Local variations in old age care in the welfare state: The case of Sweden

Health Policy, 24 (1993) 175-186 @ 1993 Elsevier Scientific Publishers

175

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HPE 00532

Local variations in old age care in the Welfare State: The case of Sweden Stig Berga, Laurence G. Branchb, Anne Doyle”?* and Gerdt Sundstriim” aInstitute of Gerontology, Jiinkiiping, Sweden and bAbt Associates Inc., Cambridge, MA, USA Accepted I1 October, 1992

Summary Swedish local municipalities are responsible for the provision of social welfare, including old age care. Local autonomy is far-reaching, and local inequities are indeed great for all kinds of domestic and institutional care for the elderly. Not only coverage rates differ widely but also costs per citizen and spending per elderly person vary vastly. Numerous parameters of the political, economic and geo-social structure of the municipalities explain only very little of these local variations. It seems that local differences are often of long standing: this may explain why ‘rational’ indicators of needs and local capacity fail to explain much of the inequities. Yet, one factor of socio-political importance emerges as significant: the system of tax redistribution enforced on largely autonomous municipalities. Old age care; Welfare; Inequity; Sweden

Introduction Sweden is an example of a Welfare State with a strong tradition of providing both home-based and institutionally based care to its older citizens. Home help was initially ‘copied’ from the British system. In order to meet the needs of the expanding population there has been a dramatic growth in old age care expenditures in the past 2 decades [l]. Yet, the basic features of Swedish old age care have remained untouched. Home-based care has so Address for correspondence: Dr. Stig Berg, Institute of Gerontology, Box 1038, S-551 11 Jiinkliping, Sweden. *At the time of the study, a Fulbright scholar at the Institute of Gerontology, Jiinkhping, Sweden.

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far not replaced institutional care to any noticeable extent. Public money for old age care goes primarily to institutional care, and to the same degree in 1985 as it did in 1965 [I]. Most of the older people who are cared for at home need only minimal assistance, usually provided through the Home Help Services. home help is provided by the municipality after an assessment of need. Most of the support is help with shopping, cooking and cleaning; much less is support with personal hygiene or other tasks. Elderly who need substantial assistance are still often found in institutional settings. The planning and provision of old age services in Sweden is a local responsibility, with the 284 municipalities and the 24 county councils constitutionally mandated to accomplish these functions wholly on their own. In practice central government has little capacity to monitor and control local governments. Since the comprehensive constitutional reform 125 years ago, the local municipalities and county councils have far-reaching autonomy and power to tax their citizens and use the money totally at their own discretion. At the present time most public money raised and spent in Sweden is municipal. There is a state-controlled system for tax redistribution from more affluent to less affluent municipalities which enables poorer local governments to provide services at a reasonable level. Central state money is involved only marginally, even when used as an incentive. Typically, state subsidies are proportional to what the municipality spends of its own money. The tax redistribution has often caused heated political discussions. The national legislation provides only a broad outline of what social services and health care shall be provided with locally. However, some of these enabling laws use vague phrasing and therefore disputes between clients and bureaucracies occur which occasionally have to be resolved in administrative courts. It is worth noting that the possibility of appeal in home help disputes has occured only during the last few years. Thus the relative paucity of national standards may in part contribute to large local variation. Few previous studies have analyzed regional variations in health care consumption and old age care in Sweden [2] and only two have looked at local (municipal) variations [3,4]. None, however, has used information on all the major kinds of formal old age care at the local level where it is provided. The purpose of this analysis is to describe variations in old age care in the Swedish Welfare State. These variations will be correlated to characteristics of the municipalities where old age care is provided.

Methods We distinguish between parameters that indicate population needs for care, factual characteristics that suggest the capacity of the municipality to provide care, and factors that suggest the political will of the municipality to do something about these needs. Needs are inferred by the proportion of elderly in the population (65+, 80+). The capacity to meet their needs are indicated by the economic potential of the community (tax base, person power availability, degree of urbanization, proportion of women employed, and so on). The political will to

