Suchergebnisse

Kuntoutusjärjestelmä on Suomessa rakentunut monitahoiseksi ja monen osajärjestelmän muodostamaksi kokonaisuudeksi. Oikeus kuntoutukseen määrittyy sen mukaan, minkä osajärjestelmän piiriin ihminen kuuluu. Tämä johtaa siihen, että yksilöille voi määrittyä erilainen oikeus kuntoutukseen riippuen siitä, minkä osajärjestelmän piirissä hän on. Myös eri sosioekonomiset ryhmät saavat erilaisia kuntoutusetuuksia. Aihe on erittäin ajankohtainen, koska viimeaikainen keskustelu työuran pidentämisestä nostaa areenalle myös kuntoutuksen yhtenä keinona pidentää työssä jaksamista. Sari Miettisen väitöskirja Muutoksen mahdollisuus Suomen kuntoutusjärjestelmässä tarkastelee Suomen kuntoutuspolitiikkaa kuntoutuksen institutionaalisen kokonaisuuden näkökulmasta. Tutkimuksessa tarkastellaan ensimmäistä kertaa kuntoutusjärjestelmää laajana institutionaalisena kokonaisuutena. Tarkoituksena on jäsentää kuntoutusjärjestelmän monimutkaisuutta ja sen muotoutumista sekä näiden kautta tehdä johtopäätöksiä järjestelmän muutoksen mahdollisuudesta. Tutkimuksen lähtökohtana on vuosikausia samanlaisina säilyneet epäkohdat järjestelmässä. Järjestelmän ongelmiksi on vuosikymmenten kuluessa katsottu esimerkiksi vastuunjaon epäselvyydet ja asiakkaiden putoaminen eri toimijoiden väliin. Näitä epäkohtia on pyritty korjaamaan erilaisilla uudistuksilla, joista tähän asti laajin on ollut vuonna 1991 voimaan astunut kuntoutuslainsäädännön uudistus. Uudistuksista huolimatta samat ongelmat ovat esiintyneet erilaisissa kuntoutusjärjestelmän kuvauksissa aina tähän päivän asti. Kokonaisuutta lähestytään analysoimalla valtionhallinnon asiakirjoja ja täydentäen aineistoa tarvittavilla avainhenkilöhaastatteluilla. Tutkimus osoittaa kuntoutusjärjestelmästä erilaisia sisäisiä keskusteluareenoja vuosikymmenien aikana sekä erityisiä valta-asetelmia eri osajärjestelmien kesken. Yhteinen puhe kokonaisuuden hallinnasta on puuttunut ja järjestelmän kokonaisuutta kehittäessä puhe on keskittynyt lähinnä neljään erilaiseen kehykseen. Käytännön tasolla asiakkaan oikeus kuntoutusetuuksiin näytti määrittyvän usealla erilaisella perusteella ja erilaisiksi eri väestöryhmien kesken. Oikeuden ovat myös määrittyneet monenlaisissa erilaisissa paikoissa, kuten yksilön kuntoutuksesta päättävien tahojen ja osajärjestelmien yksittäisten ohjeiden tasolla. Kuntoutusjärjestelmää tulisi tutkimuksen mukaan uudistaa kokonaisuus huomioiden. Usein uudistuksia on toteutettu osa kerrallaan, jolloin eri osien välisiin ongelmiin ei ole puututtu riittävässä määrin. Nykyisellään kuntoutusjärjestelmän osat toimivat erillisinä. Mikäli tätä halutaan muuttaa, pitäisi uudistuksia tehdä kokonaisuus huomioiden ja myös perustaa toimintaa selkeästi koordinoiva taho. Nykyiset keskustelut työuran pidentämisestä voisivat tarjota paikan kuntoutusjärjestelmän kokonaisuuden uudistamiseen, koska kuntoutus voi toimia välineenä saavuttaa näitä tavoitteita. ; Rehabilitation in Finland is part of many welfare systems and as an institutional entity it has many separate subsystems. It has been described as a fragmented and complex entity. Several problems have been attached to the Finnish rehabilitation system, such as unclear division of responsibilities between different subsystems. The rehabilitation system have undergone several coordination attempts especially since the 1990 s. A large legislative reform was launched in 1991. The purpose of the reform was to overcome the problems appearing in the system. The legislative reform was to be evaluated every four years and it was presented in the form of three government rehabilitation reports. Besides the major legislative reform in 1991, parts of the system have been reformed through single legislative reforms in the last three decades. However, despite many reforms in the rehabilitation reports and in other descriptions of the system the same problems have recurred. It seems that no extensive solutions have been found to the problems of the whole rehabilitation system, at least in the short-term. Macro-level studies of the rehabilitation system are needed in Finland. Studies are usually focused on the practical level and different methods of rehabilitation. Although some studies concern the whole rehabilitation system, the perspective is usually on certain sub-system or the entity is contemplated from the client s perspective. In this study the focus was on the institutional entity of rehabilitation in Finland called rehabilitation system. The concepts used were governance and historical institutionalism. The purpose was to analyse the complexity of the institutional entity of rehabilitation in Finland and its development and draw conclusions on the possibility of change in the rehabilitation system in Finland. The legislative reform in 1991 was used as a starting point because it has been the largest reform to develop the whole system in Finland so far. The complex system was analysed using several data. The data used were national rehabilitation policy documents and their background reports and statements, interviews with key authors, legislation and also literature and documents describing the history of the rehabilitation system in Finland. The data were analysed using data based and theory oriented content analysis, frame analysis and the basis of historical sociology. This dissertation consists of four publications which analysed the governance of the rehabilitation system from different perspectives. First, the focus was on the construction of governance in the complex system. The perspective was on the roles of different institutions in the rehabilitation system. According to the results different co-operation forums have promoted change in the system. However, at the same time different power constellations in rehabilitation agendas inside the system have inhibited change. Second, the system was studied through so-called basic modes of governance (hierarchy, network and market). The results showed that certain parts seemed to be emphasized in the reform talk. Common talk of governance was missing. In the third part the main focus was on the interpretations of problems and their policy solutions for the whole system in its reform agenda. The results showed four different frames which were used in discussions. In the frames the problems and policy solutions usually did not meet. In the fourth part the governance of citizens rights was studied. According to the results the rights to rehabilitation benefits are determined in different ways for different population groups and the right to benefits was decided in many places. The overall results of this study showed a deep division between the subsystems. Instead of single and small reforms a reform of the whole system requires attention of all parts of the system in the reform and perhaps a strong coordinating body. It seems that through single and small reforms it is difficult to overcome the problems of this complex system.

Background In 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. Methods Interview 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. Results Five 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. Conclusions This 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. ; BioMed Central open access

Abstract Background In 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. Methods Interview 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. Results Five 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. Conclusions This 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.