Vouchers in social and health care - follow up 2

• Abstract
• Characteristics of this policy
• Purpose and process analysis
• Expected outcome
• References

Abstract

Since the beginning of 2004 legislation has provided a legal framework for the use of service vouchers in certain municipal social and health services. Despite this their use has been modest. In March 2009 the government passed a bill to the parliament on service vouchers. It proposes that the option to offer service vouchers would be extended to all municipal health and social services. It also proposed that national definitions for maximum user fees would not be applied to service vouchers.

Neue Entwicklungen

Since the beginning of 2004 legislation has provided a legal framework for the use of service vouchers in municipal social sector home care services (see HPM 3/2004). In the beginning of 2008 the option to use service vouchers was broadened to home nursing in health services (see HPM 10/2007). However, the introduction of service vouchers has progressed at a rather slow pace.

In May 2006 the Ministry of Social Affairs and Health set up a working group to explore the possibilities to further broaden the use of vouchers in social and health services (See HPM 10/2007). This was based on the government programme (HPM 10/2007) which states that the use of municipal service vouchers will be extended as appropriate. The report of the working group was completed in June 2008. The working group proposed that the option to offer service vouchers would be extended to all municipal health and social services. It also suggested that national definitions for maximum user fees would not be applied to service vouchers, instead the municipality is free to set the amount of service voucher and provider is free to set the price of service. The amount of a voucher could be fixed or depend on the income of the recipient. The municipality would still be obliged to provide services itself in cases when a person does not want to use a service voucher.

The municipality would still independently decide if it will offer service vouchers, and for what services. The municipality could also decide which providers are included in the system. Municipalities must provide information on accepted providers to the patients.

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

The service voucher system is a rather innovative reform because traditionally municipalities have produced most welfare services themselves. The most fundamental aspects of the proposal are that user-fee restrictions are not applied to service vouchers and that patients would have considerable freedom of choice of provider.

Previous reforms concering service vouchers have applied only to a very limited group of services (home care and home nursing). This reform would give municipalities the option to use service vouchers in the majority of health services, which in the long run may have a rather fundamental systemic impact. The most controversial issue regarding this reform is that definitions for maximum user fees would not be applied to service vouchers.

Purpose and process analysis

Current Process Stages

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

Initiators of idea/main actors

• Regierung

• Kostenträger

• Patienten, Verbraucher

• Privatwirtschaft, privater Sektor

• Politische Parteien

Stakeholder positions

The working group included representatives from the Ministry of Social Affairs and Health, the Ministry of Finance, the Ministry of Employment and the Economy, the Social Insurance Institution, the Association of Finnish Local and Regional Authorities, the Finnish Innovation Fund (SITRA), the Association Physician Service Companies, Federation of Finnish Enterprises, Association of Social Services Employers and Businesses, and the City of Harjavalta. Interestingly some rather important stakeholders were not included in the working group, such as patient organisations, the National Research and Development Centre for Welfare and Health, and professional associations.

Most prominent supporters of the reform are private providers, right-wing political parties (forming the current government) and the Finnish Medical Association. Left-wing political parties oppose the reform. Supporters argue that service vouchers would increase patient choice, increase competition, promote innovativeness in service delivery, influence positively on employment, support private service providers (especial small enterprises) and decrease waiting-times. Supporters argue also that the reform would decrease user-fees as patients could have municipal reimbursement for the use of private services.

Opponents argue that the reform would increase inequality as patients could have higher quality services and faster access to municipality funded services when paying higher user-fees. Opponents also argue that the reform would harm public provision, as resources for service vouchers would be taken from public service production. This would be especially problematic when combined with economic recession. Additionally, some groups would not have sufficient capabilities to make choices and act as active consumers of social and health services. In rural areas there is few or none private providers, so the users of service vouchers would have to travel far.

Actors and positions

Regierung
the Government	sehr unterstützend		stark dagegen
The Ministry of Social Affairs and Health	sehr unterstützend		stark dagegen
Kostenträger
Municipalities	sehr unterstützend		stark dagegen
Patienten, Verbraucher
Service users	sehr unterstützend		stark dagegen
Privatwirtschaft, privater Sektor
Private service providers	sehr unterstützend		stark dagegen
Politische Parteien
Rigth-wing parties	sehr unterstützend		stark dagegen
Left-wing parties	sehr unterstützend		stark dagegen
current    previous

Influences in policy making and legislation

In March 2009 the Government passed a bill to the parliament on service vouchers. The content of the bill was similar to recommendations made by the working group. Additionally the bill states that the user-fees of service vouchers would not be counted in the annual user-fee ceiling of municipal health services (590 Euro). The parliament's decision on the bill is expected in June 2009. It is rather probable that parliament will accept the bill as proposed by the government.

Legislative outcome

n/a

Actors and influence

Regierung
the Government	sehr groß		kein
The Ministry of Social Affairs and Health	sehr groß		kein
Kostenträger
Municipalities	sehr groß		kein
Patienten, Verbraucher
Service users	sehr groß		kein
Privatwirtschaft, privater Sektor
Private service providers	sehr groß		kein
Politische Parteien
Rigth-wing parties	sehr groß		kein
Left-wing parties	sehr groß		kein
current    previous

Positions and Influences at a glance

Adoption and implementation

So far the introduction of service vouchers has progressed at a rather slow pace. After the bill is enacted the municipalities have a very central role in the implementation, as the law would give only the option to use service vouchers. Municipalities must then consider for which services vouchers could be used and to which extent.

Monitoring and evaluation

Neither the working group report nor the bill define any mechanism for monitoring or evaluation.

Expected outcome

The outcome will depend greatly on how the reform is implemented by the municipalities. The reform would certainly increase the use of private services and patient choice. At this point it is difficult to estimate the impact of the reform on equity, efficiency and quality of services. At least in the beginning extra costs would arise from new administrative tasks. There is danger that the reform would increase inequities in access to services between socio-economic groups.

Impact of this policy

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

 

References

Sources of Information

Raija Volk and Tuula Laukkanen. The use of service vouchers in municipalities in Finland. Reports of the Ministry of Social Affairs and Health 2007:38. www.stm.fi/Resource.phx/publishing/documents/11722/summary_en.htx. 

Reform formerly reported in

Vouchers in social and health care Process Stages: Umsetzung, Gesetzgebung

Vouchers in social and health care - follow up Process Stages: Evaluation, Gesetzgebung

Author/s and/or contributors to this survey

Vuorenkoski, Lauri

 

Empfohlene Zitierweise für diesen Online-Artikel:

Vuorenkoski, Lauri. "Vouchers in social and health care - follow up 2". Health Policy Monitor, April 2009. Available at http://www.hpm.org/survey/fi/a13/1