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Private financing of elder care in Sweden: Arguments for and against.



The idea that there is a need to increase the share of private financing of the costs of elder care is expressed by several actors attempting to influence the direction of social policy Sweden these days. This idea fundamentally challenges established ways of financing and organising delivery of elder care services in Sweden. Underlying proposals for increasing private financing is the claim that the future scope of public elder care provision must contract, both vertically and horizontally. Underlying this claim is the assumption that both the quantity and quality of services demanded will increase, while the supply of public funds cannot. Vertical contraction aims to draw new funds from users willing to pay more to get higher quality services. Horizontal contraction aims to reduce the scope of public sector’s responsibility in service provision. This paper outlines recent developments in private provision of elder care services and examines arguments and actors for increasing private financing. Although the proposals have been put forward by influential actors, opposition to increasing private financing has been expressed, and support for solidaristic funding of elder care remains strong. Accordingly, we also consider these dissenting arguments and actors. Our purpose is to set out and evaluate the arguments, evidence and interests behind the proposals, and the likely outcomes of their implementation.
Gabrielle Meagher & Marta Szebehely
Private financing of
elder care in Sweden
Arguments for and against
Arbetsrapport/Institutet för Framtidsstudier 2010:1
ISSN: 1652-120X
ISBN: 978-91-85619-61-0
Gabrielle Meagher & Marta Szebehely
Private financing of elder care in Sweden:
Arguments for and against
Arbetsrapport/Institutet för Framtidsstudier; 2010:1
Working Paper/Institute for Futures Studies; 2010:1
Stockholm 2010
Institutet för Framtidsstudier/Institute for Futures Studies
Arbetsrapport/Working Paper 2010:1
Gabrielle Meagher. Faculty of Education and Social Work, University of Sydney, NSW
2006 Australia,
Marta Szebehely. Department of Social Work, Stockholm University, Sweden,; and Institute for Futures Studies, Stockholm, Sweden,
The idea that there is a need to increase the share of private financing of the costs of elder care
is expressed by several actors attempting to influence the direction of social policy Sweden
these days. This idea fundamentally challenges established ways of financing and organising
delivery of elder care services in Sweden. Underlying proposals for increasing private
financing is the claim that the future scope of public elder care provision must contract, both
vertically and horizontally. Underlying this claim is the assumption that both the quantity and
quality of services demanded will increase, while the supply of public funds cannot. Vertical
contraction aims to draw new funds from users willing to pay more to get higher quality
services. Horizontal contraction aims to reduce the scope of public sector’s responsibility in
service provision. This paper outlines recent developments in private provision of elder care
services and examines arguments and actors for increasing private financing. Although the
proposals have been put forward by influential actors, opposition to increasing private
financing has been expressed, and support for solidaristic funding of elder care remains
strong. Accordingly, we also consider these dissenting arguments and actors. Our purpose is
to set out and evaluate the arguments, evidence and interests behind the proposals, and the
likely outcomes of their implementation.
I dagens Sverige finns ett antal starka röster som argumenterar för att öka den privata
finansieringen av den svenska äldreomsorgen. Förslagen innebär ett drastiskt avsteg från
äldreomsorgens nuvarande finansiering, organisering och fördelning. Bakom förslagen ligger
antaganden om att medborgarnas anspråk på äldreomsorg kommer att öka i takt med
välståndsökningen i samhället, samtidigt som de offentliga resurserna inte kan öka. Den
offentliga äldreomsorgen måste därför avgränsas i höjd- och sidled. Vissa tjänster föreslås
helt tas bort från äldreomsorgen, medan andra tjänster endast ska erbjudas på en basnivå och
kompletteras med privat köpt hjälp. På så sätt förväntas en större del av äldreomsorgen
finansieras av de äldre själva. I denna rapport granskas problemdefinitionerna, argumenten
och aktörerna bakom kraven på ökad privat finansiering. Även om förslagen förs fram av
inflytelserika aktörer finns samtidigt ett starkt stöd för en fortsatt solidariskt finansierad
äldreomsorg. I rapporten presenteras även dessa röster: aktörer och argument mot ökad privat
finansiering. Avslutningsvis diskuteras de troliga konsekvenserna av en ökad privat
finansiering av äldreomsorgen.
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Private financing of elder care in Sweden: Arguments for and against................. 4
Introduction ......................................................................................................................... 4
Background: The evolution of privatisation in Swedish elder care .................... 4
Proposals to increase private financing .......................................................................... 7
Proponents of increased private financing ..................................................................... 9
In whose interests is increasing private financing? .............................................. 13
Dissenting voices: Actors and arguments against private financing ............... 18
Organised actors ............................................................................................................. 18
Public opinion on financing elder care ......................................................................... 20
Service users in elder care ............................................................................................. 22
Dynamic effects of increased private financing ..................................................... 23
Democratic impacts of increased private financing .............................................. 26
Conclusion ........................................................................................................................ 28
References ........................................................................................................................ 29
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Arbetsrapport/Working Paper 2010:1
Private financing of elder care in Sweden:
Arguments for and against
Gabrielle Meagher and Marta Szebehely
In recent decades, policies on elder care have changed in Sweden. This paper explores a
proposal for further policy change in this field of welfare services: increased private
financing; that is, increasing the extent to which services are financed by individual users, in
line with their capacity to pay. This proposal directly challenges the organising principle of
the Swedish welfare services system: that services are financed collectively so that need,
rather than purchasing power, determines who receives what.
Our aim is to contribute to debate about the future financing of welfare services, particularly
elder care. We believe that the arguments, evidence and interests behind proposals for
increasing private financing require close, critical scrutiny, and the likely outcomes of their
implementation need to be carefully assessed. This paper does not complete these tasks, but
we hope to raise some useful questions for further research alongside the analysis we are in a
position to develop and present.
Background: The evolution of privatisation in Swedish elder care
Before discussing proposals currently on the table, it is important to recognise that change in
the social service system in Sweden is not new. Indeed, one way of conceptualising the
current proposals for elder care is to see them as part of a process of privatisation that has
been going on for some time.1
Privatisation is a multi-dimensional process because the organisation of welfare services
involves separable activities, each of which can be undertaken by a different actor, or
combination of actors. Core activities include assessing need for services, financing services,
providing services, and overseeing their quality. A form of privatisation happens when one or
more of these activities are passed from the public sector to private sector actors. Private
sector actors include for-profit organisations in the market, non-profit or voluntary
organisations in the associational sphere, and service users and their families in the household
sector. Policy on welfare services largely determines the distribution of these activities
1 Trydegård (2003); Szebehely (2005).
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between the public sector and different private actors. Most welfare states operate with a
mixed economy, such that private and public actors are involved in all activities to a degree.
In the Nordic countries, including Sweden, the public sector plays a larger role in funding,
providing, and overseeing elder care services than elsewhere; nevertheless, as in all other
countries, informal care by family members is the most important.
Our focus in this paper is on proposals to increase the financing of elder care services by users
of elder care, in other words, on privatisation of financing by passing more of the cost from
the public sector (tax financing) to the household sector (user financing). This section
provides some brief background information about other shifts of elder care out of the public
sector, to give a context for the private financing proposal.
Several developments have accelerated the process of different forms of privatisation during
the 1990s. One is that, starting in the 1980s and accelerating during the economic crisis of the
1990s, public funding for elder care services has not kept pace with the ageing population.
Across the last three decades, there has been a decline in real spending per person aged over
80 years; indeed, since the 1990s, there has been an absolute decline in spending on elder care
services.2 As a result, municipalities have cut back services by increasing needs thresholds
and user fees. Between 1980 and 2005 the proportion of old people (80 years+) in the
population receiving home care services or living in residential care declined from 62 to 37
per cent.3 This decline can only to a small extent be explained by increased health among the
oldest old.4
When needs thresholds increase, users who do not meet the new, higher threshold are not able
to access tax-financed services, and must either purchase them on the market, accept support
from their family, or go without services. As a result of the decline in number of recipients of
tax funded elder care services, there has been an increase both of informal care and of care
purchased on the market.5
In order to mitigate the negative effects of the increasing user fees, a bill capping fees for
publicly financed elder care services was passed in 2002. However, the increase of informal
care as well as of care purchased on the market continued.6 In 2007 this latter strategy
2 Szebehely & Trydegård (2007); Socialstyrelsen (2009b).
3 Larsson & Szebehely (2006)
4 Thorslund et al 2004; Larsson (2006).
5 Szebehely (2005).
6 Szebehely & Trydegård (2007).
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ntives to
received a boost from a policy introducing personal income tax rebates of 50 per cent of
expenditure up to SEK 100,000 on household services, including care services. The rebate,
then, is up to SEK 50,000 per year per person.7
People have always had the opportunity to purchase services on the market with their own
funds. This kind of user-financed private provision has, until the introduction of the tax
rebate, sat outside direct policy influence. Although the level of publicly-financed provision
affects demand for privately funded and provided services, those who purchase services on
the market using their own funds do not have their needs assessed in the formal elder care
system. Accordingly, measuring the scale of these privately financed, market-provided care
and support services for the elderly is difficult. The new tax rebate generates some data.
Although not aimed at elderly people, 35 per cent of claimants are 65 years or older; twice
their share of the population. However, at least during its first year, the new tax rebate was
used by only a very small fraction of the elderly population, around one per cent.8
Further, the new Local Government Act of 1992 enabled municipalities to out-source
provision of tax-financed care services to non-government actors, both for-profit and non-
profit.9 Since then, there has been a growth in the proportion of services provided by for-
profit organisations. Although the Local Government Act opened up tax-financed provision t
the voluntary sector, growth in provision by non-profit organisations has been very modest,
and has certainly lagged behind growth in for-profit providers.10 Another market-oriented
legal reform was introduced in 2008; the LOV (Lag om valfrihet or Legislation on choice).