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do something for the older population with needs is inferred from the political situation of the municipality. One might expect socialist parties to be more eager to provide formal care and spend public money on these needs than the other political parties. Consequently, the proportion of socialist (Social Democrats and Communists) seats on the municipality board serves as our indicator of political will at the municipal level. Data were obtained from three primary sources. One is the annual statistics on home help and old age homes in the municipalities for 1985. A second source is a long-term care/nursing home survey also undertaken in 1985. Annual fiscal and other municipal data are a third source. Scattered sources are used for electoral statistics. All the data were merged into one tile at the Institute of Gerontology in Jonkoping. The data give a nearly complete picture of home-based care and a complete picture of institutional care. The only ommission of note for home-based care are home health care patients who are not receiving home help (a marginal fraction). In the 24 Swedish counties in 1985 there were 284 municipalities of very varying sizes (area and population). Two of the municipalities did not provide complete information on home help, thus they are not included in our analysis. Slightly different frames of reference engender a certain incompatibility within the data, as information on residents in institutional care refers to a single-day cross-sectional reference, while the number of home help clients refers to the total number of persons helped during the calendar year. Turnover rates of about lo-15% annually therefore somewhat inflate the latter figures. While complex statistical manipulations may correct this anomaly, we have not done so because the corrections do not affect the patterns of care examined in our analysis. A few other, rather costly, forms of care of the aged and the handicapped are not considered in this analysis such as transportation service, meals-onwheels, snow clearance. The reason for their exclusion is that they overlap and also presuppose use of some of the other services. Persons benetitting from them are probably home help clients as well.

Results Variations in old age care Most evaluations of old age care tend to report averages. Yet, a significant but largely unknown aspect of the situation in Sweden is the large variations for both institutional and home-based care. As both kinds are primarily used by the oldest segment of the populations [ 11, Figures 1 and 2 present the distributions for those 80 years or older. The percentage of those 80 years and older receiving home help range from a low of 17% in one municipality to 80% in another, with an average of 43%. The average for those 65+ receiving home help is 19% across all municipalities with a range between 8% and 33%. The sparsely populated and rural areas, especially those in the North, tend to provide a larger segment of the old-old with home help as well as with institutional care.

178 Number of nnunicipalities 150-

100 -

50 -

O(20

20-29

30-39

40-49

Q-m50-59

60-69

70+

% of population 60+ receiving Home Help services Fig. 1. Percent of population aged 80 and over receiving home help in Swedish municipalities, 1985.

However, not only is there variation in the proportions of the old who get home help at all, but there are also variations in the number of hours of help one gets. While municipalities provided an average of about 4.4 h per client per week, there were municipalities that provided less than 3 h on average and others who averaged more than 7 h per client per week. It is clear that these hourly averages provide only a superficial representation of the everyday reality. In many municipalities a tenth of the clients use half the hours provided, i.e. the distribution of help volume is very skewed. Most clients get (and usually need) only minimal assistance, a few get (and usually need) many hours. Regardless of age, clients typically receive only 2-3 h/week [5]. Variation in the percentages receiving institutional care is just as large across municipalities as the percentage receiving home help. Among those aged 80 or older in Sweden, on average 24% live in institutions (old age homes, nursing homes or long-term care hospitals), but there are municipalities with percentages as low as 9% and some where it is 37%. If so-called service-apartments are considered as a component of institutional

179 Number

of

100

< IO

lo-14

15-19

20-24

25-29

% of population

30-34

35+

80+

in institutions

Fig. 2. Percent of population aged 80 and over receiving institutional care in Swedish municipalities, 1985.

care, variation across municipalities are still just as large. There appears to be little substitution among the various forms of institutional care. It is also informative to consider the utilization rates of any type of old age care. In principle, a person can only use one kind of old age care: either home help, or be in the old age home or a nursing home/long-term care ward. The substitution hypothesis would suggest that if there is not a sufficient supply of one kind of care in a given area, there would be an increase in another type of care. Yet, the evidence is that variation is very large at the comprehensive level as well. For those aged 80 or over, the average utilization level of any type of old age care is 66%, with variation across municipalities between 31% and 100%. This variation is illustrated in Fig. 3. Variation in old age care and its local correlates Conceptually, the publicly sponsored provision of old age care is influenced by a number of distinct factors: first and foremost, the need for care found in its population; second the capacity of the public agencies to provide; third the willingness to do so.

180

Number of nwnicipalities 150 I-

100 I

-

50 /

-

(40

40-49

50-59

60-69

70-79

80-89

90*

% of population 80+ receiving any old age care of total old age care for persom eged 80 end over in Swedish municipaliti~ 1985, defhFtg. 3. DitMbatto1~3 ed es the sum of proportiom that receive beme helpor placedin oldage homes or long term cere/mwsing homes.

