«State expenditure of the Canton of Basel-Stadt and unpaid work Summary Mirjam von Felten This study examines the question of whether cuts in public ...»
Source: Public income and expenditure according to function (1990 – 2000), Federal Finance Administration Figure 4 shows that there was primarily a decline in personnel costs in the canton of Basel-Stadt, whereas costs of goods and services remained virtually constant or rose slightly from 1998. The main increase in costs was attributable to medicines and medical equipment.
10 Thus the proportion of healthcare costs paid by the cantons dropped slightly from 12.9% in 1995 to 12.1% in 2000, while the proportion paid for by basic insurance premiums under the Federal Law on Health Insurance rose from 30.0% to 32.5% (Federal Statistical Office 2002:11).
11 In contrast to the 1998 to 2000 period, when expenditure on Spitex (home-based care) was recorded under outpatient care in the Federal Finance Administration’s data, between 1994 and 1997 this was listed under senior citizen’s homes. This inconsistency was corrected in the coding for the purposes of this analysis.
Source: 1990-2000 financial statements of public administrations, Federal Finance Administration Reasons for the decline in expenditure on hospitals, and the related consequences As demonstrated in the following section, based on the trend in personnel costs and the employment situation between 1995 and 200012, the decline in salary costs for hospitals is attributable to the restructuring of cantonal services and changes in the method of financing. For instance, from 1996 expenditure on vocational training centres was no longer included in hospital costs. Moreover, 1999 saw the creation of University Children’s Hospital for Basel-Stadt and Basel Country cantons, which is now financed by both cantons.
Despite the fact that personnel expenditure remained virtually constant, the number of hospital staff dropped between 1995 and 2000. Whether, as is to be assumed, this mainly affected nursing staff and whether a simultaneous shift occurred within hospital staff leading to an increase in administrative staff, requires further investigation. However, it is also necessary to determine the reasons behind this decline in hospital staff. One important reason could be the reduction in the number of beds.
On 1 January 1998, in response to the Federal Law on Health Insurance which requires that the cantons plan and ensure the most appropriate and cost-effective inpatient care, the cantonal governments of both Basel-Stadt and Basel Country issued the Basel hospital lists. Based on the hospital lists, the number of intensive care beds was reduced in 2002 by almost one third. The reasons given for this decision were surplus capacity and structural adjustments (Administrative Report
12 This chapter of the report is not translated into English
State expenditure of the Canton of Basel-Stadt and unpaid work 123 Gender-responsive budget analysis in the Canton of Basel-Stadt, Switzerland 1997:240). The reduction in the number of beds in intensive care wards was also included as a rationalising measure for the healthcare sector in the “2000 Budget” package of measures proposed by the Cantonal Council in autumn 1997 in a bid to economise on public spending (Government Report 1997–2001:28f.).
The reduction and restructuring of bed capacities resulted in better utilisation of the available hospital beds. However, this also resulted in a marked drop in the average duration of hospitalisation per patient (see Fig. 5). In 2000, patients in public hospitals spent 30% less time in hospital than in 1990, corresponding to a reduction in days from 19 to 13. Conversely, after declining in the second half of the 1990s the average duration of hospitalisation in private and publicly subsidised private hospitals returned to the original position in 1990.
Fig. 5 Average hospitalisation period 1990 to 2000 (Index 1990=100%)13
Source: Statistisches Jahrbuch des Kantons Basel-Stadt, various years Since the average duration of hospitalisation in public hospitals had already dropped sharply prior to the reduction in beds in 1998, additional factors may be
responsible for this decline. Two are discussed here:
1. Following a restructuring of bed availability in the canton of Basel-Stadt, longterm care and geriatric beds in hospitals were converted to nursing home beds in order to relieve the burden on intensive care hospitals. However, at the same time new beds were created for rehabilitation and palliative care, in order to offset the reduction in intensive care beds.14 13 Public hospitals include the cantonal hospital, the Felix Platter Hospital and the children’s hospital.
14 In 1998 this involved close to 70 beds at Bethesda and Merian Iselin Hospital, and at the Felix Platter Hospital existing intensive care beds were converted to rheumatology-rehabilitation beds (Administrative Report 1998, p. 243).
2. The reduction in average duration of hospitalisation could also be a consequence of medical advances. Improved techniques enable patients to be operated on as outpatients. In 1996 a pilot project was launched to promote and expand day surgery in Basel’s hospitals (Administrative Report 1997:242).
Hypotheses concerning knock-on costs
The question of whether the reduction in expenditure on hospitals and the reduction in average duration of hospitalisation resulted in patients being discharged earlier or prematurely and therefore dependent on being cared for by relatives and acquaintances at no charge, can only be answered hypothetically.
