Juhani Lehto

Transfer of Health for All policy – What, how and in which direction? A two-case study

BackgroundThis article explores the transfer of World Health Organizations (WHO) policy initiative Health for All by the Year 2000 (HFA2000) into national contexts by using the changes in the public health policies of Finland and Portugal from the 1970s onward and the relationship of these changes to WHO policy development as test cases. Finland and Portugal were chosen to be compared as they represent different welfare state types and as the paradigmatic transition from the old to new public health is assumed to be related to the wider welfare state development.MethodsThe policy transfer approach is used as a conceptual tool to analyze the possible policy changes related to the adaptation of HFA into the national context. To be able to analyze not only the content but also the contextual conditions of policy transfer Kingdons analytical framework of policy analysis is applied.ConclusionsOur analysis suggests that no significant change of health promotion policy resulted from the launch of HFA program neither in Finland nor in Portugal. Instead the changes that occurred in both countries were of incremental nature, in accordance with the earlier policy choices, and the adaptation of HFA program was mainly applied to the areas where there were national traditions.

Purchaser–provider splits in health care—The case of Finland

The purchaser-provider split (PPS) is a service delivery model in which third-party payers are kept organizationally separate from service providers. The operations of the providers are managed by contracts. One of the main aims of PPS is to create competition between providers. Competition and other incentive structures built into the contractual relationship are believed to lead to improvements in service delivery, such as improved cost containment, greater efficiency, organizational flexibility, better quality and improved responsiveness of services to patient needs. PPS was launched in Finland in the early 1990s but was not widely implemented until the early 2000s. Compared to other countries with PPS the development and implementation of PPS in Finland has been unusual. Firstly, purchasing is implemented at the level of municipalities, which means that the size of the Finnish purchasers is extremely small. Elsewhere purchasing is mostly implemented at the regional or national levels. Secondly, PPS is also applied to primary health care and A&E services while in other countries the services mainly include specialized health care and residential care for the elderly. Thirdly, PPS in health and social services is not regulated by any specific legislation, regulative mechanisms or guidelines. Instead it is regulated within the same framework as public procurement in general.

Framing the decision to contract out elderly care and primary health care services - perspectives of local level politicians and civil servants in Finland.

BackgroundIn the literature there are only few empirical studies that analyse the decision makers’ reasoning to contract out health care and social services to private sector. However, the decisions on the delivery patterns of health care and social services are considered to be of great importance as they have a potential to influence citizens’ access to services and even affect their health. This study contributes to filling this cap by exploring the frames used by Finnish local authorities as they talk about contracting out of primary health care and elderly care services. Contracting with the private sector has gained increasing popularity, in Finland, during the past decade, as a practise of organising health care and social services.MethodsInterview data drawn from six municipalities through thematic group interviews were used. The data were analysed applying frame analysis in order to reveal the underlying reasoning for the decisions.ResultsFive argumentation frames were found: Rational reasoning; Pragmatic realism; Promoting diversity among providers; Good for the municipality; Good for the local people. The interviewees saw contracting with the private sector mostly as a means to improve the performance of public providers, to improve service quality and efficiency and to boost the local economy. The decisions to contract out were mainly argued through the good for the municipal administration, political and ideological commitments, available resources and existing institutions.ConclusionsThis study suggests that the policy makers use a number of grounds to justify their decisions on contracting out. Most of the arguments were related to the benefits of the municipality rather than on what is best for the local people. The citizens were offered the role of active consumers who are willing to purchase services also out-of-pocket. This development has a potential to endanger the affordability of the services and lead to undermining some of the traditional principles of the Nordic welfare state.

System innovations in the making: hybrid actors and the challenge of up-scaling

The article addresses the problem of how to create sustainable change in health care. It builds on two case studies that examine endeavours to develop system innovations so that they deliver high quality services more efficiently. The innovation processes are studied through the lens of a multiple-level model of change. The model suggests that change takes place as the outcome of linkages between external pressures on the current regime, policy measures, and local initiatives. The results highlight the critical role of hybrid actors for (1) assuring the societal quality of the innovation, and (2) developing the embryo so that it is relevant beyond the local level. The up-scaling of an innovation embryo entails that local actors adopt a wider perspective and that policy-makers support the spreading of local innovations. The findings are thus useful for policy-makers and local developers.

Integrating public and private home care services: the Kotitori model in Tampere, Finland

Purpose – This case study aims to introduce a novel home care service integrator model called “Kotitori”. In the model the City contracts with a private provider, which, in turn, works with public, private, and third sector providers in order to meet the customer needs in a personalised way.Design/methodology/approach – The case study draws from key policy documents and stakeholder interviews.Findings – The study introduces a unique form of public‐private partnership in Finland, and describes the basic elements of Kotitori, the development process of the model, and the models distinctive features compared to more traditional ways of home care service delivery.Research limitations/implications – The Kotitori model is still in its early stages of implementation and reliable data on performance are limited.Practical implications – The transferability potential of the Kotitori model is good both nationally and internationally. The model is potentially beneficial for countries with an interest in developing i...

