Mental Health Care Financing in the Process of Change: Challenges and Approaches for Austria by Ingrid Zechmeister

1. Introduction 
1.1. Background and Motivation of Research 
From around 1960 onwards, provision of mental health care in most of the 
'Western societies' has undergone substantial changes (Bauer, Engfer and Rappl 
1991; Bennett 1995; Goodwin 1997). In many countries these processes are still 
under way. The common idea of the developments has been to reorganise and 
reshape mental health care from centralised asylum based care to decentralised 
and deinstitutionalised community based mental health care. Central charac-
teristics of the transformation process have been that firstly, the concept of mental 
illness has changed from the hitherto normal-pathological dualism to the concept 
of illness development on a continuum, ranging from normal to pathological. 
Secondly, the causes for mental illness and the factors for progression of the 
illness have been recognised as being multiple including biological, psychological 
and social aspects. Thirdly, the location and organisation of service provision has 
been characterised by the replacement of asylums with decentralised structures of 
services. And, finally, the number of involved occupational groups has increased. 
Treatment or care are carried out by multiprofessional teams and they are 
characterised by a less paternalistic relationship with the patient (Forster 1997). 
As a consequence of the ongoing restructuring processes, current mental health 
care issues are associated with several challenges. Thus, after a period in which 
mental health care reform was very much focusing on removing the worst 
conditions, e.g. by closing several large asylums (Goodwin 1997; Haug and 
Rossler 1999), more differentiated questions about adequate service provision 
have arisen. With shifting paradigms in mental health care, new approaches in 
service provision are required ( e.g. Balk 1998; Thornicroft 2001 ). Notably, 
various actors have postulated a change from so-called supply-oriented to 
individual person-oriented and needs-based mental health care ( e.g. Bundes-
ministerium fiir Gesundheit 1999; Kruckenberg 2000). 
Apart from restructuring, further challenges are posed by the fact that mental 
health care ranges beyond the health care system, as it is understood in a 
traditional sense. Thus, it is very common that mental illness is associated with 
social isolation, homelessness and accommodation problems or unemployment. 
Both, the characteristics and aims of the ongoing restructuring processes in mental 
health care as well as the difficulties linked with mental illness per se imply that 
reorganising mental health care not only requires medical discussions but has to 
be embedded in the broader context of economic and social policy issues. 
At the same time, overall conditions within which needs and service provision 
are being discussed, have changed. Concerning health and social policy, a greater 
emphasis has been put on issues of efficiency, effectiveness and quality of 
services, the more so, as expenditure limits within the social and health care sector 

have become increasingly tight. This, once again, makes clear that mental health 
care implies more than 'psychiatry' in a narrow sense. Warner (1994, xi) 
emphasises: "To understand [mental illness] we need to step outside psychiatry. 
We have to venture into the territory of the sociologists, the anthropologists and 
the historians; we must enter the province of epidemiologists, social psychiatrists, 
economists and political scientists". I believe that this is equally true for 
understanding mental health care. In addition to multidisciplinary perspectives, I 
consider it important to address different levels of mental health care. That is to 
take into account content as well as context and actors as well as structures of 
mental health care, whichever the specific areas of interests are. These viewpoints 
are reflected in the approach of the thesis which attempts to address mental health 
care from a multi-level and interdisciplinary perspective. 
Since the project is a one-person undertaking it would, obviously, be 
impossible to integrate all disciplines which might be relevant. Hence, this thesis 
will be guided by a social policy perspective, whereby social policy is understood 
in an interdisciplinary manner as the intersection of economics, sociology and 
political science. This perspective has been found important for two reasons. 
Firstly, it has been rather neglected in research so far. For example, despite 
growing awareness of the costs of mental illness from a macro-economic point of 
view ( e.g. Rice et al. 1992), mental health care has rarely been addressed in health 
policy and related health care economics research. Research on specific topics has 
mainly been conducted in Anglo-American countries (e.g. Frank and Manning 
1992; Knapp 1995; N etten and Beecham 1993; Williams and Doessel 2001 ). In 
continental Europe, as for example in Germany ( e.g. Frick, Rehm and Cording 
2001; Rossler 2001; Salize 2001) and in Austria, a discourse is only at the 
beginning. 
Apart from the research area, a thorough social policy perspective has secondly 
been neglected in the more practical field of mental health care planning. This 
observation is not least based on my own experience when I was involved in the 
evaluation of the 'Lower Austrian Mental Health Care Plan' (Katschnig, Denk 
and Weibold 2003) and in the 'Upper Austrian Mental Health Care Planning 
Project' (Landesregierung Oberosterreich 2003). While numerous debates have 
taken place concerning the adequate type and level of mental health care, little 
attention has been drawn to the challenges these issues imply for social policy 
measures. Or otherwise, where social policy aspects have been addressed, the 
debates have either taken place rather isolated from general debates on reforming 
mental health care provision or relevant social policy issues have not been 
covered in detail. Hence, one central personal interest of the thesis is to further 
integrate the fields of mental health care and social policy in an interdisciplinary 
manner for the Austrian context. This, I believe, is not only a challenge from an 
academic point of view but, as mentioned above, should also shed some more 

Mental Health Care Financing in the Process of Change: Challenges and Approaches for Austria by Ingrid Zechmeister