As an indicator of population need, we use the proportion of old persons (65+) in the municipal population. The capacity to care for them is inferred by the magnitude of the tax base, the proportion of population of 16-64 years gainfully employed, urbanization and similar factors. We assume that the municipality’s willingness can be inferred by the composition of the political party of the municipal board and the innovative potential of the local social services department (whether the department applied or not for govermnent funds for development programs in old age care). For administrative and analytical reasons each Swedish municipality is offkially categorized in one of six ‘H-regions’, with the big cities in H-region 1 and the remote, sparsely populated municipalities in H-region 6. The regions thus combine aspects of population and geography with economic characteristics. The means of the above factors and their correlations with institutional and home-based care are shown in Table 1 (multiple regressions will be presented in Table 2). The needs-factor is a substantial correlate of the percentage of recipients

of population

aged 65+

Percent socialist votes Development programs in old age care

Local willingness

Proportion of average tax capacity Tax redistribution factor Employment level of population Employment level of women Unemployment level Degree of urbanization Economic region

Local capacity

Proportion

Population need

Municipal characteristics

50.3% 0.6

91.2% 108.5% 59.7% 51.5% 2.8% 72.9% NA

17.4%

Mean

with

0.24 -0.05

-0.18 0.34 -0.35 -0.32 0.29 -0.21 0.40

0.27

Proportion with Home Help (65+)

Correlations

0.20 0.04

0.18 -0.17 -0.13 0.18 0.02 0.18

0.04

0.09

Proportion Home Help (80+)

-0.07 -0.25

0.18 -0.30 -0.35 0.10 -0.48 0.30

-0.46

0.34

Proportion in Institutions (65+)

-0.09 -0.24

-0.02 -0.07 -0.04 -0.27 0.08

-0.25 0.07

0.04

Proportion Institutions (80+)

in

Mean values and correlation of local characteristics with old age care of various types among those aged 65+ and 80+ in Swedish municipalities, 1985

Table 1

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Table 2 Local characteristics

Age 65+ Cumulative

Employment level of population Tax redistribution factor Degree of urbanization Percent socialist votes Tax redistribution

factor

Multiple R

R square

Beta

8.: 0:51 0.52

0.19 0.25 0.26 0.27

-0.44 0.24 -0.13 0.14

0.05

0.23

;f;

80+

aged 65+, but less so among those aged 80+. Many of the factors connected with capacity are also substantially correlated with the percentage receiving assistance, but negatively: the municipalities least able to help - those with a weak tax base, etc. - provide more help and care. Help to the old-old (80+) is forthcoming to varying degrees, but is less bound to local factors. The old-old seem to be cared for, but the younger-old seem to be helped only when local governments have high ambitions. Of special interest in this connection are the regional inequalities. These are noticeable in many ways: age structure, jobs structure and unemployment (though still low by international standards even in hard struck areas), tax capacity of the inhabitants, etc. The pattern emerging from the bivariate analysis of municipalities individually also holds regionally. The less urbanized and poorer regions provide more and costlier care for their elderly, at a higher cost per capita for their citizens. It is thus not true that the less urbanized areas have poorer services for their elderly; often the case in other societies. This finding is partly attributable to the system of Municipal Tax Redistribution. Without that arrangement of forced ‘equality’, many municipalities would be unable to provide much old age care. This redistribution is done according to a formula based mainly on demographic considerations. To appraise the total impact of these factors and their relative importance, we present stepwise multiple regresson of all these factors on old age among those 65+ and also among those 80+ in Table 2. Collectively, these variables ‘explain’ 25% of the variation in rates of total old age use rates among those aged 65+. This is relatively high for this type of study. Among the 80+ only one variable was statistically significant, namely the tax redistribution factor which explained about 5% of the variance. Variations in costs of old age care The availability of reliable estimates of costs of various programs of old

183

age care enables us to assess both care costs per retired oldperson (65+) and per citizen in each municipality.

The average cost per old person in 1985 was 19 000 SEK (US!$ 3000)’ for home help, old age homes and long-term care/nursing homes together. Adding health care, housing allowances, and other programs for the aged raises the sum to a total of about 32 000 SEK (US$ 5000) [6,7]. Pensions amount to another 50 000 SEK (US$ 8000) per elderly person. These first mentioned costs vary considerably among municipalities, and in general are slightly higher in rural areas. A similar pattern holds for costs per citizen. Averaging approximately 3300 SEK (US$ SOO),it is 1800 in the Stockholm area, and 4300 SEK in the sparsely populated Northern areas. Remarkably, the rates of total old age care provided to those aged 65+ in the municipalities is only moderately associated with costs per recipient. This implies that municipalities may provide very differently, at about the same cost! Looking at the component parts of these total costs, we find that 19% of the costs of care for old persons is spent on home help, 30% on the old age homes, and the rest (51%) on long-term care. There is a slight tendency for rural areas to spend a larger share on home help, a tendency that gains momentum from generally greater spending on the aged in these areas (above). It is also worth noting that approximately one-fifth of the costs of care for the elderly are spent on in-the-home care in countries which are as diverse as Norway and the United States [8,9].

