The analysis resulted in five frames, which the local politicians and civil servants interviewed in this study applied to describe their decisions on contracting out of health care and social services. The insights did not differ considerable between the civil servants and local politicians. There were arguments for and against contracting out in each stakeholder group and in each frame arguments from both civil servants and local politicians.
The decisions were framed in five ways. Firstly, the interviewees portrayed the decisions as rational and free from political, ideological or other exogenous influences. Occasionally, however, the use of rational descriptions rather resembled a rhetoric tool than the actual grounds for the decisions. This finding lends support to the study by Stold and Winbland  suggesting that while the decision-making process leading to contracting with the private sector seems to include e.g. economic arguments there are also ideological factors as well as elements form policy diffusion that guide the decisions. As a whole it seemed that the interviewees were aware that it might be more reasonable to argue the decisions on contracting with the private sector through strategic grounds rather than revealing personal preferences of the issue.
In the first frame several interviewees mentioned that there are certain ‘core services’ that the local authorities are not willing to contract out. Argumentation through ‘core services’ has also appeared in previous studies on outsourcing and contracting out but the consensus on the content of these services has remained elusive (e.g. [9, 11, 22, 24, 31]). Our data suggest that the ‘core services’ would include at least preventive and regulatory services (compare [8, 23]). In general, however, the core services were rather vaguely defined also in this study and might be an interesting subject for further research.
In the second frame the interviewees described situations in which they were forced to choose an alternative which, from their point of view, was suboptimal or undesirable but which was the only possible alternative in the present situation. In this frame, the interviewees admit that the decision-making process is not rational and that they try to adapt to it even though they were not supportive towards the final decisions. Thus, the actual decisions are trade-offs between different values and interests, and the decision makers are not always able to make decisions that would be accordance with their own values nor with the best of the local people. Several interviewees reported situations in which the decisions, potentially most beneficial for citizens, were not implemented, as there were other more important objectives that were pursued at the time. This leaves us to contemplate if contracting out really is a “Faustian Bargain”  through which the policy makers are able to gain short-term efficiency improvements and costs savings, but which long-term results in political and democratic costs, because the best of the local people is has not been the point of the departure as the decisions are made.
These decisions potentially suboptimal from the citizens’ point of view are often influenced by the institutional settings and cultural contexts, as well as by individual beliefs and ideologies . In our data probably the most influential factor affecting the decisions to contract out was the administrative structures of the municipalities. All the municipalities had adopted purchaser-providers split in their organisation, which had directed the municipalities already in the path involving the aim of increasing contracting out per se.
Thirdly, contracting out was justified through the willingness to promote service provider diversity, which was believed to result in improvements in public service provision and in increased opportunities for citizen choice. The improvements in public provision were seen especially resulting from increased competition and benchmarking opportunities with private providers. These, in turn, were believed to lead to improved quality of care and efficiency in service delivery in the public sector. This rationale seems to be in line with the arguments reported in previous studies on outsourcing and contracting out (e.g. [2, 25]) as well as with the literature addressing the properties of different ownership types .
However, there are also studies that do not support these fairly stereotypical distinctions often presented in the literature. The findings of a recent study by Stolt and colleagues , for instance, did not support the notion of public providers learning from private providers. Rather, the quality of care in public units seemed to remain constant irrespective of the rate of competition between the providers in the area. In addition, studies by Warner  and by Comondore and colleagues  do not lend strong support to performance improvements of contracting in terms of quality and cost-savings (e.g. [26, 29]). There have even been cases in which the evaluation of the performance of private providers has been significantly hindered, as the contract documents have not been available for the public . The concerns of the transparency and the ability to monitor private providers’ performance were expressed also in our interviewees (see also ).
The fourth frame was based on the aim to boost municipal economy through job creation and increased tax revenue. The interviewees were mainly willing to contract with the private sector only if it meant purchasing services from local, often third sector providers. Thus, the prevalent opinion was that the multinational for-profit companies would not be the most desirable partners due to their relative market strength compared to the small local providers. There seemed to be a real concern among the interviewees that they are not able to preserve local service provision due to the current competition law dictating that public procurement procedures be applied to purchases exceeding 100 000 Euros. Other scholars have also expressed their concerns about the effect of competitive tendering procedures on especially third sector organisations (e.g. ). Several interviewees also mentioned that they are willing to preserve jobs in the public sector and thus, preserve their reputation as a good and responsible employer. Similar arguments have also been reported elsewhere [9, 24].
The fifth frame was the only frame in which citizens’ best was applied as a point of departure. In the other frames the arguments for and against contracting out were mainly related to the benefits the municipality would potentially gain trough contracting. It could be argued that the improvements in the municipal economy and the cost-savings gained through competition, for instance, would in the end also benefit the local people. Potentially this is the case. However, the reasoning for the existence of the public organisations and the legitimacy of the decision-making authorities are based on the notion of them serving the local people. The public provision and the monopoly status given to the public sector in certain service fields have been justified through the importance of the product and the protection of vulnerable client groups (e.g. ). The needs of patients in the context of primary care and elderly care are inherently complex and require cooperation between several societal sectors and promotion of integrated care. Successful integration of health care and social services especially in the care of elderly patients would potentially result in benefits for the patients  as well as in reduction of costly hospital admissions . However, the interviewees expressed very little concerns about the consistency of care chains or continuity of care. In the cases these were discussed, the interviewees described situations in which there were other factors that tip the scales in favour of other values than the best of citizens in terms of comprehensive care.
Throughout the interviews it appeared that the orientation towards the role of citizens is changing. This applies especially to elderly care services. Several interviewees saw that the senior citizens are becoming active consumers willing to “shop around” in the market place of health care and social services (compare ). In addition, there was also a fairly strong belief that citizens are willing to invest in their services and purchase them also out of pocket. The argumentation focusing on citizens’ best interests was indeed also applied to justify the increasing co-payments that would result from the introduction of vouchers and from restrictions on the eligibility criteria for receipt of services. These developments seem to be somewhat similar than those reported in Sweden .
The municipalities included in this study represent large or medium sized cities in Finland and thus, the results cannot be extrapolated to small and rural municipalities. In smaller municipalities the argumentations are potentially fairly different as the provider market is often non-existent, which undermines the feasibility of contracting with the private sector as a policy tool. In addition, small municipalities, often located in rural areas, potentially use contracting for different purposes that do the larger cities. The rural areas in Finland have experienced major difficulties in recruiting physicians in their health centres. Those municipalities have mostly used contracting as a tool to ensure physician services by contracting with recruitment agencies that deliver physician and nursing workforce for health centres that struggle with recruitment problems. The large cities, in turn, have often interest to seek also for benchmarking opportunities and provide the citizens with opportunities to choose among several service providers. The municipalities participating in this study are potentially among the municipalities with the most positive position towards contracting with private providers, because they have adopted market-oriented administrative model also in their own organisation. Thus, the results do not potentially reflect the opinions overall in the country.
The data were collected through group interviews that may influence the way the interviewees talk about contracting with the private sector. However, an effort was made to reduce the barriers to talk about contracting out by organising separate interviews with the civil servants and the politicians. In addition, we have focused only on primary care and elderly care services and thus questions related to secondary care and for instance to elective surgery have not been addressed here. These services are potentially very different from the services discussed here and thus deserve study in their own right. Finally, the cross-sectional study design results in fairly static analysis and results. However, we acknowledge that the frames used to argue different contracting strategies potentially vary over time and a contracting strategy can be argued through several frames even by one interviewee. The results of the study provide the reader with the variety of the argumentation frames which are potentially used to argue different contracting strategies over time.