This act aims at making it easier for the municipalities to introduce a ‘customer choice’
(voucher) system for their publicly financed care services. At the same time state ince
municipalities were introduced to promote the development of voucher systems. These
incentives have been taken up by 60 percent of the Swedish municipalities.11
Despite these changes, collective financing of elder care through the tax system remains
generous in Sweden in comparative terms,12 and a large majority of tax-financed services
(around 85 per cent) continue to be publicly provided, when the nation as a whole is taken as
the unit of analysis. In 2008, in some municipalities, more than half provision is private. But
7 Socialstyrelsen (2008a).
8 Socialstyrelsen (2009b:17).
9 Gustafsson & Szebehely (2009: 84).
10 Gustafsson & Szebehely (2009).
11Socialstyrelsen (2008b).
12 OECD (2006: 31).
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the majority of municipalities do not purchase services from private companies – an outcome
of the deep decentralisation of social services organisation in Sweden.13 Further, private
financing is currently limited in the publicly-financed elder care system: around 5 per cent of
the cost of publicly funded care is financed by user fees.14
These facts suggest that we should be cautious about understanding – and projecting – ‘the
process of privatisation’ as an inexorable and irreversible retrenchment of public provision.
Very wide variation between municipalities in the extent of different kinds of privatisation is
stark evidence of the extent to which the process remains under political control.
Arguments and actors for increasing private financing in elder care
The idea that there is a need to increase the share of private financing of the costs of elder care
is widely expressed by actors attempting to influence the direction of social policy Sweden
these days.15 In this section, we seek to set out what the proposals are, who is making them,
and how they are arguing the case.
Proposals to increase private financing
With some differences of emphasis, and of level and content of detail, advocates rely on the
same arguments, and make similar policy proposals. Proposals are based on two broad
assumptions: i) that the quantity and quality of elder care demanded by users will increase,
and ii) that tax revenues cannot. Thus, additional, private funds need to be drawn into the
system to make up the gap between growing demand on one hand and the stable (or
declining) level of supply that taxes are able to finance on the other.
The assumption that demand will increase is explained by two factors. The most important in
more recent documents is rising incomes: proponents of private financing argue that, as
households’ incomes rise in line with economic forecasts, they will demand more and better
welfare services. Some variants of the argument rely on structural development of spending
ratios with no increase in tax rates: private consumption income is rising as a proportion of
GDP, while public consumption is declining, at ‘the level of tax rates that has been decided’.16
As household incomes rise and households’ economic welfare rises along with incomes,
13 Socialstyrelsen (2009a).
14 SOU 2004: 19 (2004: 139).
15 Some proposals deal with elderly care only (for example, Rollén & Wikman 2008), some with health and
elderly care (Borg 2008; 2009a; 2009b), and others deal with welfare services, defined as including health,
education and elderly and child care (SOU 2000:7; SOU 2004:19; SOU 2008:105; SALAR 2008).
16 SOU 2004:19, p. 50.
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proponents assume that, to remain acceptable to users, the quality of welfare services will
need to increase in line with private consumption.17 Others add what we might call a
generational-cultural inflection to this argument, to claim that the coming generation of
elderly people want something better from elder care than did the previous generation.18
Population ageing is also assumed to be driving quantitative demands – as proportion of
elderly people increases, the proportion of the population needing elder care services also
increases, while the size of the workforce paying taxes to fund these services decreases. A key
early official exploration of the issue of ‘future challenges for welfare systems’, in the Long
Term Survey of the Swedish economy for 1999/2000 discussed only the demographic driver.
The emergence of a ‘demanding user’ driver is a later development in the discourse.19 Indeed,
in the Long Term Survey of 2008, the ‘demanding user’ driver is the only problematic
development, since
According to the estimates in the base scenario, it would be possible to meet future
expenditure pressure from an increased percentage of elderly in the population with
no change in tax rates. Sweden is relatively well positioned in this respect compared
with other industrial countries with similar demographic trends.20
Proponents of increasing private financing also assume that tax cannot be increased to meet
future increases in demand. Increased taxes are generally posed as a threat to economic
growth, through a variety of mechanisms. Arguments include that international tax
competition constrains governments’ capacity to increase taxes.21 Negative effects on labour
supply are also considered a critical reason why taxes cannot be raised.22 Another problem is
that the relative cost of welfare services rises faster than the cost of other goods and services.
This is the so-called ‘Baumol effect’ or ‘cost-disease’ effect that arises because of difficulties
in increasing the productivity of labour intensive services such as elder care.23 Given this
problem, some proponents argue, to meet demand, taxes would come to consume the vast
majority of GNP.24 There is also the argument that if private financing is not increased, the
17 SOU 2004:19, p. 49-50; SOU 2008:105, p. 169-170.
18 Rollén & Wikman (2008).
19 SOU (2000:5, pp. 73-81; 104-109); SOU (2004:19, pp. 61, 65); Borg (2009a, pp. 6, 31, 35).
20 SOU (2008:105, p. 169). The ‘base scenario’ is the forecast of Sweden’s future public finance position,
assuming no changes to policies, including taxes. Similar conclusions are also drawn in SALAR (2008).
21 SOU (2000:5, pp. 90-92); SOU (2004:19, pp. 66-68).
22 SOU (2000:5 pp. 90-92); SOU (2004:19 pp. 66-68); SOU (2008: 105, p. 172).
23 SOU (2004: 19, pp. 50-53); SOU (2008:105, p. 176-78).
24 Swedish National Association of Local Authorities (2002: 76)
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e market.28
capacity of tax-financed welfare services to meet demand will be so compromised that tax-
payers will be no longer willing to pay taxes to support them.25
The mechanisms proposed for drawing in private funds are simple enough. For proponents, as
demand increases with population ageing, and users demand higher quality services, available
tax revenues will be enough to fund a basic level of service only.26 Thus, one option is that
policies change to allow users to buy services of a higher quality by ‘topping up’ with private
funds the tax-financed allocation for the basic service. Enabling topping up under this model
would involve placing a ceiling on the quality of services to be financed from taxation and so,
in effect, this is a proposal for vertical contraction of publicly financed elder care. Another
way rising demand can be met is by prioritising activities within service systems, such that a
horizontal contraction of tax-financed care occurs. On this model, activities such as cleaning
would no longer be offered as part of the welfare system.27 Thus, if consumers want
additional activities that are no longer included in the basic service, they can purchase them
with private funds on th
Proponents of increased private financing
One important institutional proponent of the idea of increasing private financing is the
Ministry of Finance, and the Long Term Surveys of the Swedish economy are a particularly
important platform. For decades, these surveys have sought to problematise the future
financing of welfare systems in Sweden.29 Over the last decade, the question of the future
financing of welfare services has become an even stronger focus in Ministry of Finance
publications.30 Indeed, the long-term survey of 2003/04 was entirely devoted to examining the
‘conditions for funding the welfare services that are expected to be in demand in the future’.31
In the Long Term Survey of 2008, the framing of ‘future challenges for welfare systems’ used
in the earlier surveys is replaced with the idea of ‘renewing’ welfare systems, but the
arguments for private financing remain much the same. Other official economic organisations
have also given support to the idea. For example, in its commentary on the Long Term Survey
25 SOU (2004:19, pp. 13, 69, 166).
26 SOU (2004: 19, pp. 160-61), SOU (2008:105, p. 194).
27 SOU (2004: 19, pp.157-59), SOU (2008:105, p. 194), Borg (2009a; 2009b).
28 The Long Term Survey of 2003/04 poses horizontal and vertical contraction as practical alternatives, but they
are not logical alternatives – both could be pursued at the same time (SOU 2004: 19, pp. 157-61).
29 Antman (1994).
30 SOU (2000:7); SOU (2004:19); SOU (2008:105). These studies also have more detailed appendices,
published separately, which explain and justify the positions put in the presumably more widely read surveys.
31 SOU (2004:19, p. 10).
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of 2003/04, the Riksbank (the Swedish Central Bank) agreed with the analysis, conclusions
and recommendations of the Ministry of Finance.32
Within the public sector, another very important player is the Swedish Association of Local
Authorities and Regions (SALAR), which is a politically-controlled employer organisation
for municipalities and county councils.33 This organisation is, in general, a key player in elder
care, because the highly independent municipalities it represents are responsible for collecting
taxes and funding and organising elder care services. The question of the future financing of
welfare services, including increasing private financing, has been on the agenda for some time
in the municipal sector. In 2002, the precursor body to SALAR, the Swedish National
Association of Local Authorities, issued its own long-term survey of needs and resources in
the municipal sector. This report argued that ‘services that today are tax-financed increasingly
must be financed in other ways’.34 In 2007, SALAR established a ‘Programme Committee on
the Financing of Welfare Provision’, with the stated goal of ‘promoting a broad debate among
its members’ about ‘the sustainable financing of welfare services’ in Sweden.35 In describing
the problem the committee is to investigate, the action plan for the committee set out the
SALAR leadership’s assumptions. These included the now familiar statement that increasing
demand for welfare services cannot be met by increased taxes, and that there is a need for
alternative means of financing these services. The action plan also included the following
rallying call for political action: ‘It’s important to package the message pedagogically and
accessibly in such a way as to be eye-opening, and maybe create some form of “crisis
consciousness”, and thus even get the message through to the broader society’.36
The need to create ‘crisis consciousness’ is also argued by Per Borg. Borg has developed a
model to show how change agents and the creation of crisis consciousness are necessary to
generate policy change.37 He is emerging as the most consistently heard voice in favour of
increasing private financing – or as he also calls it ‘increased citizen responsibility’. Now a
policy entrepreneur seeking to influence the future of welfare financing, Borg, a former Social
32 Sveriges Riksbank (2004). It is part of the Swedish democratic process that all citizens have the right to
comment any proposal made by the Government or a specific Ministry. Reports published by a government
commission (like the Long Term Survey) are circulated for consideration among different parties affected. We
draw here on the public, written comments submitted under this process by some key organisations.
