Resource distribution in mental health services: changes in geographic location and use of personnel in Norwegian mental health services 1979-1994.
BACKGROUND: During the last decades, a central aim of Norwegian health policy has been to achieve a more equal geographical distribution of services. Of special interest is the 1980 financial reform. Central government reimbursements for the treatment of in-patients were replaced by a block grant to each county, based on indicators of relative "need". AIMS OF THE STUDY: The aim of this paper is to assess whether the distribution of specialized mental health services did take the course suggested by the proponents of the reform (i.e. a more equal distribution), or the opposite (i.e. a more unequal distribution) as claimed by the opponents. METHODS: Man year per capita ratios were used as indicators for the distribution of mental health services by county. Ratios were estimated for "all personnel", and for MDs and psychologists separately. Man years were assigned to counties by location of services (i.e. in which county the services were produced), and by residence of users (i.e. in which county the services were consumed). Indicators of geographic variation were estimated using the standard deviation (STD) as a measure of absolute variation, and the coefficient of variation (CV) and the Gini index as indicators of relative variation. Indicators were estimated for 1979, 1984, 1989 and 1994, based on data for all specialized adult mental health services in the country. Changes in distributions over the period were tested, using Levene's test of homogeneity. RESULTS: Relative variations in the distribution of personnel by location of services were substantially reduced over the period, the CV being reduced by more than 50% for all groups. Variations in the personnel ratios by residence of users were smaller at the start of the period, and the reductions were also smaller. Still, relative variations were reduced by 20-35, 40 and 60% approximately for "all personnel", MDs and psychologists respectively. In spite of a major increase in the supply of MDs and psychologists, absolute variations in the personnel ratios were in all cases either reduced, or fairly stable. These results give little support to the views expressed by the opponents of the 1980 reform, although the main result seems to have been relocations in the production of services, more than re-distributions in the consumption of services. DISCUSSION: These results can be seen as a result of three aspects of the reform: 1 Distributing government grants to counties in their capacity as users of services rather than producers of services. This shift has primarily facilitated relocations in the production of services. 2 Relocation of services was also expected to produce a more equal distribution in the use of services, since reduced distances would increase accessibility. This, however, was counteracted by increased county control with use of services in other counties. 3 Distribution of grants based on "needs" rather than services produced was expected to produce a more equal distribution in the use of services. This effect seems to have been less than expected, probably because counties with high reimbursements under the old system also provided services to people from other counties. Other policy reforms have, however, contributed to the results. These reforms include increased supply of personnel, de-institutionalization of services, regionalization/sectorization of services, and the establishment of smaller psychiatric units in general hospitals. POLICY IMPLICATIONS: In recent years the 1980 reform has been under attack; partly due to alleged inequalities created by the system. As a result of the critique, government reimbursements for in-patient treatment have been reintroduced for general hospital services. In mental health services, more resources are distributed to specific projects. According to this study, this shift in policy is based on faulty premises and might lead to greater inequalities in the future.
Pedersen
Per Bernhard
PB
SINTEF Unimed NIS Health Services Research, N-7465, Trondheim, Norway, per.pedersen@unimed.sintef.no
Lilleeng
Solfrid
S