The funding of wellbeing services counties is determined by need – but who creates that need?

The basic idea of funding for wellbeing services counties is clear and seemingly fair: resources should be determined by residents’ service needs. The central government collects taxes and distributes funding based on a computational model. The model utilises register data – age structure, diagnosed morbidity, past use of services and socio-economic risk factors – and generates a need coefficient on that basis. The more there are recorded illnesses and risks, the more funding is allocated.

This is an understandable principle. Still, we should stop and ask what we mean by “service need”. It is often talked about as if it was a pre-existing, measurable characteristic within a human being. As if a diagnosis were the same as a need. As if the funding model just reflects reality.
However, service needs are not natural constants. They are created.

Diagnosis is not the same as need

In health care, diagnosis often serves as a substitute for need. When a person is diagnosed with depression, diabetes or a memory disorder, the idea is that a need has been identified – and becomes visible in the funding model at the same time.

Still, a diagnosis is the result of classification. It requires professional interpretation, criteria, indicators and records. It is created in an interactive process where an experience is formulated into a medical category.

A diagnosis opens certain service paths and closes others. It justifies appointments, rehabilitation and medication – or not. At the same time, the diagnosed person’s experience may be related to loneliness, financial distress or the fragility of everyday management. These aspects may increase the burden on services, but if they do not turn into written patient records, they will also not turn into computational needs. If funding follows diagnosis, it is determined by the factors that professionals have managed to name and codify.

Service needs arise in interaction

When a patient and professional have a conversation, it is not only about identifying the problem but also a negotiation: what is considered essential, for what issues are there available solutions, what kind of language is the situation described with and what the system is prepared to hear.

The conversation often gets directed towards an issue that is associated with an existing service, budget item and patient record code. The need is formed by the combined effect of personal experience, professional practices and information systems. It is not just a characteristic of the individual, but an outcome that builds on the relationship between the system and the human being.

Indicators create reality

The same logic can be observed at the regional level. The wellbeing services county receives funding for what is observable in the registers – not the resulting experience. The register measures recorded use and diagnosed conditions.

A region where people seek out services actively and where records are logged systematically may appear to have more needs than a region where problems remain unnamed. Funding follows the needs that are identified and made visible, not necessarily the lived reality.

In other words, indicators are not neutral. When funding is tied to certain variables, those variables also garner attention. This way, the funding model not only measures service needs but also participates in creating them: it steers record-taking, diagnoses and decisions on what kind of problems are highlighted.

Service needs are questions of negotiation

What we consider a service need is also a political and societal question. Is loneliness a need? What about the deterioration of work ability without a diagnosis, risky use of substances or an older person’s experience of insecurity?

The recognition of a need requires institutional status: a budget item, service format, patient record code and indicator. Only then does it become part of the computational reality based on which funding is distributed.

What entails is that service needs are the results of continuous negotiations between patients, professionals, classification systems, information systems and funding models. Needs-based funding is not just a technical solution. It shapes the reality it claims to measure.

What does all this mean?

This does not mean that needs-based funding is the wrong premise. On the contrary: the objective of fair resource allocation is important and shared. But if we want to develop the system responsibly, we have to ask: who defines the needs, with what instruments and whose voice gets left unheard?

This challenge is not faced jus by individual professionals, office holders or decision-makers, but all of us. If we talk less about “objectively measurable real needs” and more about how these needs are structured in relations and structures, we can make the funding model more aware of its own impacts.

Otherwise, there is a risk that we keep building models that are more and more accurate and are excellent at measuring what we have first made visible – and then we call it reality.

Service needs are not just a starting point of funding. They are also its end result.