Raising user fees in public sector health services

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: G-politik in Industrieländern 12

Abstract

A government decree defines maximum user fees for the municipal health services in Finland. User fees have covered on average 8 % of the expenses of primary health care services, 4 % of specialised health care services and 20 % of oral health care services. In 2008, the government decided to raise maximum user fees on average by 17 % (in dental care on average 28 %) to adjust for inflation. Maximum user fees had been raised previously in 2002.

Purpose of health policy or idea

In Finland municipalities have the organizational responsibility for public sector health services. A government decree defines the maximum user fees for these services. The great majority of the municipalities has set the user fees to the allowed maximum, although they would be free to set lower user fees if they wanted to. In 2006 user fees covered on average 8 % of the expenses of primary health care services, 4 % of specialised health care services and 20% of oral health care services. User-fees in municipal health services have been rather high in Finland compared to many other European countries.

Previously, the maximum user fees had been raised in 2002 for the last time. In 2008 the government decided to raise them again to adjust for inflation. The decision came into effect in August 2008. Maximum user fees were raised on average by 17 %, in dental care on average by 28 %. The new maximum user fee for a physician visit in primary health care is 12.80 euros (can be charged for a maximum of three appointments per calendar year), for a visit to a hospital outpatient department 25.60 euros and for inpatient hospital care 30.30 euros per day. User charges have an annual ceiling of 590 euros, after which clients receive services free of charge. The majority of the municipalities have already raised the user fees to this new maximum in September 2008.

Concurrently with the raise the state decreased state subsidies which municipalities get for organizing health services by the same amount so that municipalities did not get any financial benefit from the raise. The parliament also concurrently reformed the act on user fees in municipal social and health services so that in future maximum user fees are raised automatically every two years to reflect the changes in actual cost levels.

Main points

Main objectives

The stated objective of the raise of user fees was to correct user fees to adjust for inflation and to secure funding, provision and quality of municipal health services. Additionally, the objective was to decrease the differences in user fees between municipal dental care and private dental care (which are partly reimbursemed by National Health Insurance).

Type of incentives

To decrease proportion of public expenditure on health care services.

Groups affected

Patients

Innovationsgrad	traditionell		innovativ
Kontroversität	unumstritten		kontrovers
Strukturelle Wirkung	marginal		fundamental
Medienpräsenz	sehr gering		sehr hoch
Übertragbarkeit	sehr systemabhängig		systemneutral

The raise of user fees itself is not very novel as user fees have been raised several times previously. A novel innovation, however, is the regular two year interval raise of user fees in future. The raise of user-fees has been a politically controversial issue and it has been debated by the public rather extensively.

Political and economic background

A new government came in to office in April 2007. Compared to the previous government, the most notable change was the move of the Finnish Social Democratic Party from government to opposition and the move of the National Coalition Party from opposition to government. As a consequence the new government is more of a right-wing government than the previous had been.

Change of government

April 2007

Purpose and process analysis

Current Process Stages

	Idee	Pilotprojekt	Strategiepapier	Gesetzgebung	Umsetzung	Evaluation	Veränderung/Richtungswechsel
Implemented in this survey?

Origins of health policy idea

The idea to raise user fees was brought up in the programme of the current government (a plan of action agreed upon by the political parties forming the government and defining the main tasks facing the incoming administration). It stated among other things that the user-fees of municipal social and health care services will be revised to adjust for inflation (see HPM 10/2007). Previously user fees were raised in 2002 for the last time.

Initiators of idea/main actors

• Leistungserbringer

• Patienten, Verbraucher

• Politische Parteien

Approach of idea

The approach of the idea is described as:
renewed: User fees have been raised several times previsouly, last in 2002

Stakeholder positions

Left wing political parties in the opposition strongly opposed the raise of maximum user fees. They argued that it would create an even higher barrier to access to health services for low-income people. In addition, several patient organisations opposed the raise. Right-wing politicians argued that the raise is still rather modest and that it will just raise the user fees to the same level as in 2002 (in real prices).

This political division is supposedly similar in municipalities which make the final decisions on user fees.

Actors and positions

Leistungserbringer
Municipalities	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Patient organisations	sehr unterstützend		stark dagegen
Politische Parteien
Right wing political parties	sehr unterstützend		stark dagegen
Left wing political parties	sehr unterstützend		stark dagegen

Influences in policy making and legislation

Parliament accepted the legislation change as proposed by the government (the introduction of a regular raise of user fees in the future). The decree defining the actual maximum user fees is a government decision; parliament has very limited possibilities to influence it. Therefore the right wing political parties forming the government strongly led the raise of user fees.

Legislative outcome

success

Actors and influence

Leistungserbringer
Municipalities	sehr groß		kein
Patienten, Verbraucher
Patient organisations	sehr groß		kein
Politische Parteien
Right wing political parties	sehr groß		kein
Left wing political parties	sehr groß		kein

Positions and Influences at a glance

Adoption and implementation

Municipalities have the leading role in the implementation. The majority of the municipalities have decided to raise the user fees to the new maximum level. One incentive for municipalities to raise user fees is the fact that state subsidies for municipalities to organise health services are decreased by the corresponding amount. If municipalities would keep the user fees at the earlier level, they would have to actually increase their own level of funding.

Monitoring and evaluation

There is no mechanism in place to monitor the impact of the raise of user fees.

Review mechanisms

keine Angaben

Expected outcome

The reform will have a negative impact on socio-economic differences in access to services, which even currently are rather significant in Finland. Raising user fees in the municipal health care system will especially have an influence on low-income people as more affluent use occupational health services (free of charge) or private health services. As state subsidies for municipalities are decreased correspondingly, it is not clear how the reform will increase the quality or access to services (which was one objective of the reform).

Impact of this policy

Qualität	kaum Einfluss		starker Einfluss
Gerechtigkeit	System weniger gerecht		System gerechter
Kosteneffizienz	sehr gering		sehr hoch

The impact of the raise on health services is rather modest, but it will have a negative impact on access to services for low-income people, especially access to dental services.

References

Author/s and/or contributors to this survey

Vuorenkoski, Lauri

Empfohlene Zitierweise für diesen Online-Artikel:

Vuorenkoski, Lauri. "Raising user fees in public sector health services". Health Policy Monitor, October 2008. Available at http://www.hpm.org/survey/fi/a12/4