Tradition, Change and Variation : Past and Present Trends in Public Old-age Care

The general aim of this dissertation is to describe and analyse how public old-age care in Sweden has developed and changed during the last century. The study applies a provider perspective on how care has been planned and professionally carried out. A broader social policy perspective, studying old-age care at central/national as well as local/municipal level, is also developed. A special focus is directed at the large local variation in care and services for the elderly. The empirical base is comprised of official documents and other public sources, survey data from interviews with elderly recipients of public old-age care, and official statistics on publicly financed and controlled old-age care and services. Study I addresses the development of old-age care in Sweden during the twentieth century by studying an important occupation in this field – the supervisors and their professional roles, tasks and working conditions. Throughout, the roles of supervisors have followed the prevailing official policy on the proper way to provide care for elderly people in Sweden; from poor relief at the beginning of the 1900s, via a generous level of services in the 1960s and 1970s, to today’s restricted and economy-controlled mode of operation. Study II describes and compares two main forms of public old-age care in Sweden today, home help services and institutional care. The care-load found in home-based care was comparable to and sometimes even larger than in service-homes and other institutions, indicating that large care needs among elderly people in Sweden today can be met in their homes as well as in institutional settings. Studies III and IV analyse the local variation in public old-age care in Sweden. During the last decades there has been an overall decline in home help services. The coverage of home help for elderly people shows large differences between municipalities throughout this period, and the relative variation has increased. The local disparity seems to depend more on historical factors, e.g., previous coverage rates, than on the present municipal situation in levels of need or local economy and politics. In an introductory part the four papers are linked together by an outline of the demographic situation and the social policy model for old-age care in Sweden. Trends that have been apparent over time, e.g. professionalisation and market orientation, are traced and discussed. Conflicts between prevailing ideologies are analysed, in regards to for instance home-based and institution-based care, social and medical culture, and local and central levels of decision-making. ’Welfare municipality’, ‘path dependency’, and ‘decentralisation’ are suggested as a conceptual framework for describing the large and increasing local variations in old-age care. Finally, implications of the four studies with regard to old-age care policy and further research are discussed.

Living conditions in old age: Coexisting disadvantages across life domains

The aim of this thesis was to analyse coexisting disadvantages in the older Swedish population. Coexisting disadvantages are those that occur simultaneously in various life domains. A person who simultaneously experiences several disadvantages may be particularly vulnerable and less well-equipped to manage daily life and may also need support from several different welfare service providers. Concerted actions may be needed for older people who experience not only physical health problems and functional limitations, but also other problems. Research that encompasses a wide range of living conditions provides a basis for setting political priorities and making political decisions. The studies in this thesis used data from two Swedish nationally representative surveys: the Level of Living Survey, which includes people aged 18 through 75, and the Swedish Panel Study of Living Conditions of the Oldest Old, which includes people aged 77 and older. Study I showed that the probability of experiencing coexisting disadvantages was higher in people 77 and older than in those aged 18 through 76. These age differences were partly driven by a high prevalence of physical health problems in older people. In all age groups, coexisting disadvantages were more common in women than men. The longitudinal analyses in Study II indicated that coexisting disadvantages in old age persist in some people but are temporary in others. Moreover, the results suggested a pattern of accumulating disadvantages: reporting one disadvantage in young old age (in particular, psychological health problems) increased the probability of reporting coexisting disadvantages in late old age.   Study III showed that physical health problems were a central component of coexisting disadvantages. The results also showed that being older; female; previously employed as a manual labourer; and divorced/separated, widowed or never married were associated with an increased probability of experiencing coexisting disadvantages. However, the experience of coexisting disadvantages differed: the groups associated with coexisting disadvantages tended to report different combinations of disadvantage. Study IV showed that the prevalence of coexisting disadvantages in those 77 and older increased slightly between 1992 and 2011. Physical health problems became more common over time, whereas limited ability to manage daily activities (ADL limitations), limited financial resources and limited political resources became less common. Associations between different disadvantages were found in all survey years, but certain associations changed over time. The results suggest that in general, the composition of coexisting disadvantages in the older population may have altered over time. In sum, results showed that coexisting disadvantages were associated with specific demographic and socio-economic groups. Physical health problems and psychological health problems were of particular importance to the accumulation and coexistence of disadvantages in old age.

Travel behaviour change in old age : the role of critical incidents in public transport

Older people’s travel behaviour is affected by negative or positive critical incidents in the public transport environment. With the objective of identifying such inci- dents during whole trips and examining how travel beha- viour had changed, we have conducted in-depth interviews with 30 participants aged 65–91 years in the County of Stockholm, Sweden. Out of 469 incidents identified, 77 were reported to have resulted in travel behaviour change, 67 of them in a negative way. Most critical incidents were encountered in the physical environment on-board vehicles and at stations/stops as well as in pricing/ticketing. The findings show that more personal assistance, better driving behaviour, and swift maintenance of elevators and escala- tors are key facilitators that would improve predictability in travelling and enhance vulnerable older travellers’ feeling of security. The results demonstrate the benefit of involving different groups of end users in future planning and design, such that transport systems would meet the various needs of its end users.

