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Vouchers in social and health care - follow up

Country: 
Finland
Partner Institute: 
National Institute for Health and Welfare (THL), Helsinki
Survey no: 
(10)2007
Author(s): 
Lauri Vuorenkoski
Health Policy Issues: 
Role Private Sector, Long term care, Remuneration / Payment
Reform formerly reported in: 
Vouchers in social and health care
Current Process Stages
Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes no yes no
Featured in half-yearly report: Health Policy Developments 10

Abstract

Since the beginning of 2004 a new law has provided a legal framework for the use of vouchers in municipal social and health services, especially in home care services. However, the introduction of service vouchers has progressed at a rather slow pace. New legislation enacted in September 2007 broadens the use of service vouchers to home nursing. In addition, recently the Ministry of Social Affairs and Health set up a working group to examine the further expansion of the use of service vouchers.

Recent developments

Since the beginning of 2004 a new law has provided a legal framework for the use of vouchers in municipal social and health services. Particularly, the new legislation encourages the use of vouchers in home care services (social services). Municipalities are still not obliged by law to provide services vouchers and clients must be given choice to get the same services directly from the municipality if they wish so. Service providers must be approved by the municipality before hand. When using vouchers in home care services user-fees can exceed user-fees in similar services provided by the municipality (in other services this is not possible).

In the beginning of 2007 about 25 % of municipalities organised some municipal social and health services by offering clients a service voucher. The services provided most often included home help and cleaning services and services in support of informal care given by relatives. In 2006, the municipal authorities granted service vouchers to more than 4 000 clients. The majority of the service providers used are very small private companies.

Current legislation provides the possibility to use service vouchers also in other social and health care services, but this has been rare. One example is the city of Helsinki which started in 2007 to give service vouchers to some patients needing dental care. This was done because Helsinki has had significant difficulties in recruiting enough dentists and subsequently had very long queues in dental care. With these vouchers patient can go to a private dentist and pay the same user-fee as in the municipal health centre.

The new legislative reform enacted in September 2007 facilitates the use of service vouchers in home nursing (medical care). In addition, recently the Ministry of Social Affairs and Health set up a working group to examine further expansion of the use of service vouchers.

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Characteristics of this policy

Degree of Innovation traditional rather innovative innovative
Degree of Controversy consensual rather consensual highly controversial
Structural or Systemic Impact marginal rather marginal fundamental
Public Visibility very low low very high
Transferability strongly system-dependent neutral system-neutral
current current   previous previous

The service voucher system is a rather innovative reform because traditionally municipalities have produced most welfare services themselves. The voucher system has not been debated much in the media recently.

Purpose and process analysis

Current Process Stages

Idea Pilot Policy Paper Legislation Implementation Evaluation Change
Implemented in this survey? no no no yes no yes no

Initiators of idea/main actors

  • Government
  • Payers
  • Patients, Consumers
  • Private Sector or Industry

Stakeholder positions

The current government (appointed in April 2007) strongly supports expanding the use of service vouchers in municipal services. The government programme (HPM 10/2007) endorses private service production in several ways. According to the programme the government promotes partnerships between the public, private and third sector in the provision of services. The adoption of the purchaser-provider model in municipal services is also encouraged. Additionally, the programme specifically states that the use of municipal service vouchers will be extended as appropriate and that service vouchers will be accepted in home nursing from the beginning of 2008. Service vouchers were mentioned also in the government programme of the previous government.

Municipalities have somewhat differing views on the introduction of service vouchers, but mainly they are supportive. Municipalities still have the opportunity not to introduce service vouchers. The private sector has been very supportive as they see that the use of service vouchers will expand the markets where they are operating.

For some time already, there has been a more general debate among politicians about what should be the role of the private sector in municipal social and health care: left-wing politicians tend to oppose and right-wing politicians tend to support purchasing services from private providers.

Actors and positions

Description of actors and their positions
Government
the governmentvery supportivevery supportive strongly opposed
Payers
Municipalitiesvery supportivesupportive strongly opposed
Patients, Consumers
Service usersvery supportivesupportive strongly opposed
Private Sector or Industry
Private service providersvery supportivevery supportive strongly opposed
current current   previous previous

Influences in policy making and legislation

New legislation enacted in September 2007 facilitates the use of service vouchers in home nursing as well. In previous legislation only home care was specifically mentioned. According to the new legislation, user-fees in the service voucher system can exceed user-fees in similar municipal services in home nursing as well. Parliament accepted the legislation reform unanimously.

In June 2007 the Ministry of Social Affairs and Health set up a working group to examine how to further expand the use of service vouchers in municipalities. It also prepares the necessary new legislative reforms. The working group should have a proposal ready in June 2008. Its members come from the state administration, municipalities and the private sector.

Legislative outcome

Enactment

Actors and influence

Description of actors and their influence

Government
the governmentvery strongstrong none
Payers
Municipalitiesvery strongvery strong none
Patients, Consumers
Service usersvery strongneutral none
Private Sector or Industry
Private service providersvery strongweak none
current current   previous previous
Private service providersthe governmentService usersMunicipalities

Positions and Influences at a glance

Graphical actors vs. influence map representing the above actors vs. influences table.

Adoption and implementation

The main actors in the implementation have been the municipalities and private service providers. Until now the introduction of service vouchers has progressed at a rather slow pace and only one fourth of the municipalities have used the system. One obstacle has been that almost half of the municipalities have integrated home care and home nursing services. In this situation it is not practical that service vouchers could be used only in home care but not in home nursing. Also a lack of private providers in sparsely populated areas may form an obstacle to the implementation of the system. Additionally, municipalities having adequate services already may not have as strong an incentive to introduce service vouchers as those who have not.

Monitoring and evaluation

The Ministry of Social Affairs and health has conducted a study that reviews the implementation of the service voucher legislation that came into force in the beginning of 2004. The report came out in May 2007. According to the study the introduction of service vouchers has progressed at a rather slow pace and service vouchers have not yet had any significant impact on the municipal service strategies and structures.

According to the report, municipal authorities and clients in general are satisfied with their experiences of the use of service vouchers and municipalities express their interest in increasing their use. The service providers likewise consider the service voucher system good and hope that its use will increase in future. Due to the vouchers, the numbers of clients of the private providers has increased somewhat, but there were in general only few clients using vouchers per service provider.

The report proposed the enaction of a framework law regarding service vouchers so that municipal authorities could more easily organise other services apart from home care by granting clients service vouchers.

Expected outcome

The impact of the introduction of the service voucher system to home care has been rather modest, more modest than it was previously estimated. The new legislation will probably increase the use of service vouchers somewhat, especially in municipalities with integrated home care and home nursing services. But further measures of the government are probably needed to get municipalities to adopt service vouchers in health services more widely.

Impact of this policy

Quality of Health Care Services marginal rather marginal fundamental
Level of Equity system less equitable neutral system more equitable
Cost Efficiency very low neutral very high
current current   previous previous

At the current level the use of service vouchers play only a marginal role in municipal health services. However, it is expected that the current government will take other measures as well to scale up the use of service vouchers in next few years.

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 http://www.stm.fi/Resource.phx/publishing/documents/11722/summary_en.htx  

Reform formerly reported in

Vouchers in social and health care
Process Stages: Implementation, Legislation

Author/s and/or contributors to this survey

Lauri Vuorenkoski

Suggested citation for this online article

Lauri Vuorenkoski. "Vouchers in social and health care - follow up". Health Policy Monitor, October 2007. Available at http://www.hpm.org/survey/fi/a10/4