Table 8 provides details of past and present changes in pharmacy education and training in Finland.  Table 9 represents teaching and learning methods in student hours.

Teaching and Learning Methods-Student Hours
The first year is devoted mainly to lectures and the second and third years are devoted to traineeship.

Subject Areas
Table 10 provides details of subject area (for definitions of the subject areas, see Reference [1]).  ), the students take 50 ECTS general studies (of which 20 ECTS are elective) and 70 ECTS major studies. The number of hours spent in every subject area in major studies varies from student to student. Due to this, it is difficult to give an average number of hours. The 30 ECTS of general, compulsory studies for every M.Sc. degree student include highly integrated studies in chemical, biological, medical, and societal sciences, together with pharmaceutical technology, pharmacoeconomics, and statistics. Due to the integrated nature of the studies, detailed information about the hours is not available. Therefore, only a sum of the hours of lectures, assignments, and group works is reported here. # Total hours by subject area are calculated for the years 1-3, the total hours include also the general, compulsory studies (30 ECTS) of fourth year. The percentage values are not informative and, therefore, are not reported here. The studies cover chemical, biological, and medical sciences, together with pharmaceutical technology, quite evenly throughout the first two years, with the emphasis on medical sciences in the first year. The third year is devoted mainly to generic substances together with traineeship. All the subject areas are covered in the studies of the fourth year in a highly integrated manner.
The hours calculated in every column represent the time scheduled for lectures, assignments, and group works. The time a student takes for individual work is not calculated here. Students also have to take 20 ETCS of elective studies for B.Sc. These hours were not calculated here, as the hours spent vary for each student and may even be on non-pharmaceutical subjects. Figure 1 shows a graphical representation of the above.
The third year is devoted mainly to generic substances together with traineeship. All the subject areas are covered in the studies of the fourth year in a highly integrated manner.
The hours calculated in every column represent the time scheduled for lectures, assignments, and group works. The time a student takes for individual work is not calculated here. Students also have to take 20 ETCS of elective studies for B.Sc. These hours were not calculated here, as the hours spent vary for each student and may even be on non-pharmaceutical subjects. Figure 1 shows a graphical representation of the above. Year 1 is devoted mainly to chemical and medical sciences, year 2 is devoted to generic subjects and pharmaceutical technology, year 3 is devoted to generic subjects and medical sciences, and year 4 is devoted to chemical sciences and pharmaceutical technology. It can be seen that the MEDISCI/CHEMSCI ratio in the master program (year 4 and 5) is 2.83, thus reflecting the importance of medicinal science subjects. The overall ratio of MEDISCI/CHEMSCI (years 1-5) is 0.73. In the EU, some HEIs such as Spain have a "balanced" course with a medicinal sciences/chemical sciences index of 1.2. Others have more "medical" courses, such as Ireland and the Netherlands, with indices of 2.6 and 1.6, respectively [1].

Impact of the Bologna Principles [3]
Table 11 provides details the various ways in which the Bologna declaration impacts on the pharmacy HEIs of Finland.  Year 1 is devoted mainly to chemical and medical sciences, year 2 is devoted to generic subjects and pharmaceutical technology, year 3 is devoted to generic subjects and medical sciences, and year 4 is devoted to chemical sciences and pharmaceutical technology. It can be seen that the MEDISCI/CHEMSCI ratio in the master program (year 4 and 5) is 2.83, thus reflecting the importance of medicinal science subjects. The overall ratio of MEDISCI/CHEMSCI (years 1-5) is 0.73. In the EU, some HEIs such as Spain have a "balanced" course with a medicinal sciences/chemical sciences index of 1.2. Others have more "medical" courses, such as Ireland and the Netherlands, with indices of 2.6 and 1.6, respectively [1].

Impact of the Bologna Principles [3]
Table 11 provides details the various ways in which the Bologna declaration impacts on the pharmacy HEIs of Finland. Finland adopted the Bologna system with a two-tier degree system, the use of ECTS, etc. The number of Erasmus and other exchange students increased steadily over the past 5-10 years.

Impact of European Union (EU) Directive 2013/55/EC [2]
Table 12 provides details on the various ways in which the EC directive impacts on pharmacy education and training in Finland.
Finland conforms to the different aspects of the EU directive with a five-year degree and a six-month traineeship. Suitable balance between theoretical studies and practical excercises is to be found in order to reach the curriculum objects and learning outcomes of the B.Sc. and M.Sc. degrees. Both Bachelor and Master students perform the six-month traineeship. At least three months have to be spent in a community pharmacy and the remaining three months can be spent in a community or hospital pharmacy. The first three months of traineeship are performed in the second study year and the second three months are performed during the third year.
"The balance between theoretical and practical training shall, in respect of each subject, give sufficient importance to theory to maintain the university character of the training" This point was object of intensive discussion during the degree reform according to Bologna. From the university point of view, we need to place emphasis on the theoretical knowledge in order to prepare the students for further studies (Ph.D.).

Discussion and Conclusions
We developed pharmacy education in Finland based on teacher and student feedback, and also based on the field-specific feedback from societal stakeholders including community pharmacists, hospital pharmacists, industrial pharmacists, and drug authority experts, and also according to the recommendations and suggestions of the EAFP (European Association of Faculties in Pharmacy)-based PHARMINE and PHAR-QA projects. One main point (but not the only point) is the close correspondence of the Finnish system to the spirit of the essential points of the original Sorbonne 1998 declaration [3], as follows: • University education will have a first-cycle degree (undergraduate, three years) with "international recognition of the first cycle degree as an appropriate level . . . ", providing the qualifications needed for immediate employment. the above will be followed with a Master degree (M.Sc., two years), and eventually a Ph.D. degree (four years) • Qualifications in both cycles can be obtained in several EU countries; in an "extreme" case (going beyond the typical case of a semester spent abroad), a foreign B.Sc. could be accepted as a requirement for acceptance into the Finnish M.Sc. program.
The main conclusions/implications to be drawn from this survey of pharmacy education and training in Finland are that it follows EU directives and additionally provides a description of the two-tier Sorbonne/Bologna B.Sc./M.Sc. model.
Possible biases in our study could involve flaws in the representativity of the survey methodology. However, given that Finland is a relatively small EU country with but three pharmacy departments (Helsinki, Kuopio, Turku), we estimate that such biases are of little importance.