33 Swedish National Association of Local Authorities (2002), SALAR (2008), Borg (2009a; 2009b).
34 Swedish National Association of Local Authorities (2002: 9).
35 Swedish Association of Local Authorities and Regions (2007: 1).
36 Swedish Association of Local Authorities and Regions (2007: 3).
37 Borg (2009a, pp. 38-40).
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Democratic ministerial adviser, has recently written three reports on the subject, one each for
the Ministries of Finance and Education and another for SALAR.38
Think tanks and employer organisations are also making concerted interventions on the
question of the future financing of welfare services. The market-oriented think-tank, Timbro,
has been active, with claims that ‘the people are ready for private financing – are the
politicians with them?39 Employer organisations, including the Confederation of Swedish
Enterprise (Svenskt Näringsliv), Almega, and Vårdföretagarna (Care Companies) have also
produced reports in this area, with the aim of influencing policy.
The Confederation of Swedish Enterprise is Sweden’s largest and most influential business
federation. It represents 50 member organisations and 54,000 member companies with some
1.5 million employees. It was established in 2001 following the merger between the Swedish
Employers’ Confederation (SAF, founded in 1902) and the Federation of Swedish Industry
(SI, founded in 1910). One of the Confederation’s member organisations is Almega, the
employer and interest organisation for service industries, which has 9,200 member companies
with 420,000 employees. Vårdföretagarna is a member of Almega and thus also of the
Confederation, and is the interest organisation for private employers in the health and social
care sector. Vårdföretagarna represents 1,800 employers with 50,000 employees.
Interestingly, some of the arguments on private financing have been put earlier by employer
organisations. In 1997, the Federation of Swedish Industry argued for opening up health care
for competition and for private provision and financing.40 More recently a report from the
Confederation of Swedish Enterprise in 2005 argues strongly against raising taxes and equally
strongly for increasing private financing for elder care, through the instrument of mandatory
insurance, to be paid by those 50 years and older in the population.41 In keeping with the trend
towards generating crisis consciousness, the report is called Listen to the rain before it falls.
The report stresses that such insurance has to be administered by private insurance companies,
including the right of ‘topping-up’, and the Confederation expects that a market for a variety
38 Borg (2008; 2009a; 2009b).
39 Timbro (2009).
40 Federation of Swedish Industry (1997), see also Gustafsson (2000).
41 Hansson (2005).
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of extra products and services will emerge.42 This mode of financing is strongly related to a
voucher system and the different private providers’ possibilities to offer extra services.
All the actors on the provider side mentioned here argue strongly for more private provision.43
But representatives of provider groups within the elder care industry do not argue against
public financing. From their perspective it is the relatively generous tax funding of elder care
which makes Sweden such an attractive market for private providers. However, a report from
Nutek (now called Tillväxtverket) together with Almega, points out health and social care as
an ‘industry of the future’. In the report it is argued that ‘in order to be able to meet new
needs, and therefore create conditions for the expansion of the industry, a key question is the
possibilities for drawing in increased resources’.44 This report also argues that service users
should have the opportunity to pay for ’extra services’ from private providers delivering tax
funded services to them.45 Further, the report asserts that the government must make clear its
strategy for the future financing and resource development of health and care, and that it is
important that it is made clear what is to be financed by taxes and what citizens will be
expected to pay from their own pockets. Not surprisingly Almega makes similar arguments in
their response to the 2008 Long Term Survey, and stresses the need for more private
financing of welfare services.46
The role of the right wing parties is a little more difficult to discern. The policy platform of
the Moderates, for example, says that elder care shall be tax financed, and emphasises choice
of providers rather than changing financing. But at the same time the Moderates have claimed
to be the party of tax cuts, and that they will continue to reduce taxes.47 This would seem to
create precisely the problem that the Long Term Surveys highlight: that private consumption
is increasing faster than public, so that tax-financing of welfare services comes under severe
Alongside formally organised interests within Sweden, individuals with various connections
to these institutional actors, both public and private, have contributed to raising and
publicising the proposal for increasing private financing. For example, former senior civil
42 Hansson (2005, p. 74).
43 In recent years the Confederation of Swedish Enterprises and its member organisation Almega have been very
active in advocating private provision and competition. See, for example, Confederation of Swedish Enterprises
(2006), Almega (2008a; 2009).
44 Nutek (2007, p. 50).
45 Nutek (2007, p. 50).
46 Almega (2008b).
47 Äldreomsorgen ska vara offentligt finansierad. From
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servants at both national and region levels, Berit Rollén and Monika Olin Wikman, support
increased private financing in their book, titled We don’t want to get old, the way elder care
looks today (2008). They argue that middle class people born in the 1940s will not be satisfied
with the present quality of Swedish elder care, and that more private financing is needed to
meet the increasing demands.
International organisational actors are also involved. International support for the idea is also
offered by the OECD in its surveys of the Swedish economy, which recommend increasing
private financing in welfare services alongside its routine recommendations for (further)
privatisation, tax cuts and liberalisation of the labour market.48
In whose interests is increasing private financing?
Concerted calls for profound change to social policy from a range of actors are unlikely to
arise at random, or to be detached from organised interests of some kind. In this section, we
try to understand whose interest proposals for private financing might serve.
Private companies have a clear interest in increasing the private provision of tax-financed
welfare services in Sweden, where public subsidies are secure, and very generous by
international standards. These companies also have an interest in the opening up of market
opportunities within and around tax-financed services, particularly in the ‘topping up’
arrangements that allow companies providing tax-financed services to offer additional
services to subsidised customers. Such a situation would create opportunities to tap a pool of
relatively unregulated funds on top of large, secure subsidies.
Since the private sector entered the field of elder care services in Sweden in the early 1990s,
both the number and the size of private companies have increased. According to
Socialstyrelsen there were 170 companies providing elder care in Sweden in 2003 compared
to 120 in 1999. In 2003 the five largest actors had 60 per cent of the private market.49 The
increased use of voucher systems is probably leading to an increasing number of small
companies, especially in home care, but today there are four large companies at the elder care
market: Attendo Care, Carema, Aleris and Förenade Care.50 In 2008 the two biggest of these
actors, Attendo Care and Carema, seem to have at least half of the tax-funded, privately
48 See, for example, OECD (2008). However, also the OECD expects a need for significantly increased public
spending on elder care in all the OECD countries; interestingly enough least so in Sweden (OECD 2006).
49 Socialstyrelsen (2003).
50 Stolt & Jansson (2006); Dagens Samhälle (2008).
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provided care market or 6-7 per cent of the entire elder care sector.51 This industry profile is
the result of a period of merger and take-over activity in the elder care market since 1997.52
Attendo Care is the largest of the private actors on the Swedish elder care market. In 2008,
more than 10,000 persons (7,000 FTE) were employed by the company in almost one third of
the Swedish municipalities. Attendo Care is part of Attendo, a company which, besides care
for older and disabled people in Sweden, also runs elder care companies in Finland, Denmark
and Norway as well as health care services in Finland. The turnover for Attendo Care was 3.6
billion SEK in 2008 while the turnover for the entire company (Attendo) was 4.9 billion. In
2005 the British private equity company Bridgepoint bought Attendo but today the company
is owned by the Swedish private equity company Industrikapital.53 Between 2004 and 2008
the growth of Attendo Care’s turnover was 265 percent.54
The second biggest elder care actor, Carema, is engaged in both elder and health care. In
2008, at total of 11,600 persons were employed in the company; 9,700 of them (4,300 FTE) in
the elder care sector. Carema runs 139 elder care work places in Sweden and three in Norway.
The turnover was 2.9 billion SEK in 2008, of which 2.25 billion SEK in the elder care sector
– an increase of 180 percent since 2004. The largest owner of Carema is the international
private equity company 3i, which owns 75 percent of the shares.55
Between 2004 and 2008 the number of elderly people receiving their tax funded care by
privately employed care workers increased by approximately 25 per cent.56 Thus the two
largest companies have grown much faster than the entire private care sector. As a result they
most probably also have become a stronger voice when it comes to affecting Swedish elder
care policy.
In a study from 2006, top business representatives for Attendo, Carema and Aleris were
interviewed. The study does not explicitly focus on the financing of care services, but the
three interviewees believed that there will be an increase of private financing; however, they
expected that the vast majority of the financing will be public also in the future.
51 According to Konkurrensverket (2009:13) these two actors have half the private home care market, and
according to Dagens Samhälle (2008:4) Attendo and Carema have half the private elderly care market while
Aleris and Förenade Care have 10 per cent each.
52 Stolt & Jansson (2006, p. 33).
53 Attendo Care (2008).
54 Attendo (2009a; 2009b).
55 Carema (2009).
56 Calculated from Socialstyrelsen (2005) and (2009a).
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Unsurprisingly, given the context of ongoing and generous tax financing, and the potential for
increased private financing, all three companies expressed a very positive view on the future.
They expected their companies to grow at an annual rate of 10 per cent, such that, in the
longer term the private elder care sector in Sweden will have a presence comparable that of
the private sector in the United Kingdom, where two thirds of all elder care is privately run.
The authors of the report interpret the fact that all three companies are owned by private
equity firms as a sign of high expectations of growth and profitability on invested capital.57 A
similar positive view on the possibility to expand the private care market is found in
documents from Vårdföretagarna (the employer organisation for care companies), which
expects that private providers will have 25 per cent of tax-funded health and social care in
2012 and in the longer term they expect to have half the market.58
The broader context of these developments is the ‘financialisation’ of the global economy.
