Analysis of cost and quality indicators of day activity service programmes in Sweden

ABSTRACT

Several countries provide day activity programmes for people with intellectual disabilities. Little is known about the quality of these programmes or about their effectiveness in providing vocational training. In this study, we analysed the distribution across Swedish municipalities of the cost per user and how this is related to five structure quality and one outcome quality variables. We observed that the expenditure per attendee varies considerably between different municipalities. Statistical analysis was used to study to what extent expenditure per user correlates with supply-side factors, (political) demand-side factors and quality indicators. This indicated that the variation of expenditure is not explained by supply-side factors only. The local tax base and other local economic and/or political circumstances are statistically significant covariates, in spite of the entitlement legislation that gives eligible persons right to services of equal quality independent of such location-specific factors. We also found that municipalities that conduct regular user surveys find reasons to, on average, spend more per user. Finally, we found that the probability for transitions to employment at a regular workplace is higher in municipalities where as an annual routine, a review is made of whether each participant can be offered an internship or work.

KEYWORDS:

• Day-activity programmes
• intellectual disabilities
• autism
• regional differences
• cost per user
• structure quality
• transition to work

Acknowledgements

We are grateful for comments from Linda Andersson, Mikael Svensson and participants at the Economics seminar at Örebro University.

Notes on contributors

Emelie Värja recently received a Ph.D. in economics at the Örebro University School of Business and is currently employed as an advisor at PwC Sweden. Her research interests involve equality and efficiency issues in local government.

Susanna Larsson Tholén is an Affiliated Researcher at the School of Health Science at Örebro University and belongs to the Swedish Institute for Disability Research (SIDR).

Lars Hultkrantz is professor of economics at the Örebro University School of Business and a member of the Expert Group on Public Economics (ESO) at the Swedish Ministry of Finance. His current research interest is cost–benefit analysis.

Notes

1. NBHW (2007) and Lövgren, Markström, and Sauer (2013) observe a lack of research regarding daily activities.

2. Structure denotes the attribute of the setting in which care occurs. Process denotes what is actually done in giving and receiving care. Outcomes denote the effects of care on the patients (Mainz 2003, p. 525; Donabedian [1966] 2005). This typology is discussed in relation to quality in social-work practice in Blom and Morén (2012).

3. There is a large literature on how to measure quality of life for people with intellectual disability. Recent reviews are Bertelli and Brown (2006) and Browns, Hatton, and Emerson (2013). In Sweden, Eklund (2009) measures quality of life among participants in daily activities among persons with mental illness (most with schizophrenia).

4. Some reported studies are from the municipalities of Karlskoga (Gustafsson 2002; Jonsson 2013) and Kramfors, Sollefteå, Timrå, Örnsköldsvik and Ånge (Rönnbäck 2013).

5. In 40% of the municipalities, the respondents assessed that there were DA participants who could and wanted to get an employment. The share of such participants in these municipalities was, on average, estimated to be 10%.

6. These difficulties for people with intellectual disabilities to obtain paid work are internationally recognized (Campbell 2012; Lövgren, Markström, and Sauer 2013; McGlinchey et al. 2013).

7. The lower cost decile had significantly higher unemployment, higher tax rates and lower average income (tax base). Of the quality indicators, the only significant difference between the means where that the lower cost decile had a lower share of municipalities that had a competence plan.

8. For validity, the indicators were selected based on a model developed for measurement of quality of social services in NBHW & SALAR (2007). Representatives of providers and users of the services were involved in the work and have probably assessed the relevance of the chosen indicators. The reliability has been controlled in various ways. An initial check was made for extreme values and if such were found, contact was made with the respondent for clarification. The respondents were invited to make a comment on every question and all such comments were examined to see whether there was any ambiguity. In fact, one such problem was found but it was not related to the indicators that were selected for this study.

9. The measurement date was 21 November 2012. Some indicators refer to the 12-month period preceding this date.

10. All 13 indicators for Coordination and all 7 indicators for Information about LSS (see Table 1) were tried in preliminary estimations but skipped because results for these were considered difficult to interpret. The related regression coefficients were not significant, neither when all variables were introduced separately nor when they were aggregated. This possibly reflects that coordination and information activities of various kinds are organized differently in the municipalities. Formal routines for internal coordination are not always needed when, as especially in small municipalities, the same administrator is responsible for multiple action areas. For Individual plan, we used the main question; most municipalities that have an individual plan routine also have a routine for documenting that such a plan has been offered. The indicator variable on payment of habilitation fees was skipped since 89% of all municipalities make such payments. The variable on case workers with a university degree was likewise deemed to be statistically uninformative as 95% responded yes.

11. ‘Work’ is defined as employment on the open labour market, employment with state grants (‘lönebidragsanställning’), internship or sheltered employment (not funded as a LSS activity). Transitions to education are not included.

12. More precisely, the sum of the county and municipality tax rates.

13. Comparing the control variables over the response and non-response groups, the only significant difference between the two groups is the number of residents, where we have a lower average population in the non-response group. There is, however, no significant difference in the amount of LSS fee/grants per resident.

14. When these municipalities were contacted because they had stated very low costs, they acknowledged that something was wrong, but could not provide accurate cost measures.

15. The number of factorials including one to five of these variables are 31. Estimations were made for all these combinations. Table 4 shows the full equation and equations with one indicator at the time. There were some changes of significance of the variables in a few other combinations and these are reported in notes to Table 4.

16. The VIF test is under 1.5 for all the indicator variables.

17. We estimated all 31 possible combinations including one, two, three, four or all five structure quality indicator variables, with the number of observations ranging from 233 to 252 due to internal non-responses, but the results did not change.

18. For instance, Samson and Terziovski (1999), in a study of 1200 Australian and New Zealand manufacturing organizations, found ‘customer focus’ to be one of three Total Quality Management factors that proved to be strongly and positively related to performance.

19. Some examples of practices that seem to work (mostly based on ‘supported employment’ models) are presented in NBHW (2010).

Additional information

Funding

This research has been funded by grants from Jan Wallander’s and Tom Hedelius’ Foundation, Tore Browald’s Foundation and the City of Örebro [grant number P2011-0186:1].