Eldercare in sweden: an overview
| Autor | E. Peterson |
| Páginas | 90-108 |
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This article provides an overview of the policies and practices related to help and support for older dependent people in Sweden. To start with, it should be noted that in the Swedish language, the concept ‘dependency’ is not used, neither is the internationally well-established notion ‘long-term care’. Instead, the policies in this field are defined as ‘eldercare’ (äldreomsorg). In Sweden, there are different policies directed to older people on the one hand, and people with disabilities on the other hand. These are considered two separate fields of social care, rather than health care (Meagher and Szebehely, 2013). Key aspects are certainly common for older dependent people and people with disabilities, such as the principle of universalism. At the same time, there are important dissimilarities given that these groups are dealt with in different legislations. The help and support provided to people with disability under 65 years of age is also framed very differently than the help and support for older people, that is, over 65 years. Hence, while the policies related to the framework of the Disability Act is mentioned in the article as a contrast, this overview focuses on the Swedish eldercare system, regulated through the Social Services Act. The article pays special attention to the role home care services have played in the development of universal services in Sweden, and the changes that these services have gone through since the emergence in the 1950s. The changing conditions of care work in context of New Public Management, retrenchment and marketization are also outlined.
First, the article situates the Swedish eldercare system within the Nordic universal care regime, explaining the key features of this care regime. Then, the historical background of the Swedish eldercare system is outlined, with particular focus on the development of home care as a universal service for all older people. After that, current policies and the contemporary organization of eldercare are delineated, as well as the implications of the decline in Swedish eldercare services. Marketization is a trend that has substantially shaped Swedish eldercare in the last decades. The article accounts for the policies and practices related to the marketization of care services and discusses some of the challenges involved in this process. Finally, the changing conditions of care work are considered with reference to the prospects for quality care.
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The Nordic universal care regime has been characterized by the extensive publicly financed care provision directed to all citizens (Anttonen and Sipilä, 1996; Sipilä, 1997).
In Sweden as in the other Nordic countries, care for older people is underpinned by the normative ideal of public responsibility for care (Meagher and Szebehely, 2013). In contrast to many other European countries, grown-up children bear no legal responsibility for older parents (Szebehely and Trydegård, 2011). In the Nordic universal care regime eldercare is not only publicly financed, but also largely publicly provided, and high-quality services are available to all citizens according to need rather than ability to pay (Trydegård, 2012). This means that access to services is not means-tested, although there are a user fees. An important aspect of universalism is that services are affordable for the poor and attractive enough to be preferred by the middle class. Thereby the same services are directed towards and used by all social groups. A central aspect of the Swedish universal care regime is also that municipalities are highly independent, they collect taxes and organize the services. Universalism does not mean uniformity or sameness. In order to be attractive, services must be individualized, that is, adopted to individual situations, needs and preferences.
Universal policies generally aim to reduce gender and class inequalities. Universalism means that all citizens are entitled to the same rights irrespective of their class or labour market situation. By providing a wide range of public social services the Nordic welfare state has been regarded as the most ‘de-familializing’ (Esping-Andersen, 1999). Universal rights and universal care services have been considered the guarantee of women’s right to paid work and to combine employment and care (Anttonen, 2002). Social policy and social care services have therefore been represented as the key to the gender equal social model (Kantola and Dahl, 2005). In a comparative perspective, the Nordic care regime can hence be defined as ‘women-friendly’ (Hernes, 1987).
Nevertheless, the distribution of resources and responsibility in eldercare - between the state, the family and the market - has changed in Sweden during the last decades. For example, the coverage has decreased, informal family care has increased and care is increasingly provided by private care companies. Scholars have argued that this development is threatening universalism (Brodin, 2005; Szebehely and Trydegård, 2011; Ulmanen, 2012; Vabø and Szebehely, 2012; Meagher and Szebehely, 2013). At the same time, it is important to bear in mind that universalism is a contested concept and it can be seen as an ideal type beyond reach -and as a matter of degree rather than a dichotomy (Anttonen et al., 2012). In this vein, it is possible to discern a trend of ‘de-universalization’ in the Swedish universal care regime. This trend will be dealt with later on in the article.
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In Sweden, the political discourse of the time after the second World War involved the argument that only public funding and public provision can guarantee equally good services to all social groups according to need and not purchasing power. Formal eligibility was not considered to be not enough, it was stressed that services have to be accessible, affordable and attractive - to gain and keep the support of the middle class. It was emphasized that if the same services are used by all social groups the quality will improve for all.
The development of municipal home care services in the beginning of the 1950s was an important step in the building of the Swedish welfare state. Home care services made it possible for frail older persons to stay at home without being dependent on their children. The initiative of home help for older people came from the voluntary sector: in Sweden the Red Cross started a pioneer project in 1950. A key shift came with the recognition of the ‘principle of homecare’ in public policy in 1957. Home care services represented individualized alternatives to the more standardized forms of care available in old-age homes and nursing homes. Home care was the first form of eldercare to be offered not only to the poor, but to all social groups. The services were affordable for the poor and attractive enough to be preferred by the middle class and in this sense home care became a universal welfare service. With the expansion of public care provision, the care for older people was no longer constructed as poor relief, but a citizen right. The association of residential care with its legacy of stigmatized poor relief also made home help a welcomed alternative and these services became widely used (Brodin, 2005; Szebehely and Trydegård, 2011).
The ‘golden years’ of the Swedish welfare state, the 1960s and 1970s, involved a great expansion of social care services and particularly home care services (Anttonen, 2002; Trydegård, 2012). Sweden had achieved a well-developed system of tax-funded eldercare services in 1980s (Meagher and Szebehely, 2013). Public elder care was not articulated as part of gender equality policies in the same way as childcare (Ulmanen, 2013). However, from a historical perspective, the build-up of public eldercare contributed to women’s raising labour market participation. The employment rates among middle-aged women increased in Sweden parallel to the expansion of home help: between 1960 and 1996 the employment rate rose from 33 per cent to 80 per cent (Szebehely, 2003). In this perspective, the expansion of home care services clearly shaped middle-aged women’s freedom of choice - to care or not to care.
The needs of older people and people with disabilities were recognized in the Social Services Act of 1982, still in force today. The act establishes the legal obligation of municipali-
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ties to provide services for all residents according to need. The possibility of older people to stay in their ordinary living environment is a fundamental goal of the Social Services Act. Hence, the principle of homecare has been reinforced as opposed to residential care (Brodin, 2005). Later on, in 1993, the specific needs of people with severe disabilities were recognized in the Act Concerning Support and Service for Persons with Certain Functional Impairments (LSS). In contrast to the Social Services Act, the Disability Act focuses on promoting independent living and active participation in society.
The Community Care reform from 1992 (Ädelreformen) shifted the responsibility for nursing homes from the health care sector, administered and funded at the county council regional level, to the social care sector, administered and funded at the municipal level. The stated aim was to increase quality of life for older people by ‘demedicalizing’ care (Brodin, 2005). Nonetheless, the reform was implemented just as Sweden entered in deep recession and the focus...
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