The vast accumulation of private financial assets seeking investment opportunities and the
pressures on public budgets combine to create strong interests in privatisation among
investors and governments. According to political economist, Joseph Huffschmid, private
equity firms are playing a leading role in opening new areas for investment, such as public
assets and services.59
Financialisation has also created significant growth in income and wealth at the top of the
income distribution.60 Increased inequality and strong growth of top incomes creates a social
group with resources and demands that are outside social norms: citizens with very high
relative incomes have little economic interest in redistribution of income or in maintaining
and extending public services. Evidence on the changing distribution of income in Sweden
shows that inequality in real disposable income has increased a great deal since the mid
1990s. In 1995, the Gini co-efficient was 0.227; in 2004 it was 0.258, and by 2007, it had
reached 0.307. Although average real incomes grew in every decile across the period, growth
was higher in the top half of the income distribution, and highest at the top. In the top decile,
average real income grew 117 per cent, compared to 57 per cent in the ninth (next highest)
57 Stolt & Jansson (2006) In their Annual Reports for 2008, both Attendo and Carema are still very optimistic.
The annual report from Attendo for 2009 claimed that the company had ‘good prospects of improved
development during 2009 towards the long-term goal of becoming Europe’s leading care company’ (Attendo
2009, p. 3), while Carema’s annual report claimed: ‘2008 was one of Carema’s most successful years to date.
This suggests positive developments will continue during 2009’ (Carema 2009, p. 5).
58 Vårdföretagarna (2009).
59 Huffschmid (2008).
60 Roine & Waldenström (2008).
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decile, and 44 per cent in the median. At the 95th percentile, average incomes grew 149 per
cent, and in the 99th percentile, real income growth among these very high earners was well
over 200 per cent.61
This pulling away of high incomes, driven by earnings on capital in the form of dividends and
capital gains, intensifies the socio-economic gap between the highest income group on one
hand and the rest of the population on the other, even though inequality has grown within the
rest of the population too. This development in the income distribution, one would expect,
intensifies differences in the interests of the two groups in the welfare state and its financing.
There is evidence that the opinion of elite groups diverged from the mainstream views and
values of the Swedish population before the recent increase in equality. One key study was
undertaken a decade ago by Stefan Svallfors, who sought to understand the impact on
attitudes of the welfare state retrenchment that had occurred in Sweden during the economic
crisis of the 1990s. Svallfors argues that when income replacement levels and service quality
had been high before the crisis, there were ‘few incentives for broad sections of non-manual
employees to opt out of the welfare state’. But, he goes on to ask, ‘how will members of the
middle class react to welfare state retrenchment, when replacement levels are lowered and the
quality of services decline? Will they come to the defence of welfare policies, or will they opt
for private solutions?’62 Although the context prompting the questions was different, the
structure of the ‘problem’ is much the same as that assumed by proponents of private
financing: that a resources gap has or will open between the demands of the middle class and
what the public system can offer.
Svallfors’ study considered two dimensions of privatisation: provision and financing of
services. Using occupational data to define classes, Svallfors found little support for the
polarisation hypothesis overall, during his study period (1992-1996). In general, support for
public provision and public financing of welfare services was high among the middle and
working classes in both periods, in line with findings from studies we discussed earlier. What
he did find was that the elite group of ‘upper level executives’ had negative views on public
financing of welfare services that diverged significantly from other middle class groups, and
the working class. He speculates in the concluding discussion that this divergence might be
61 Statistics Sweden (2009). In 2008, the Gini coefficient fell to 0.289, due to a fall in average incomes in the top
decile. Falls were sharpest in the top 5 per cent of the income distribution, presumably because of the Global
Financial Crisis.
62 Svallfors (1999: 35).
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explained by the personal economic success of members of this group, social distance
between them and those affected negatively by the crisis, and the evident impact of neo-
liberal ideas on their attitudes.
Our own analysis of data from the International Social Survey Program a decade later
confirms Svallfors findings. Although there is an income gradient towards the top of the
distribution, the top decile of household income is the only income group that, on average,
does not support increased government spending on health and retirement (see chart 1).
Chart 1: Preferences for more spending on health and retirement, mean scores, by
decile of family income, Sweden, 200663
-1 -0,5 0 0,5 1 1,5 2 2,5 3 3,5
Bottom decile
2nd decile
3rd decile
4th decile
5th decile
6th decile
7th decile
8th decile
9th decile
Top decile
Source: International Social Survey Program, 2006.
The findings of these attitudes studies are interesting for our argument in two ways. First, an
elite group that is relatively hostile to the public sector exists in Sweden. We suggest that this
is a group with a strong voice in the present public debate about elder care. Second, and a
point to which we return in the next section, the lack of divergence on attitudes to the public
63 The question asked respondents to say whether they thought the government should spend more or less on a
range of activities among them health and retirement. These provide a rough measure of support for elderly
people – they are not a direct measure of support for public spending on elder care. Response categories for the
question were ‘spend much more, spend more, spend the same as now, spend less, spend much less’, as well as a
‘can’t choose’ category, which was excluded from this analysis. Responses were recoded into a 10 point scale,
shown in this chart centred on 0 (-5 to +5). This chart presents the summed, mean scores of individuals’
preferences for spending on health and retirement, with 0 as the neutral preference (spend the same as now).
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sector between the middle and low income groups provides some evidence against the claims
of ‘rising demands’ made by proponents of private financing and public sector contraction.
The middle class is not turning away en masse from the public system in search of a new,
higher tier of services for itself in the private sector. Thus, elite opinion on these issues
diverges markedly from the mainstream of Swedish opinion – including the middle class.
Dissenting voices: Actors and arguments against private financing
Proponents of private financing form a significant and influential group of policy actors.
However, there is not a political consensus on the idea that increasing private financing is the
key to the secure future of high quality welfare services in Sweden. Some organised actors,
majority public opinion, and assessments of elder care services by their users all challenge the
assumptions and arguments of proponents of increasing private financing.
Organised actors
In the final report of a policy consultation process on the future of welfare policy, the Social
Democrats (SAP) make a renewed commitment to solidaristic funding of welfare services,
and to continuing the relatively high level of taxation required to do so. According to the
SAP’s proposal, ‘One should not need to pay extra to get good quality in publicly financed
welfare’. That said, to enable citizens to choose among diverse alternatives, the SAP
continues to welcome private providers of welfare services, suitably regulated to protect
quality, equity and the public purse.64
Further, one of the largest organisations of the elderly themselves, who have a keen interest in
the future of welfare services, has expressed opposition to increasing private financing. The
National Organisation of Pensioners (PRO), via its response to the Long Term Survey for
2008, explicitly rejects the Survey’s recommendation that an official inquiry be established to
investigate the possibilities for increased private financing of welfare services. Instead, these
services ‘should be financed solidaristically’. According to PRO, ‘An increase in private
financing leads to negative distributional effects and deepens divisions in society. Welfare
services should be distributed according to needs and not capacity to pay’.65
The most articulate dissenting voice probably belongs to the LO economists. The economists
of LO, the Swedish Trade Union Confederation, produced a strong counter argument to the
64 Social Democrats (2009, pp. 12-16).
65 National Organisation of Pensioners [PRO, Pensionärernas Riksorganisation] (2009).
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2004 Long Term Survey.66 Similar but less developed counter arguments are voiced by LO in
its response to the 2008 Long Term Survey.67
The LO economists agree with the 2004 Long Term Survey that there will be increased
demand for welfare services. In opposition to the LTS, however, they expect that this can be
met by increased public spending but they also argue that it is possible to increase the
productivity in welfare services. They start with discussing two options for increased private
financing suggested by LTS: increased user fees and private insurances. The first is ruled out
with the argument that even drastically increased fees would not cover the expected increased
need for resources; the second is ruled out with the argument that it would lead to very limited
gain in efficiency but a great loss in justice.68 Instead different ways of increasing the public
financing are discussed: raising income taxes, raising the goods and services tax, or
introducing a mandatory elder care insurance financed by a ‘generational tax’ (a tax paid only
by those 50 to 65 years old) earmarked for spending on elder care in a ‘generational fund’.69
The LO economists argue most strongly for the last alternative. The reasoning is that it is
important both that there will be enough public resources in the future and that the citizens
can trust that these resources will be used for accessible and high quality care services. The
ideal is therefore a form of public financing which has the same distributional effects as a tax
but without affecting individuals’ working and consuming behaviours. They argue that people
in the suggested age group have both the capacity and the willingness to pay an extra tax to
meet their future elder care needs. People with higher incomes would pay somewhat more,
while the standard of the services would be equal for everybody.
The idea behind saving money in a fund is to make sure that there will be enough resources
for future needs (to be used twenty years ahead when there will be a rapid increase in the
proportion of people aged 80 and over in the population). It is argued that such a fund in the
first place should be built up by the suggested ‘generational tax’ administered at the state
level, but an alternative could be increased municipal or goods and service taxes.
In its response to the 2008 LTS, the generational tax or the generational fund is not
mentioned. Instead the LO stresses the possibility to increase the tax base by different
66 LO (2004). Kan framtidens välfärd finansieras? – LO om LU is a 100 page publication aimed both as a
response to the Ministry of Finance and to a wider audience.
67 LO (2009) LOs yttrande över Långtidsutredningen 2008 (SOU 2008:105) is signed by the president of LO and
is a shorter (11 pages) comment sent to the Ministry of Finance.
68 LO (2004, p. 58).
69 Mandatory elderly care insurance schemes have been suggested by a number of actors among them the
National Social Insurance Board (today Swedish Social Insurance Agency) (2001).
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measures to increase the labour market participation, but increased taxes are not ruled out.
The LTS is criticised for its focus on welfare services as a cost, without regard to their
positive effects on productivity more broadly. In particular the role of women in providing
informal care for elderly people is stressed, and it is argued that reduced public elder care
services will negatively affect women’s labour market participation. Finally, the LO
welcomes the suggestion of a parliamentary commission on the financing of welfare services
but, in contrast to the LTS, such a commission should not only focus on increased private
financing. Instead the commission must also analyse how welfare services can be developed
through public financing, for instance by alternative forms of taxation.
