Mental health policy and practice across Europe: an overview

Financing and funding 71
employment-related services such as special assistance, consulting or
educational training).
The current financing system causes several difficulties. Firstly, according
to the General Social Security Act (Allgemeines Sozialversicherungsgesetz),
social health insurance schemes cover acute health problems
whereas people with long-term (mental) health problems are ‘transferred’
or allocated to the social care and social assistance sector. This is not only
disadvantageous in terms of rehabilitation (due to changes in providers,
treatment and often a lack of rehabilitation services) but also because of
the different financing patterns.
Secondly, reform documents emphasize the reduction in hospital care
in favour of non-institutionalized care in the community. The latter is
mostly within the social care sector. Without reform more community
mental health care will lead to increased out-of-pocket payments for users
and their relatives. Compared to people with somatic illnesses, these contributions
are likely to be disproportionately higher for mentally ill people
(Zechmeister and Osterle 2004).
Thirdly, some incentives in the current financing system actually create
obstacles to reform aims. Extended coverage in the health care sector
favours hospital care rather than social care. This runs contrary to shifting
the focus to community care and to providing complex person-oriented
service arrangements (Zechmeister et al. 2002). These conflicting incentives
may, and in fact partly do, lead to transinstitutionalization rather
than deinstitutionalization.
So far, Austria has not generally brought together the objectives stipulated
in its mental health care reform plans and the question of how to
finance mental health care. Linking these spheres, however, will be crucial
for the future development of mental health care provision and financing.
As a first step, it is particularly important to discuss what the different
concepts of mental health care (such as individualization, normalization,
person-oriented care, needs-based care, customer orientation etc.) exactly
require in terms of Austrian financing and reimbursement structures.
Current arrangements that are characterized by a fragmentation of
responsibilities between public authorities and between service sectors
often hinder rather than support new developments in mental health care
or innovation in the mix between institutional and community-based
services. For an effective allocation of funds it is necessary to overcome the
strict division between health and social care. This requires the pooling of
funds and a redefinition of public responsibilities.
However, there is evidence of growth of niche areas where private insurance is
one way of generating additional funding for mental health. For example, in
both the United Kingdom and Germany, VHI provides some coverage for addiction
programmes (Dixon 2002). Accident and unemployment insurance
schemes funded privately by individuals or employers may provide benefits in