An analysis of ophthalmology services in Finland - has the time come for a Public-Private Partnership?

BackgroundWe studied the prerequisites for Public-Private Partnership (PPP) in the context of the Finnish health care system and more specifically in the field of ophthalmology. PPP can be defined as a more or less permanent cooperation between public and private actors, through which the joint products or services are developed and in which the risks, costs and profits are shared.The Finnish eye care services system is heterogeneous with several different providers and can be regarded as sub-optimal in terms of overall resource use. What is more, the public sector is suffering from a shortage of ophthalmologists, which further decreases its possibilities to meet the present needs. As ophthalmology has traditionally been a medical specialty with a substantial private sector involvement in service provision, PPP could be a feasible policy to be used in the field. We thus ask the following research question: Is there, and to what extent, an open window of opportunity for PPP?MethodsIn addition to the previously published literature, the research data consisted of 17 thematic interviews with public and private experts in the field of ophthalmology. The analysis was conducted in two stages. First, a literature-based content analysis was used to explore the prerequisites for PPP. Second, Kingdons (1995) multiple streams theory was used to study the opening of the window of opportunity for PPP.ResultsPublic and private parties reported similar problems in the current situation but defined them differently. Also, there is no consensus on policy alternatives. Public opinion seems to be somewhat uncertain as to the attitudes towards private service providers. The analysis thus showed that although there are prerequisites for PPP, the time has not yet come for a Public-Private Partnership.ConclusionShould the window open fully, the emergence of policy entrepreneurs and an opportunity for a win-win situation between public and private organizations are required.

A qualitative study on clinical research in Finland: fragmented governance and volume in the 2000s

Objectives Although concerns over clinical research have been expressed, the governance of clinical research has been little studied. The aim was to describe research policy, volume, funding and concerns over clinical research in Finland. Design A qualitative study and the data were collected from various sources, including documents, statistics and semistructured expert interviews. Setting Finland. Results We found no national policy for clinical research. Many actors were responsible for facilitating, directing, regulating and funding clinical research, but no actor had the main responsibility. Health professionals were the main drivers for clinical research. The role of the health ministry was small. The ministry distributed state money for clinical research in health services (EVO-money), but did not use it to direct research. Municipalities responsible for health services or national health insurance had little interest in clinical research. The Academy of Finland had had initiatives to promote clinical research, but they had not materialised in funding. Clinical research was common and internationally competitive, but its volume had declined relatively in the 2000s. Industry was an important private funder, mainly supporting drug trials made for licensing purposes. Drug trials without an outside sponsor (academic projects) declined between 2002 and 2010. The funding and its targeting and amount were no ones responsibility. Concerns over clinical research were similar as in other countries, but it had appeared late. Conclusions Our results suggest fragmented governance and funding in clinical research. The unsystematic research environment has not prevented clinical research from flourishing, but the public health relevance of the research carried out and its sustainability are unclear.

Mental health in complex health promotion policy programmes: The contribution of programme evaluations

Background: In order to develop policymaking, evaluation is required. The research project studied national health promotion policies concentrating on mental health promotion policy. In this paper the focus is on the position of evaluation. Aim: To explore the position of evaluation in the development of the national public health strategies of England and Finland and particularly with regard to mental health promotion policies. The evaluation phase of the policymaking process is also scrutinised through multiple streams of policy change. Methods: Meta-evaluative approach applying a conceptual framework of policy analysis. Results: Evaluations of national health strategies were executed in both countries. These evaluations entailed multiple tasks; not only to monitor the progress of the targets but to learn for the future in a wider perspective. Aims of mental health policy are not easily turned into quantitative targets and therefore outcome evaluation was not felt to be satisfactory as it lacks focus on process as well as null, perverse, and unintended consequences. Conclusions: While the position of evaluation is almost always more complicated than is assumed in so-called rational policymaking theory, mental health appears to be even more challenging in this respect. Possibilities for alternative evaluation strategies should be studied further.

Rule detection in preschool-aged children

Executive functions (EF) in preschool children were investigated using a novel version of the Brixton Anticipation Test. To sustain motivation a cover story based on tales familiar to the children was introduced. The task was also framed in the form of a hiding game. The participants were children aged 3 and 5. The results suggested that rule detection can be measured in children as young as 3 years. Maturational effects were observed between the age groups. Of the executive subfunctions the new task version was interpreted as tapping inhibition rather than shifting (switching).

Betting on a different horse: a qualitative analysis of mental health in health promotion policies

The aim of this study is to analyse the position and role of mental health in health promotion policy. Policy documents from Finland, Sweden, Denmark, the Netherlands, England and Portugal indicate that, although mental health is considered a serious issue, it is problematic in policy terms. A range of arguments are put forward, making the case for the importance of mental health within the health promotion agenda, including the classification of mental illness as a public health problem, socio‐economic and individual costs of mental health problems and the view that mental well‐being is a crucial element of overall health. However problems of definition, measurement and a traditional focus on treatment and care continue to make mental health promotion problematic for policy makers.