Public opinion on financing elder care
As already discussed above, survey evidence shows widespread public support for a tax
funded welfare state. Indeed, surveys conducted over decades show a relatively stable balance
of opinion against reducing the size of the public sector in Sweden since the late 1990s.70 On
more specific questions about preferences for elder care provision and financing, survey
evidence is clear. On average, Swedes prefer raising taxes to increasing private financing and
raising taxes to decreasing service quality in elder care.
A survey conducted in 2008 on behalf of SALAR asked respondents whether, if their
municipality was to have a good economic result in the following year, would they prefer it to
increase the quality of a range of services or to reduce taxes.71 The vast majority – 93 per cent
– preferred increased quality in elder care to tax cuts. Asked if they would consider paying
higher taxes to increase the quality of elder care for all, 83 per cent responded ‘yes’. This is
clear evidence that solidaristic norms remain strong. However, a high proportion (78 per cent)
is also willing to pay extra to get better elder care services for themselves. Respondents were
also asked to choose between higher pensions, which are paid to individuals, or increasing
staffing levels in elder care, which benefits older people needing care in general. Opinion was
more than 2:1 against increasing pensions; 68 per cent preferred increasing staff levels in
elder care, while 29 per cent preferred higher pensions. These results confirm the finding of
an earlier study of attitudes to tax increases over time, which found stable majority support for
70 Holmberg & Weibull (2008).
71 SALAR and Synovate (2008). The survey asked about elder care, schools, health care, child care, leisure
activities, public transport and cultural activities. We discuss the findings on elder care only here.
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paying more taxes, if they were to be spent on support to the elderly (including pensions and
care) between 1997 and 2002.72
There is some opportunity to test the idea of middle class rejection of collective solutions with
the data from the SALAR survey, using university education to distinguish the middle class.
The survey data reveal no significant differences between educational groups in the
preference for tax cuts over quality increases or in preferences for pension increases over
increasing personnel in elder care services. On the question of willingness to pay more to
receive higher quality services for oneself, the findings on class are more complex:
respondents with the lowest level of education (compulsory schooling only) and with the
highest level of education (university degree) are somewhat more willing to pay than the
middle group (those who completed upper secondary school). In other words, while there is
some difference by education, there is no evidence of a clear class cleavage.
In the context of general support for public financing of welfare services, interpreting
widespread willingness to pay extra requires a little more discussion. Our interpretation is that
Swedes believe that it is important that more resources be devoted to elder care, and that they
are personally willing, through the tax system and by personal contributions, to devote more
of their own resources to it.
Very strong preferences for formal care in Sweden are also likely to underpin the willingness,
expressed by all social classes, to devote more resources to elder care services. A
Eurobarometer survey on long-term care in 2007 found that Swedes are more likely to prefer
formal elder care than citizens of any other European country. Eighty per cent of Swedish
respondents believed that formal home care or residential care is the best option for elderly
parents, compared to the EU-27 average of 37 per cent. Denmark came second with 72 per
cent preference for formal care.73 In comparative perspective, also, trust in elder care
personnel is high in Sweden. Swedish respondents were among those most likely to agree
with the statement that ‘Professional care staff looking after dependent elderly people are
72 Svallfors (2003).
73 Eurobarometer (2007, p. 67). The survey asked respondents to choose what they thought was the best option
for an elderly parent no longer able to live at home without regular help. The options offered were that the parent
should live with one of their children; public or private service providers should visit the parent’s home and
provide them with services; one of their children should visit regularly to provide the necessary care; and the
parent should move to a nursing home. To create a measure of formal care, we added the proportion of those
respondents choosing service providers coming to the home and nursing home together.
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highly committed to doing an excellent job’ (80 per cent, compared to the EU-27 mean of 59
per cent).74
The strong support for formal care services found in the Eurobarometer survey confirmed an
earlier national study in Sweden, which contributes a further important detail. Among the
large majority preferring formal care, publicly provided care is strongly favoured over care
provided by companies under outsourcing arrangements, and over care purchased privately on
the market.75
We pointed out in an earlier section that informalisation of care is underway in Sweden.
Further informalisation of care is unlikely to be popular among Swedes, a large majority of
whom already see the extent of informal care as burdensome. The Eurobarometer in 2007
found that 70 per cent agreed that ‘Dependent people have to rely too much on their relatives’,
compared to the EU-27 mean of 71 per cent, and the lowest reported result of 42 per cent in
Denmark.76 Presumably, Denmark’s low score on this measure can be explained by the very
high coverage of elder care services in that country.77
Service users in elder care
There is little evidence to suggest widespread or deep dissatisfaction with the quality of elder
care services today. The Socialstyrelsen (National Board of Health and Welfare) conducted a
national study of user satisfaction with elder care in 2008.78 A mail survey was sent to more
than two thirds of all elder care recipients of tax funded elder care services in Sweden. The
response rate was 72 per cent for those receiving home care and 61 per cent for those in
residential care (91,000 respondents altogether).79
The study shows that, on a scale of one to ten, the average level of satisfaction with both
home care and residential care services was around seven. The elements of service quality
receiving the highest scores were the way in which elderly people felt they were treated
(bemötande), the scope of the help offered and, in residential care, the housing standard of the
facility. Elements receiving the lowest scores were information, social activities and food. Of
74 Eurobarometer (2007, p. 74).
75 Szebehely and Trydegård (2007, p. 212).
76 Eurobarometer (2007, p. 73).
77 Nososco (2008).
78 Socialstyrelsen (2009c).
79 A majority of the home care recipients filled in the survey themselves, but among the elderly in residential
care the survey was most often filled out by a family member, reflecting the poor health, mainly dementia,
among elderly in residential care.
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particular interest here is that the study found no class difference in evaluations of service
quality, neither in home based nor in residential care. Elderly people with a university
education are just as satisfied with the services as are elderly people with compulsory
education only, and former senior salaried employees are as satisfied as former unskilled
The survey shows that, overall, satisfaction with the quality of elder care services is
reasonably high. Significantly, there does not seem to be any sign of dissatisfaction among the
middle class. Important in this context is that, in Sweden, people from all income groups use
tax-funded services. Some studies suggest no difference in patterns of use of tax-financed
elder care services between class groups.80 One study has found some evidence that people
with higher levels of education are slightly more likely to receive home help and to be in
residential care.81
Dynamic effects of increased private financing
Policy that changes the structure of welfare institutions by changing the roles of the public
sector, the market and households in financing, providing and overseeing welfare services
will have dynamic effects that emerge over time. What would be the effect of increasing
private financing on the distribution of elder care services? Is increasing private financing
likely to improve the quality and quantity of care services available in Sweden?
Changes to means of financing care are also linked to changes in means of providing care. At
the institutional level, even if the current absolute size of public sector provision does not
shrink, the share of the private sector (both market and household) will necessarily rise with
horizontal and vertical contraction of public financing. It is extremely unlikely that
proponents of private financing envisage that the public sector will get involved in selling
additional or supra-basic services on the open market! Actually, in contrast to private
providers of tax funded home care services, public providers are legally forbidden to offer
‘extra’ services. Under Sweden’s free choice model, then, the private providers have an
advantage in the competition.82 As mentioned in the background section of this paper, in 2008
a new piece of legislation was introduced with the aim of facilitating the introduction of a
voucher system for care services in the municipalities. The Government Bill that preceded the
new legislation stresses that an important aspect of the free choice model is that it gives
80 Szebehely (1999; 2009); Szebehely & Trydegård (2007).
81 Larsson (2004).
82 Szebehely & Vabø (2009).
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‘external suppliers’ (that is, private providers) the ‘possibility to offer extra services and
hence increase their operation and reach a higher profitability’.83 Further, given the very slow
growth of non-profit providers in elder care compared with for-profit providers over the last
decade and a half, within the private sector, growth is likely to be concentrated among for-
profit providers. Thus, privatisation of financing would entail further marketisation of
provision of elder care.
Proponents of marketisation of services typically believe that services will be more efficient
and of higher quality than public services, because of the effect of competition.84 This means
the same resources should yield a greater amount and/or better quality of service. Yet as the
Long Term Surveys themselves argue, the labour-intensive nature of welfare services such as
elder care means that productivity improvements are difficult to make, regardless of the
competitive environment. In other words, when private organisations take on the activities of
public sector organisations, the properties of those activities do not change. Thus, it is
difficult to see how changing the institutional environment can significantly improve the
efficiency of welfare services.
Indeed, there is reason to believe that marketisation of welfare services actually increases the
total social costs of elder care. With a system of public financing, or mixed public and private
financing, private provision increases the transactions cost of organising services at the inter-
institutional level.85 Under outsourcing models, for example, contracts must be written and
performance monitored ‘at arms length’. Under user choice models, a variety of costs may
increase at the level of provider organisations. One example is the increased cost of travel
time in home care organisations that offer services not to a defined local area, but to
‘customers’ who choose them from within a much larger geographical area. Private providers
also have an interest in increasing the scope of needs for which users receive public subsidies,
to increase their income.86
83 Government Bill 2008/09:29 (p. 123).
84 Competition Commission (Konkurrenskommittén) (1991).
85 There is very little information on transaction costs in Sweden but according to the National Board of Health
and Welfare the public expenditure in 2003 was somewhat higher in the municipalities that had introduced
competitive tendering of elderly care services compared to those where all the services were still public. The
Board is very cautious about the basis for the analysis, but concludes that competitive tendering of elderly care
does not seem to have lowered the costs (Socialstyrelsen 2004, p. 8).
