In the past decade, the responsibility for organizing and funding youth care in the Netherlands has shifted to local authorities. This decentralization was aimed at making care more accessible to care users and their families and to adapt it to the specific needs of the local community. Yet, how youth care is organized and funded varies greatly per municipality. We talked to Caitlin Kiernan, PhD candidate at FEB, who, together with her supervisors Hermien Dijk, Gerard van den Berg, and Jana Knot-Dickscheit, examines how municipal policies impact youth care. Her project is funded by the Ubbo Emmius Foundation M20 Program and embedded in the Aletta Jacobs School of Public Health (AJSPH).

In her research, Caitlin Kiernan, a fourth-year PhD candidate at FEB, combines two of her interests: economics and health. After working at the Accare Child Study Center for two years, she realized the importance of researching youth mental healthcare. A major development in youth care in the Netherlands was its decentralization in 2015. Municipalities became responsible for organizing and financing youth care, which resulted in regional differences in how access to youth care is organized, as well as how youth care is reimbursed.

For youth care providers, who are often contracted in several municipalities or regions, this means that they are faced with different care provision requirements, administrative requirements, reimbursement schemes, and reimbursement amounts for clients from different municipalities. “In (inter)national studies on physical healthcare and adult mental healthcare, researchers found that the decisions that healthcare providers make can be influenced by the way they are reimbursed, influencing the treatment trajectories of patients, as well as patient outcomes. In my PhD projects, we want to study whether this is also the case in youth mental healthcare, and if so, what the consequences are for the care that children and adolescents receive”, Kiernan explains. 

Importance of accessible and adequate youth care

Regional differences, as well as the challenges posed to care providers, have raised questions about how to best maintain the accessibility and quality of youth care. Kiernan: “In light of municipal budget constraints it is important to study the consequences of such a major policy change. Youth care services should be organized so that children and their families can access appropriate care on time. In addition to being timely, the care they receive must also be effective.”

According to Statistics Netherlands, approximately 11% of Dutch children used a form of youth care in 2023. This can consist of support services through the municipality or treatment from a (specialized) youth care professional. Youth care can support children with behavioural, social, emotional, or mental health problems. Without adequate and timely support, such problems may have impactful and adverse effects into adulthood, such as reduced educational and labour market outcomes.

Three sub-projects

In three sub-projects, Kiernan and her colleagues focus on how the organization of youth care by municipalities can influence the care children receive and their outcomes. For the first project — in which Arjen van Assen (Faculty of Behavioural and Social Sciences, AJSPH) is also involved — Kiernan conducted interviews with providers, referrers, and purchasers of youth care to determine how municipalities' organization of youth care influences youth care organizations’ decisions about the clients they take on, the care they provide, as well as other challenges they might face as an organization. Kiernan: “These factors can be difficult to disentangle quantitatively, but interviews can provide important insights. For instance, we found that the introduction of municipal social teams that can offer support or initial treatment created competition in the youth care professional labour market. Given the tight healthcare labour market, this can create challenges for municipalities and youth care organizations.”

The second project is focused on reimbursement schemes. “In this project, we use unique administrative data on youth care referrals and link this to information on reimbursement amounts in various regions. Using econometric techniques, we study whether youth care providers adjust the degree with which they transfer clients to another provider in response to changes in reimbursement amounts. This sub project examines whether the changes in reimbursement amounts and - any resulting financial incentives - have an influence on the referrals.”

In their third sub-project, Kiernan and her co-authors examine the determinants of child and adolescent mental health, educational achievement, and delinquency by using econometric methods to analyze combined register data from Statistics Netherlands with data from the Lifelines Cohort Study. Through their analysis, Kiernan and her co-authors aim to uncover whether the reimbursement schemes that municipalities use influence teenage mental health, educational outcomes, and the likelihood that youth will come into contact with criminality.

Insights into the consequences of policy decisions

The researchers hope that their results will provide useful insights into the consequences of municipal policy decisions and the range of factors that influence child and adolescent well-being. Kiernan: “As the funds to finance support and treatment are scarce, it is important to organize youth care efficiently: the funds should be distributed in such a way that the outcomes for children and adolescents are maximized. As such, we hope that our results will contribute to research on mental health and the organization of care, as well as to policy in the Northern Netherlands and other regions.”

Comparing outcomes through comprehensive data

When embarking on their research, Kiernan and her co-authors found that there is very little (linkable and detailed) micro-data available on child mental health outcomes and youth care use in the Netherlands. In their studies, they attempt to bridge this gap by linking various data sources, such as administrative data from youth care organizations, publicly available data on reimbursement amounts, data from Statistics Netherlands and data from the Lifelines Cohort Study. Kiernan: “Access to data on a large population of children enables us to compare outcomes across municipalities over time, allowing us to perform causal inference. To be able to analyze provider decisions and child outcomes, there is a need for detailed and national data on specific treatment decisions and child outcomes.”