The Emergence of the Post-Socialist Welfare State - The Case of the Baltic States : Estonia, Latvia and Lithuania

This dissertation takes a step towards providing a better understanding of post-socialist welfare state development from a theoretical as well as an empirical perspective. The overall analytical goal of this thesis has been to critically assess the development of social policies in Estonia, Latvia and Lithuania using them as illustrative examples of post-socialist welfare state development in the light of the theories, approaches and typologies that have been developed to study affluent capitalist democracies. The four studies included in this dissertation aspire to a common aim in a number of specific ways. The first study tries to place the ideal-typical welfare state models of the Baltic States within the well-known welfare state typologies. At the same time, it provides a rich overview of the main social security institutions in the three countries by comparing them with each other and with the previous structures of the Soviet period. It examines the social insurance institutions of the Baltic States (old-age pensions, unemployment insurance, short-term benefits, sickness, maternity and parental insurance and family benefits) with respect to conditions of eligibility, replacement rates, financing and contributions. The findings of this study indicate that the Latvian social security system can generally be labelled as a mix of the basic security and corporatist models. The Estonian social security system can generally also be characterised as a mix of the basic security and corporatist models, even if there are some weak elements of the targeted model in it. It appears that the institutional changes developing in the social security system of Lithuania have led to a combination of the basic security and targeted models of the welfare state. Nevertheless, as the example of the three Baltic States shows, there is diversity in how these countries solve problems within the field of social policy. In studying the social security schemes in detail, some common features were found that could be attributed to all three countries. Therefore, the critical analysis of the main social security institutions of the Baltic States in this study gave strong supporting evidence in favour of identifying the post-socialist regime type that is already gaining acceptance within comparative welfare state research. Study Two compares the system of social maintenance and insurance in the Soviet Union, which was in force in the three Baltic countries before their independence, with the currently existing social security systems. The aim of the essay is to highlight the forces that have influenced the transformation of the social policy from its former highly universal, albeit authoritarian, form, to the less universal, social insurance-based systems of present-day Estonia, Latvia and Lithuania. This study demonstrates that the welfare–economy nexus is not the only important factor in the development of social programs. The results of this analysis revealed that people's attitudes towards distributive justice and the developmental level of civil society also play an important part in shaping social policies. The shift to individualism in people’s mentality and the decline of the labour movement, or, to be more precise, the decline in trade union membership and influence, does nothing to promote the development of social rights in the Baltic countries and hinders the expansion of social policies. The legacy of the past has been another important factor in shaping social programs. It can be concluded that social policy should be studied as if embedded not only in the welfare-economy nexus, but also in the societal, historical and cultural nexus of a given society. Study Three discusses the views of the state elites on family policy within a wider theoretical setting covering family policy and social policy in a broader sense and attempts to expand this analytical framework to include other post-socialist countries. The aim of this essay is to explore the various views of the state elites in the Baltics concerning family policy and, in particular, family benefits as one of the possible explanations for the observed policy differences. The qualitative analyses indicate that the Baltic States differ significantly with regard to the motives behind their family policies. Lithuanian decision-makers seek to reduce poverty among families with children and enhance the parents’ responsibility for bringing up their children. Latvian policy-makers act so as to increase the birth rate and create equal opportunities for children from all families. Estonian policy-makers seek to create equal opportunities for all children and the desire to enhance gender equality is more visible in the case of Estonia in comparison with the other two countries. It is strongly arguable that there is a link between the underlying motives and the kinds of family benefits in a given country. This study, thus, indicates how intimately the attitudes of the state bureaucrats, policy-makers, political elite and researchers shape social policy. It confirms that family policy is a product of the prevailing ideology within a country, while the potential influence of globalisation and Europeanisation is detectable too. The final essay takes into account the opinions of welfare users and examines the performances of the institutionalised family benefits by relying on the recipients’ opinions regarding these benefits. The opinions of the populations as a whole regarding government efforts to help families are compared with those of the welfare users. Various family benefits are evaluated according to the recipients' satisfaction with those benefits as well as the contemporaneous levels of subjective satisfaction with the welfare programs related to the absolute level of expenditure on each program. The findings of this paper indicate that, in Latvia, people experience a lower level of success regarding state-run family insurance institutions, as compared to those in Lithuania and Estonia. This is deemed to be because the cash benefits for families and children in Latvia are, on average, seen as marginally influencing the overall financial situation of the families concerned. In Lithuania and Estonia, the overwhelming majority think that the family benefit systems improve the financial situation of families. It appears that recipients evaluated universal family benefits as less positive than targeted benefits. Some universal benefits negatively influenced the level of general satisfaction with the family benefits system provided in the countries being researched. This study puts forward a discussion about whether universalism is always more legitimate than targeting. In transitional economies, in which resources are highly constrained, some forms of universal benefits could turn out to be very expensive in relative terms, without being seen as useful or legitimate forms of help to families. In sum, by closely examining the different aspects of social policy, this dissertation goes beyond the over-generalisation of Eastern European welfare state development and, instead, takes a more detailed look at what is really going on in these countries through the examples of Lithuania, Latvia and Estonia. In addition, another important contribution made by this study is that it revives ‘western’ theoretical knowledge through ‘eastern’ empirical evidence and provides the opportunity to expand the theoretical framework for post-socialist societies.