86 This has been shown to be the case in the personal assistance scheme for disabled people: the average number
of hours used has increased much faster for those using for-profit companies organising their assistance than for
those who receive assistance from a municipal provider (Roos 2009, p. 53). The users are more satisfied with the
non-public providers, but the very rapid increase of the costs of personal assistance is a worry for Swedish policy
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Another likely economic consequence of increasing private financing is informalisation of
elder care. Proponents of private financing assume or expect the market to replace publicly
funded care services. However, as the experience of contractions over recent decades shows,
for many elderly people, both horizontal and vertical contraction of tax-financed services
means turning to informal care. Family support has increased both as a substitute for tax
funded home care among older people with smaller care needs (as a result of horizontal
contraction) and as complement to home care for those with larger care needs who still receive
home care but not enough hours (as a result of vertical contraction). The informalisation of
care particularly affects elderly people with low levels of education, while those with more
resources have instead turned to the market to buy services.87 Middle aged women, in
particular, have increased their help to their elderly parents.88 According to one calculation,
the share of the total number of hours of care provided by friends and family to older people
living at home increased from 60 to 70 percent during the 1990s.89 (The remainder was
provided by formal, tax-funded services; private, out-of-pocket services were not considered.)
On the face of it this is a cost-saving: unpaid care replaces tax-financed paid care. Yet unpaid
carers might otherwise themselves be employed and paying taxes. Women who provide help
to a person outside their own household (often a parent) at least a couple of times a week run
twice the risk of being outside the labour market compared to same age women who do not
provide regular help.90 In 2002-03 there were 80,000 individuals in Sweden (three quarters of
them women) who reported care of an older or disabled family member as the main reason for
working part time or not being gainfully employed.91 The financial cost for the individual in
terms of loss of present income and reduced pension is obvious, but so is also the loss of
municipal tax income, as the LO economists argue in their response to the 2008 Long Term
Reducing the scope of publicly financed elder care may also have other costs. We have seen
that one key proposal for increasing private financing is horizontal contraction, so that
services such as housekeeping are removed completely from the publicly financed care
system, and left for service users to organise for themselves. User fees and changes to needs
assessment practices discussed above have already commenced this process. However, one
makers, and it has been suggested that profit-maximising private companies may have contributed to this
87 Szebehely & Trydegård (2007).
88 Johansson et al. (2003).
89 Sundström et al. (2002).
90 Szebehely (2006:449).
91 Szebehely & Ulmanen (2008).
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reason why publicly-financed services exist is to provide necessary services to those who
could not or would not buy them for themselves, because of lack of money, information, or
capacity to weigh the costs and benefits in their own or the general interest. Tax-funded home
care can also have a significant preventive function, reducing demands on the health care
system and on (more expensive) residential elder care. The horizontal contraction that has
already occurred has cut back services to elderly people who might have previously been
offered a small amount of help and/or some assistance with cleaning and other household
tasks. This kind of help constitutes a small proportion of elder care spending, and a very small
proportion of welfare service spending overall, yet it can lead to considerable cost savings.
This was the argument behind a Danish legislative reform which since 1998 made in
compulsory for Danish municipalities to twice yearly offer a ‘preventive home visit’ to all
elderly people, 75 years and older. The aim of the visits is to inform citizens about how to
improve their health, but also about the services available and to inform the local authority
about potential unmet care needs in the population. This law was introduced after a study in
one municipality showing that small amounts of help could postpone institutionalisation (in
residential care as well as in hospitals).92 In contrast to Sweden, the care services are also free
of charge from the user’s point of view. Both Denmark and Sweden are big spenders on elder
care. But in relation to the numbers of elderly people Sweden spends more, while Danish
elder care services reach a much larger proportion of the population.93 The more generous
provision of small amounts of help might be the reason behind this.
Democratic impacts of increased private financing
If new forms of private financing were to be introduced into elder care, the democratic
steering, regulation and responsiveness of the service system are likely to be affected. We
have already considered the Swedish public’s attitudes to public provision and financing of
elder care. In this section we consider the issues of oversight of service quality raised by
increasing private financing.
Market models, whether financed by taxes or privately, rely on exit rather than voice for
quality regulation. There is some evidence that voice options in publicly financed and
92 Vass et al. (2005a; 2005b).
93 Nososco (2008).
Institutet för Framtidsstudier/Institute for Futures Studies
Arbetsrapport/Working Paper 2010:1
publicly provided elder care is less than ideal.94 However, it is not clear that leaving quality
‘regulation’ to the market mechanism is the best alternative.
The Swedish National Audit Office released a much publicised report on private elder care in
2008. The Audit Office criticised the state for not taking full responsibility for securing the
quality of privately provided elder care. Privately and publicly provided tax-funded elder care
are regulated by different legislation. For instance, the municipalities do not have the same
right to control out-sourced services as they do for publicly run services; publicly but not
privately employed workers are guaranteed protection from reprisals if they become whistle-
blowers; and while publicly employed care workers are required to report abuse and other
problems to the local politicians, the privately employed care workers are required only to
report to their managers (and thus to the employers/owners). The Audit Office concluded:
‘Altogether there is a risk that bad conditions within privately provided elder care go
The local political control of tax funded welfare services is specific to the Nordic welfare
municipalities. From a democracy perspective it is therefore important to note that there is a
greater distance between local politicians and care workers who are privately employed, as
suggested by the Audit Office report. A study of Swedish care workers points in the same
direction: while publicly employed care workers regard the local politicians as a supportive
factor for their working conditions and for the quality of care, their colleagues working in out-
sourced elder care hope for and expect less of local politicians. Thus the increased
privatisation of elder care provision tends to diminish care workers’ belief in political steering
of elder care in Sweden.96
The democracy aspects of privatisation are also stressed in one of the more elaborate counter
arguments to privatisation. In a report Ta tillbaka demokratin! [Take democracy back!] from
the Social-Democratic think-tank, Anne-Marie Lindgren, discusses deregulation and
privatisation of, among other areas, elder care. She focuses the marketisation of provision
rather than the issue of private financing and stresses the importance of administrative,
economic and political regulation of private provision. She argues that privatisation so far has
been governed by a naïve and romanticized – or too ideology-driven – conception of how
markets actually function. She is not dismissive of choice, but reminds us of the interests of
94 Persson and Berg (2009).
95 Riksrevisionen (2008:7)
96 Gustafsson & Szebehely (2009).
Institutet för Framtidsstudier/Institute for Futures Studies
Arbetsrapport/Working Paper 2010:1
the producers: the market for welfare services is characterized by increasing demands, is
insensitive to business cycles and relies on guaranteed financing through tax money.
Therefore, she argues, it is important to secure political control over the distribution of
welfare services. The market can never serve as a mechanism for fair and equitable
distribution of welfare, and she ends the report: ‘It is time to take back democratic influence
over the tax-funded sector’.97
The proposals we have discussed fundamentally challenge established ways of financing and
organising delivery of social services in Sweden. Indeed, the concluding section of the Long
Term Survey of 2003/04 is called ‘New funding requires new objectives’, and the final
paragraphs of the entire report, before the summary is presented, include the following:
… a greater element of private funding in addition to the funding provided by taxes
… means that the demand for welfare services would be determined by the contents
of an individual’s wallet to an increased extent. This would be in conflict with the
fundamental objective that welfare services are to be provided according to need,
irrespective of ability to pay, and equality of access and equivalence in the services
provided are to be guaranteed.98
Creating ‘crisis consciousness’ is one of the political strategies of proponents of private
financing, and we do not want to manufacture a false crisis in our own analysis. Yet increased
private financing poses a real threat to the solidaristic universalism that underpins Sweden’s
significant achievements in human development. Organised action by proponents of a reduced
role for the public sector is yet to be seriously countered by those interested in preserving the
legislated principles governing Swedish social policy, and in defending the expressed
preferences of Swedes in this crucial policy area.
More research is needed to inform the ongoing debate about the future financing of welfare
services. We propose a range of areas for research attention. One is the evolution of the
structure of the market sector and the role of market sector actors in influencing policy on
welfare services. Another is the effect of EU competition policy, itself driven by self-
interested market actors,99 on the Swedish governments’ capacity to determine social policies.
97 Lindgren (2009:46).
98 SOU 2004:19 p. 162.
99 Hermann (2007, p. 11).
Institutet för Framtidsstudier/Institute for Futures Studies
Arbetsrapport/Working Paper 2010:1
Systematic investigation is also needed into the concepts and dimensions of service quality
important to current and future users of publicly-financed elder care services, and into the cost
implications of different kinds of quality developments. Perhaps most important is research
on the ongoing role of economists in shaping social policy through documents such as the
Long Term Surveys of both the Ministry of Finance and SALAR, in line with work by Agneta
Hugemark and Peter Antman in the mid-1990s.100
We do not claim that the quality of public elder care in Sweden could not be improved, nor
deny that more resources may need to be devoted to providing high quality care.
Nevertheless, Sweden has created a strong private economy, alongside one of the more
humane systems of social support in the modern world. It would be a very sorry state of
affairs if the projected increase in total social resources make it more, rather than less,
difficult to continue to moderate inequality.
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Former Working Papers:
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Arbetsrapport/Institutet för Framtidsstudier; 2008:1
Westholm, Erik & Cecilia Waldenström, Kunskap om landsbygden. Dags för en ny agenda!
Arbetsrapport/Institutet för Framtidsstudier; 2008:2
Gartell, Marie, Jans, Ann-Christin & Helena Persson, The importance of education for the
reallocation of labor. Evidence from Swedish linked employer-employee data 1986-2002
Arbetsrapport/Institutet för Framtidsstudier; 2008:3
Strömblad, Per & Gunnar Myrberg, Urban Inequality and Political Recruitment Networks.