It can, however, be supported by the finding that unmarried persons stay in hospital on average significantly longer than married persons (Canton of Basel-Stadt Office of Statistics 2002:14). To support the hypothesis further, it is necessary to determine whether this was already the case in the early 1990s. Statements by experts on hospitals – and psychiatric clinics – lead to the conclusion that patients are increasingly being discharged earlier in order to save costs, but that paradoxically this can result in additional costs for these institutions. For example, patients discharged from the Cantonal Hospital of Basel-Stadt are increasingly using the hospital’s counselling service for discharged patients. This service will also in future be documented for quality assurance purposes.15 The sharp rise in admissions to psychiatric clinics is giving rise to the risk of “revolving-door psychiatry”: Because new patients need to be treated, existing patients are discharged prematurely, with the result that sooner or later they return to the clinic, increasing the number of admissions as well as adding further to costs (Kuhn 2002). It is therefore reasonable to assume that rationalisation in the healthcare sector incurs additional costs and gives rise to new costs not only for hospitals but also for the private sector, in the form of unpaid care-giving by relatives. While Spitex (home-based care) provides nursing services and domestic help, sick and convalescing persons often require provisioning services such as shopping and preparing meals for a longer period, unlike care these services are not covered by health insurance. It is therefore to be assumed that less affluent patients in particular, who cannot afford home based Spitex services, are dependent on being looked after by relatives.
15 Statement by Mr Pöder, Cantonal Hospital of Basel.
State expenditure of the Canton of Basel-Stadt and unpaid work 125 Gender-responsive budget analysis in the Canton of Basel-Stadt, Switzerland Example 2: Public expenditure on day-care16 The following section examines whether changes in cantonal expenditure on day-care for children (crèches, day nurseries, day-care families) in the 1990s was a determining factor in women in particular being obliged to spend more time looking after and caring for their children. The study does not cover day-care schools which significantly relieve the burden on both parents.
Expenditure on day-care for children increased by 8.9% between 1995 and 2001, from CHF 16.5 million to CHF 18.0 million. This is lower than the increase in total cantonal expenditure, which rose by 9.7% between 1995 and 2000. Up to 1998, however, expenditure on day-care for children rose much more sharply (110.5%) than total expenditure (105.8%).
Subsidies for crèches and day-care homes accounted for the largest proportion of expenditure on day-care in 2001, i.e. CHF 15.8 million. The remainder consists of CHF 1.1 million for three state-run day-care homes, CHF 0.7 million for subsidies for day-care families, and CHF 0.3 million for childcare contributions. The latter includes “parents of pre-school children who temporarily reduce their working hours in order to take care of their children and are dependent on financial support” (Canton of Basel-Stadt Department of Education website).
Fig. 6 Total public expenditure and expenditure on day-care in the canton of Basel-Stadt since 1995 (Index 1995=100%)
Source: Data provided by the Day-care Department of the Services Section 16 I should like to thank Mr Pierre Weber, Day Care Department of the Services Section, Canton of Basel-Stadt Department of Education, for making the data available.
The extent to which children in the 0-14 age group in the canton of Basel-Stadt are taken care of by crèches and day-care homes17 rose slightly from an estimated 6.7% in 1995 to 9.3% at the end of 2001/beginning of 2002. Taking children in day-care families into account, it rose by 10%. This increase is attributable on the one hand to the decline in population numbers in the canton of Basel-Stadt, where the number of children in the 0-14 age group fell by 6.8% between 1995 and 2001. On the other hand, as the following section illustrates, it is also due to the increasing number of part-time day-care facilities.
Crèches and day-care homes Between December 1995 and January 2002 the number of authorised, subsidised places in crèches and day-care homes in Basel-Stadt dropped from by 7.3% from 1,149 to 1,065, while the number of unsubsidised places increased by 41.3% from 441 to 623 between May 1998 and January 2002 (see Figure 7). At the same time the demand for childcare places rose sharply.18 Fig. 7 Places (full time equivalents) in subsidised and non-subsidised crèches and day nurseries in the canton of Basel-Stadt, December 1995 to January 200219 1'500 1'250 1'000
Source: Data provided by the Day-care Department of the Services Section The reduction in subsidised places in crèches and day-care homes was prompted by the Cantonal Council’s decision on 8 April 1997 against further expansion of boarding and half-boarding services for child and juvenile welfare services (Government decision 18/25.02, Section 4.3).
17 Percentage of all children in the canton of Basel-Stadt looked after by crèches and day care homes.
18 See following statements.
19 No data is available on unsubsidised institutions for December 1995.
State expenditure of the Canton of Basel-Stadt and unpaid work 127 Gender-responsive budget analysis in the Canton of Basel-Stadt, Switzerland The decision was made as part of the cost-cutting measures between 1998 and 2000, and was only reversed in June 2001 (Administrative Report 2001:117).
The result was that the canton supported no new day-care places after private providers had closed their subsidised day-care institutions. 20 Unsubsidised day-care institutions, however, were able to increase the number of places on offer by more than 40%. Hence there was a partial shift from publicly subsidised to unsubsidised day-care services. Nevertheless, new private daycare facilities repeatedly failed due to the lack of availability of cantonal funds as start-up capital (Administrative Report 2000:116). Unsubsidised institutions also have difficulty in filling their places because the fees they charge must cover their costs.21 At the beginning of 2002, only around one third of unsubsidised places in crèches and day-care facilities were financed by employers (“corporate places”) (Pulli et al. 2002:12).
Fig. 8 Number of children looked after in subsidised and non-subsidised crèches and day nurseries in the canton of Basel-Stadt, December 1995 to January 200222 1'500 1'250 1'000