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REFINEMENT (REsearch on FINancing systems' Effect on the quality of MENTal health care)

The overarching aim of the REFINEMENT project is to look at the relationship between different models of health care financing systems and the extent to which mental health care services can meet the goals of high quality, equity, efficiency and better long term health outcomes.

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REFINEMENT (REsearch on FINancing systems' Effect on the quality of MENTal health care)
REFINEMENT (REsearch on FINancing systems' Effect on the quality of MENTal health care)

Best practice health care financing models

The results of the research will suggest the best practice health care financing models that may be used in different parts of Europe where different mixes of tax, social health insurance, private health insurance and out of pocket payments are used to achieve these goals. Variations in the structure and characteristics of mental health financing systems will be compared in nine European countries: Italy, Austria, UK, Spain, Norway, Finland, France, Romania and Estonia.

Development of good-quality and efficient services

Mental health is a key priority area for Europe, as evidenced by the publication by the European Commission in June 2008 of its European Pact on Mental Health and Wellbeing. The REFINEMENT project arises from the necessity to compare and standardize the different and elaborate systems of both financing and performance assessment of Mental Health care in Europe, to promote knowledge of how financial systems can be used to support the development of good-quality and efficient services.

REFINEMENT presents four core objectives:

  • To map and describe the structure and characteristics (including incentives) of financing systems for mental health care.
  • To describe various qualitative aspects of service provision relative to differences in mental health financing through a detailed survey of the nine systems.
  • To describe the typical patient pathways through the service system by people with mental health needs, relative to differences in mental health financing through a detailed survey of the nine systems.
  • Based on (1) - (3), to describe financing models and incentive structures conducive to the promotion of effective, accessible and high quality mental health services.

Several new tools on financing and payment systems

The REFINEMENT project undertakes a mix of quantitative and qualitative analyses in the nine European countries. In order to analyze the different financing and care systems and their correlated outcomes, it is necessary to ensure that researchers, service planners and policy makers in different regions, countries and at the European level, compare ‘like with like’ and adequately use the data from different services systems. For such a reason, the REFINEMENT project will produce several new tools covering financing and payment systems, service structure, organization, and resources, service patterns and patient pathway and quality in health and social care services and finally a decision support toolkit to aid decision makers in respect of which health care financing arrangements to achieve difference objectives including accessibility, efficiency and quality of care.

Peer-reviewed publications

Salinas-Perez JA, Gutierrez-Colosia MR, Garcia-Alonso CR, Furst MA, Tabatabaei-Jafari H, Kalseth J, Perkins D, Rosen A, Rock D and Salvador-Carulla L (2023) Patterns of mental healthcare provision in rural areas: A demonstration study in Australia and Europe. Front. Psychiatry 14:993197. doi: 10.3389/fpsyt.2023.993197

Cetrano, G., Salvador-Carulla, L., Tedeschi, F., Rabbi, L., Gutiérrez-Colosía, M. R., Gonzalez-Caballero, J. L., Park, A.-L., McDaid, D., Sfetcu, R., Kalseth, J., Kalseth, B., Hope, Æ., Brunn, M., Chevreul, K., Straßmayr, C.,  Hagmair, G., Wahlbeck, K., and Amaddeo, F. and For the REFINEMENT group (2018). The balance of adult mental health care: provision of core health versus other types of care in eight European countries. Epidemiology and psychiatric sciences, 1-10.

Gutiérrez-Colosía M R, Salvador-Carulla L, Salinas-Pérez J A, García-Alonso C R, Cid J, Salazzari D, Montagni I, Tedeschi F, Cetrano G, Chevreul K, Kalseth J, Hagmair G, Straßmayr C, Park A L, Kalseth B, Amaddeo F and For the REFINEMENT Group  (2017). Standard comparison of local mental health care systems in eight European countriesEpidemiology and Psychiatric Sciences, 1-14.

Montagni I, Salvador‑Carulla L, Mcdaid D, Straßmayr C, Endel F, Näätänen P, Kalseth J, Kalseth B, Matosevic T, Donisi V, ChevreulK, Prigent A, Sfectu R, Pauna C, Gutierrez‑Colosia M R, Amaddeo F,  Katschnig H. "The REFINEMENT Glossary of Terms: An International Terminology for Mental Health Systems Assessment." Administration and Policy in Mental Health and Mental Health Services Research (2017): 1-10.

Salvador-Carulla L, Amaddeo F, Gutiérrez-Colosía MR, Salazzari D, Gonzalez-Caballero JL, Montagni I, Tedeschi F, Cetrano G, Chevreul K, Kalseth J, Hagmair G, Straßmayr C, Park A, Sfetcu R, Wahlbeck K, Garcia-Alonso C. "Developing a tool for mapping adult mental health care provision in Europe: the research on financing systems’ effect on the quality of mental health care mapping services tool research protocol and its contribution to better integrated care". International Journal of Integrated Care. 2015;15(4).


Kalseth J and Magnussen J in cooperation with the REFINEMENT group: APPENDIX Examples from the REFINEMENT data collection. 2013.

Kalseth J and Magnussen J in cooperation with the REFINEMENT group: The REFINEMENT Decision Support Toolkit for improving the financing of mental health care. The manual. 2013.

Heinz Katschnig, David McDaid, Christa Straßmayr, Tihana Matosevic, A-La Park, Sonja Scheffel in cooperation with the REFINEMENT group: The REFINEMENT Financing & Incentive Tool (FINCENTO). 2013.

Ilaria Montagni, Luis Salvador Carulla, Mencia Ruiz, Damiano Salazzari, Francesco Amaddeo, Laura Rabbi, Gaia Cetrano, Federico Tedeschi, Jose A. Salinas Perez, Juan Luis Gonzales Caballero in cooperation with the REFINEMENT group. The REFINEMENT Mapping services Tool (REMAST).2013.

Barbara Weibold, Heinz Katschnig, Christa Straßmayr in cooperation with the REFINEMENT group: The REFINEMENT Pathways Tool (REPATO). 2013.

Valeria Donisi, Francesco Amaddeo, Damiano Salazzari, Laura Rabbi, Gaia Cetrano, Ilaria Montagni, David McDaid in cooperation with the REFINEMENT group: The REFINEMENT Quality of care Tool (REQUALIT). 2013.

THE REFINEMENT GLOSSARY: Terms and definitions concerning Mental Health Care Provision and Financing in Europe

The REFINEMENT Project. Research on Financing Systems’ Effect on the Quality of Mental Care. Executive summary.

Policy brief

What do we need to know and how can we collect data to inform the analysis of the financing, structure and quality of mental health systems?

Key Factors

Project duration

01/01/2011 - 31/12/2013

Facts about the project 

Refinement web site


The REFINEMENT project has received funding from the European Commission under the Seventh Framework Programme (7FP) and lies within the Specific Programme "Cooperation" - Theme "Health": HEALTH.2010.3.2-1: Financing systems' effect on quality of health care.

Cooperation partners

The REFINEMENT project is conducted by an experienced team of health economists, mental health service researchers, public health specialists and social care experts from:

  • The University of Verona, Italy (project coordinator)
  • The Ludwig Boltzmann Gesellschaft, Austria
  • London School of Economics and Political Science, UK
  • Terveyden yes Hyvinvoinnin laitos, Finland
  • Asociacion Cientifica Psicost, Spain
  • University of Tartu, Estonia
  • Université Paris XII - Val de Marne, France
  • Institutul the Prognoz Economica, Romania
  • SINTEF, Norway

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