Arbetsrapport/Institutet för Framtidsstudier; 2008:4
Forsell, Charlotte, Hallberg, Daniel, Lindh, Thomas & Gustav Öberg, Intergenerational public
and private sector redistribution in Sweden 2003
Arbetsrapport/Institutet för Framtidsstudier; 2008:5
Andersson, Jenny, The Future Landscape
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Alm, Susanne, Social nedåtrörlighet mellan generationer
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Stenlås, Niklas, Technology, National Identity and the State: Rise and Decline of a Small
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Arbetsrapport/Institutet för Framtidsstudier; 2008:8
Larsson, Jakob, Den öppna samordningsmetoden. EU:s samordningsmetod av
medlemsländernas välfärdssystem
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Bergmark, Åke & Olof Bäckman, Socialbidragstagandets mönster – en studie av varaktighet
och utträden under 2000-talet
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Bergmark, Åke & Olof Bäckman, Socialbidragstagandets mönster – en studie av varaktighet
och utträden under 2000-talet
Arbetsrapport/Institutet för Framtidsstudier; 2008:10
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Zamac, Jovan, Hallberg, Daniel & Thomas Lindh, Low fertility and long run growth in an
economy with a large public sector
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Arbetsrapport/Institutet för Framtidsstudier; 2008:13
Korpi, Martin, Migration and Wage Inequality. Economic Effects of Migration to and within
Sweden, 1993-2003
Arbetsrapport/Institutet för Framtidsstudier; 2008:14
Gartell, Marie, Jans, Ann-Christin & Helena Persson, The importance of age for the
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Arbetsrapport/Institutet för Framtidsstudier; 2008:15
Korpi, Martin, Clark, William A.V. & Bo Malmberg, The Urban Hierarchy and Domestic
Migration. The Interaction of Internal Migration, Disposable Income and the Cost of Living,
Sweden 1993-2002
Arbetsrapport/Institutet för Framtidsstudier; 2009:1
Enström Öst, Cecilia, The Effect of Parental Wealth on Tenure Choice. A study of family
background and young adults housing situation
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Gartell, Marie, Unemployment and subsequent earnings for Swedish college graduates. A
study of scarring effects
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Bergman, Ann & Jan Ch Karlsson, Från shopping till sanningsserum. En typologi över
ISSN: 1652-120X
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lanthandelns betydelse för flyttning in och ut och för människorna i byn
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Lundqvist, Torbjörn, The Emergence of Foresight Activities in Swedish Government
Arbetsrapport/Institutet för Framtidsstudier; 2009:6
Thalberg, Sara, Childbearing of students. The case of Sweden
Arbetsrapport/Institutet för Framtidsstudier; 2009:7
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Hernández Ibarzábal, José Alberto, Energy policy and regulatory challenges in natural gas
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Arbetsrapport/Institutet för Framtidsstudier; 2009:10
Lundqvist, Torbjörn, Strategisk omvärldsanalys vid myndigheter
Arbetsrapport/Institutet för Framtidsstudier; 2009:11
Minas, Renate, Activation in integrated services?. Bridging social and employment services in
European countries
Arbetsrapport/Institutet för Framtidsstudier; 2009:12
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Arbetsrapport/Institutet för Framtidsstudier; 2009:13
Blomqvist, Paula & Larsson, Jakob, Towards common European health policies. What are the
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Arbetsrapport/Institutet för Framtidsstudier; 2009:14
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Arbetsrapport/Institutet för Framtidsstudier; 2009:15
Ström, Sara, Housing and first births in Sweden, 1972-2005
Arbetsrapport/Institutet för Framtidsstudier; 2009:16
Gartell, Marie. Stability of college rankings. A study of relative earnings estimates applying
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Arbetsrapport/Institutet för Framtidsstudier; 2009:17
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Arbetsrapport/Institutet för Framtidsstudier; 2009:19
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journal of policy, planning and futures studies 1968-2008
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Arbetsrapport/Institutet för Framtidsstudier; 2009:21
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... Among other things, it has been shown that the labor force is being ethnified and racialized (Lill, 2007). However, the most pressing issue is the deprofessionalization that takes place when elderly care work is moved from an institutional setting to private service work (Meagher and Szebehely, 2010). This is also where the question of work-life equality most productively can be posed. ...
... In contrast to the rest of Europe, the public sector in Sweden plays a significant role in the financing, provision and regulation of the elderly care services (Meagher and Szebehely, 2010). People have always had the opportunity to purchase private care services, but since 2007, there is a tax reduction for several of the services that previously were provided for by the municipally regulated home help service, such as cleaning, cooking and clothing, along with care in connection with visits to the bank and health centers. ...
... Various models of problem solving and organizational development have been implemented in the last twenty years. Three key areas are particularly highlighted in research: the restructuring of the tax paid welfare model (Blomqvist, 2004); the increased privatization of elderly care (Meagher and Szebehely, 2010); the working conditions in elderly care, which are characterized by low wages and low status, often in combination with unfavorable working conditions (Dahlberg, 2013). These three concerns focus on the restructuring shift of the former, welfare state organized elderly care system to the fact that relatives and close friends take more responsibility in the care of the elderly (Sand, 2007;Ulmanen, 2015). ...
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Purpose The purpose of this paper is to discuss how the labor shortage is described at the national level and how these problematizations correlate to gender and diversity politics. The paper is overview of the governance of staff shortages in elderly care, how it is articulated and how the governmental scenario of solutions, which includes the channeling of unemployed migrants into elderly care. Politicians and public media describe the situation as desperate and the issue of the staff shortages in elderly care is described as a state of crisis. A highly profiled solution is to open up elderly care for unemployed migrants. Design/methodology/approach By analyzing specific management strategies for controlling a phenomenon, the paper will also be able to highlight values surrounding the phenomenon. The ambition is to understand how institutions, authorities and organizations handle practical forms of knowledge that are aimed to implement a particular policy or working method within the welfare system. Findings One important aspect of the findings is the ways in which these official political discourses link the issues of migration and the shortages of staff in elderly care. But also visualize factors in how the government bodies with the formal responsibilities and authorities express their concerns about these links and the quality of the elderly care more generally. Originality/value It is well-known that migrants are employed to take care of the growing population of elderly in Europe. In Spain and Italy, for example, immigrants are frequently employed directly by families to care for their elderly family members. This type of employment entails a series of new social risks. The most important of those risks is the global “care chain” that these arrangements incur for the sending families, who lose a family member on whom they depend. This paper is connecting the international research on the global “care chain,” but focuses on the Swedish context, where the migrants already are established and elderly care work is not linked to migration in the same way. However, the experience of migration and the importance of transnational and cultural knowledge can be influential in understanding the changing processes in Swedish elderly care, not the least as the question of staff recruitment has been linked to migration by the highest political levels.
... But this started to change dramatically (see OECD 2022 ) as care increasingly became defi ned in policy and politics as an economic cost instead of as a social right. Large international private equity fi rms had barely anything to do with care in the 1980s, but now, many welfare states and their care systems are dependent on private care companies owned by multinational private equity fi rms ( Meagher and Szebehely 2010 ;Burns et al 2016 ). Ailment is a global political issue, and in consequence of these changes in policy and politics, it has been subjugated to profi t making and the transactions of global capital and venture, as we discuss in the next chapter . ...
This chapter introduces the concept of ailment, which is about generalised care needs, including the need for self-care. Ailment does not indicate an immediate dependency on others. Rather, it is a human condition and force that mobilises emotions, actions and relations. Responses to ailment extend from concrete encounters between human beings in the immediate environment to political and institutional responses in societies across the world. The political relatedness that ailment enacts in the world and the different kinds of social orders that emerge through different personal and collective responses to the needs of ailing subjects are discussed.
... Suomessa hoivapalveluiden organisointia muutettiin 2000luvun alussa siten, että kun tien vastuulle jäi palveluiden organisoiminen, mutta niiden tuottaminen voitiin antaa yri tyksille ja järjestöille, jotka toimivat yritysten tapaan. Ajatuksena oli, että yritykset tuottavat palvelut tehokkaammin kuin julkiset toimi jat, mutta tästä ei ole saatu yksiselitteisiä tu loksia (Meagher & Szebehely 2010). Vuonna 2023 hoivapalveluiden organisointi siirtyy hy vinvointialueiden vastuulle ja niiden tuottami nen jatkuu todennäköisesti samaan tapaa kuin aiemminkin, osin julkisena ja osin yksityisenä tuotantona. ...
... These changes in Swedish eldercare are not the result of any national reforms aimed at reducing coverage (Szebehely and Trydegård, 2012). Nevertheless, the question of 'sustainable' financing of welfare services has been on the political agenda for some time, including debates about increasing private financing (e.g. through RUT) and excluding cleaning from publicly funded home care (Meagher and Szebehely, 2010). ...
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Focusing on Swedish home care for older people, this article explores the discursive (re)production of home care as an institution. Equality and universal service provision have been described as defining features of the Nordic care regime. At the same time, Nordic research has highlighted a shift in social care policy, from a focus on universalism and egalitarian ideals towards a focus on freedom of choice, diversity and individualised services. This article takes as a starting point that home care for older people is formed by different and potentially conflicting ideas. We understand home care as a contested formation and define institutional change in terms of ongoing discursive struggles. The analysis draws on qualitative semi-structured interviews with key informants, including politicians, local authority officials and representatives of interest organisations. Informants were engaged in policy making, implementation or advocacy related to care for older people. We examine the meanings attached to home care for older people and the analysis reveals three different discourses – on choice, needs and equality. By comparing and contrasting discourses, we reveal silences, conflicts and tensions, and highlight the politics involved in (re)creating home care as an institution.
... This is because private, but not public, providers have the opportunity to offer additional services. Additional services are services which are not included in the decision for care granted under the needs assessment process, and which individuals pay for out of their own pockets subsidised by the tax deduction on household services (RUT) (Socialstyrelsen 2007;Meagher & Szebehely 2010). Home care users choosing a private provider for their needs assessed home care services can purchase such 'topping-up' services (for instance, more frequent cleaning) from the same provider and from the same care workers. ...
Denne artikkelen redegjør for sentrale forskningstradisjonersom har hatt innflytelse på nordisk omsorgsforskning – og i særdeleshetnorsk omsorgsforskning. Omsorgsforskning forstås som studiet avomsorgsarbeid, omsorgens samfunnsmessige vilkår og konsekvenserog omsorgens ontologiske grunnlag. Fra pionerene Kari Martinsen,Katie Eriksson og Kari Wærness sine tidlige bidrag på 1970- og 80-talletog frem til i dag har forskningsfeltet vokst betydelig. Mens noenforskningsmiljø vektlegger den empiriske forskningen, legger andremer vekt på teoriutvikling. Det argumenteres i denne artikkelenfor at forskningsfeltet vil tjene på en sterkere integrasjon mellomdisse. Dagens myndighetsfinansierte omsorgstjenesteforskningstår i en utfordrende posisjon mellom det å være «systemnyttig»og det å samtidig ivareta en «systemkritisk» funksjon. Videre argumenteresdet for at omsorgstjenesteforskningen i hovedsak bør omfatte tjenestersom kan bidra til «en god hverdag» for alle som lever i en livssituasjonpreget av svekkelse, tilbakegang og død. Omsorgsforskningen børholde fast på dette perspektivet, og ikke tape sitt tyngdepunktrelatert til forskning overfor de som i et økonomisk nytteperspektivansees som «resultatløse».
... As Blomqvist observes in the Swedish case (Blomqvist 2004: 149), the privatization tendencies include, on the one hand, the provision of services by independent organizations (which can be public or private) on the basis of contractual agreements and, on the other hand, an increasing importance of caregivers (informal or commercial) outside the publicly funded system, due to the eligibility criteria being more restrictive today. These measures try to contain the high cost of these services in a context of increased ageing of the population, but even so the Nordic countries have tripled their spending in this area compared with the rest of the EU (Meagher and Szebehely 2010). In 2012, according to Eurostat, Sweden and Denmark spent more than 2 per cent of their GDP on elderly care, compared to the EU28 mean of 0.5 per cent. ...
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Baltic and Nordic countries share historical and political connections as well as geographical proximity. Nevertheless, when their welfare regimes are compared, Baltic countries can be included in a post-communist model that differs from the social-democratic model of Nordic countries in many respects. This article focuses on one of these aspects, the opinion expressed towards the financial responsibility for the care of children and the elderly. In particular, childcare policies have been used to explain the development of a dual earner/dual career model in Nordic countries. Nevertheless, full-time employment of women is widespread in Baltic countries too, although family policies and attitudes strongly differ from Nordic ones. Using data from the International Social Survey Programme (2012), we compare public attitudes towards who should cover the costs of caring in five Nordic countries (Finland, Sweden, Norway, Iceland and Denmark) and two Baltic ones (Latvia and Lithuania). We find remarkable differences between both groups of nations: citizens from Baltic countries consider the role of the family more important than their counterparts in Nordic countries. Results show Latvians holding the most familistic views in terms of covering costs, and Swedish people the least. Individual socio-demographic variables are less important than national contexts in explaining these attitudes. We find important variations among the social-democratic countries and, surprisingly, in the case of childcare, Sweden shows higher differences to Denmark than to Latvia and Lithuania. This finding suggests that the social-democratic bloc in this respect is more heterogeneous than what is generally thought.
... In Sweden, the great extension of public elderly care occurred in the 'golden years' of the 1960-70s. However, the Nordic universalistic care regime is going through significant changes since the 1980s, with New Public Management inspired reforms and processes of retrenchment, familialization and marketization (Meagher & Szebehely, 2013, 2010. ...
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This chapter discusses the conditions for mobility and independent aging for a wide range of Swedish retirement migrants in Spain. It illuminates the mobility of older Europeans in the context of Freedom of Movement—and its limits. When Swedish retirees in Spain become increasingly dependent on eldercare, they find themselves in a country with one of the lowest rates of public provision in Europe and are left with a patchwork of private solutions. Gender, health, socio-economic conditions, as well as Swedish and Spanish provision of health- and eldercare influence the mobility of Swedish retirement migrants, especially in the case of widows and single women with low income.
... Nor does the research investigate the more specific innovation-marketization relationship nor the relationship between standardization and innovation. Marketization can create markets for social services, such as those we have seen emerging in elderly and child care (Meagher and Szebehely 2010). ...
Sustainability and welfare are concepts expressing a relatively recent and already institutionalized aspiration of contemporary societies and governments. The present paper attempts to highlight and demonstrate the difficulty to deal with both concepts in a very particular and discontinuous geographic space such as Greece. Moreover, the paper focuses in one of the Greek administrative regions composed of inhabited islands most of which live mainly on seasonal (generally summertime) tourism and are literally deserted in winter. Furthermore, it examines how and why the question of islands and their sustainable welfare is of interest today, especially within a global framework of a generalized economic crisis.
Välfärdsstatens insatser för personer med funktionshinder och för äldre människor särskiljs sällan i statistik och forskning. När, som i denna artikel, verksamheterna separeras, blir det tydligt att de båda välfärdstjänsterna under senare år har utvecklats åt skilda håll. Ekonomiska resurser, tjänsternas omfattning och personalens arbetsvillkor skiljer sig påtagligt mellan äldre- och handikappomsorgen, och gränsen mellan statens, familjens och marknadens roller har förskjutits på olika sätt.
The European Union’s primal actuation, the creation of a free inner market, has come to challenge the European Welfare systems national inequalities. As an answer to a more economic orientated European Union the Member States have expressed a will to cooperation in the field of social politics to meet the effects of the inner market, but without leaving any formal decisive power to a supranational EU-level. This paradox has resulted in a rising of a collective European social politic characterized of vague formulated goals whose practical adaption often stays imprecise. In 2000 the Lisbon Strategy was launched, which aims to create a globally competitive Europe with a social ambition which complements the free movement of EU citizens. The method of enforcing the high standards of social policy objectives became a method of open coordination which allow Member States governments continued formal authority but which also gives the EU institutions a soft influence where key words such as “peer pressure” and “exchange of best practices” is key concepts. The aim of this report is to set out the The Open Method of Coordination (OMC). The OMC is a form of cooperation based on continual reporting, measuring and ranking of the Member States politics on basis of common objectives. The idea is that EU trough peer pressure between the Member States would achieve greater and more effective convergence in political areas that are not included in the EU-competence. What this development is going to lead to for the Member States Welfare-systems in the future is difficult to know, thus it is clear that EU has created a potential driving force to adapt the Member States Welfare politics towards a joint EU-norm whose ultimate goal is a European Social Model.
During the 2000s, government authorities have reduced their local presence in rural areas. This study shows the extent of the rationalization in a case study of the region of Dalarna. Rural areas nearby larger cities have been worst hit, yet sparsely populated areas are most affected since services are withdrawn from several municipalities at the same time. Authorities use different economy measures, such as commissioning another authority to deliver local service or to give distance-based service through technical solutions. This creates multiple levels of service of varying quality. Cooperation between authorities and municipalities in order to maintain service is generally restricted to spots for information and distribution of forms but not for case-specific service. Thereby, the possibility to choose between local service and phone or web-based solutions is lost.
The aim of this study is to explore to what extent housing (type, tenure and number of rooms) is a constraint for first births in Sweden 1972–2005. The Swedish Housing and Life Course Cohort Study (HOLK) (n = 2242) is used. The occurrence of childbearing is measured as the event of the birth itself and the time 16 months prior to the birth, i.e. initiation of conception. The main finding is that the size of the dwelling seems to be the housing factor with the strongest association with first-birth intensities. Furthermore, an association between being established on the housing market and the propensity to have a first child is found particularly for the cohort born in 1974. The effect of housing on childbearing seems to be stronger if measured to capture time of any first birth than if measured so as to coincide with the situation 16 months prior to the birth.
Substitution among the providers of old-age care has usually meant a process whereby the state ‘takes over’ what families used to do, but during the 1980s and 1990s, both home help and institutional care were cut back substantially in Sweden as elsewhere. Comparable, nationally representative surveys in Sweden of the provision of care for older people living in the community enable analysis of the effects of these cutbacks on the sources and patterns of care. It emerges that increased inputs from families match the decline of public services, that is, a ‘reverse’ substitution has recently been taking place. Local studies, of older people who have been followed over time as the provision of home help has changed, support these conclusions. Of the increased informal care, most has been provided by daughters, but sons have also contributed. A problematic aspect of these shifting patterns of care is that an increasing number of family carers with increasingly heavy care commitments are now without formal or informal support, whereas in the recent past many could expect their responsibilities to be shared with the state. The evidence from this study also calls into question common metaphors and assumptions about the assumed interdependence between informal care and public services for older people, and challenges the so-called substitution thesis.
Over the last few decades in Sweden, the proportion of older people living in the community who receive public home-help services has decreased, even amongst the oldest old. At the same time, the abilities of older people in the activities of daily living have on average improved. This paper reports a study of the changes between 1988/89 and 2002/03 in the allocation and utilisation of public home-help services and in the support and care needs of older people (aged 65 or more years). The aims were to analyse whether the reduction in the percentage of home-help recipients could be explained by a reduction in needs among the older population, whether public home-help services had been targeted at people with greater needs, and whether informal care had increased. It was confirmed that over the 15 years, even after taking needs factors into account, the likelihood of an older person being a recipient of public home care had declined. Home help had clearly been targeted at more needy individuals. Among older women (aged 80+ years) with limitations in the activities of daily living and who lived alone, the proportion that received home help declined and the proportion that received informal care increased, which suggests that informal care had substituted for formal care. The findings indicate that the Swedish welfare system had reduced its commitment to the support of older people who require less intensive care and that, in effect, the concept of need for public social care support had been redefined.