Implications: Home-care or institutional care? The information gathered in this study highlights a number of debated issues in contemporary Swedish old age care, topics that are also discussed in other countries using the Welfare State model of providing old age care. An explicit goal of Swedish old age care is to enable the elderly to remain living in their own home because - it is argued - this is supposedly more humane and also more cost-effective [ 121. The in-the-home care policy is often buttressed by the claim that home help ‘pays’ for itself by lowering costs for institutional care in the populaton. One would expect this substitution to be evident cross-sectionally also. Yet, the correlations are very weak between home help coverage and institutional care at the municipal level, whether considered as costs per elderly person or as costs for (younger) citizens. On the other hand, this means that noninstitutional care is no costlier either, and may therefore just as well be pursued as a policy if it is preferable for other reasons. Humanitarian considerations may be a case-inpoint, even if some doubts of the general validity of that proposition have been expressed [lo]. Increasingly, the policy is to ‘ration’ home help hours to those most ‘needy.’ For example, fees have been restructured to make it excessively costly for the client to use just a little help (‘cleaning-cases’) and proportionally ‘US dollar

equivalents

in this study are set at 6 SEK.

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more economical for them to have substantial help; the rates are usually income-graded as well. The choice of strategy may be difficult. Giving priority to the neediest may seem wise, as it may hinder them from moving prematurely into institutions. On the other hand, also giving a little to low-priority clients may provide the security needed to relieve pressure on institutions and families and may ‘payoff’ in a somewhat longer run. Priority for the neediest seems to be the most common approach in the municipalities at present. In spite of increasing numbers of old persons, there are declining absolute numbers and proportions who get home help. As coverage ratios for institutional care are simultaneously declining, we expect total old age care to benefit ever fewer of the elderly in Swedish society in the future.

Discussion A previous study has shown that costs of old age care have not grown in real terms since about 198 1 [ 11. This was preceded by an unparallelled increase for 2 decades. In the future - if taxes are not raised, which seems politically unlikely with the present average tax level of 57% of GNP - a growing number of old-old persons will have to share a non-growing share of resources. The only room for maneuvers will be set by transfers from pensions/housing allowances or between institutional - home-based care internally. Another option might be private solutions (market-based or voluntary) that are actually now rapidly expanding in Sweden. Taken in its broadest meaning, old age care covers all transfers to the aged. These are nearly all publicly financed in Sweden. Monetary transfers make up about three-quarters of the value of these transfers, i.e. pensions and housing allowances. Other programs are marginal in comparison [ Ill. Judging from historical British data, the transfers total a stable proportion of the income of the working classes [ 121. We lack evidence on this for Sweden, but is is probably wise and befitting not to be complacent about contemporary provision for the aged, nor to sneer at the meager provisions for the elderly in the past. In Welfare States, old age care is frequently perceived as a contract between the generations, and the present study attempts to delineate how its ingredients are designed today in Sweden. There is little reason to assume that the broad outlines of old age care are very different from what they were 50 years ago. Home-based care, for example, is still a minor item in the total gross costs for care of the elderly. Another topic often discussed at present in Sweden is the organization of old age care. Joint responsibility for old age care, placed with the municipalities, now replaces the current model, where the municipalities have had the responsibility for ‘social’ care (home help and old age homes/service apartments, and housing allowances, primarily) and the county councils have been responsible for health care (home health care and longterm care nursing homes, primarily). Beginning in 1992, most of this care will be under the auspices of the municipalities.

185

The regional and local differences are to some degree unavoidable and are maybe even desirable, given the constitutional autonomy of the municipalities. To foreign observers, it may seem incredulous that in ‘socialist’ Sweden the national government has so little influence over the actions at the local level. It is also significant that so little of the variations are explained by ‘rational’ factors such as need or economic capacity to provide. It should be noted that the major part of taxes are appropriated and spent locally, not by and through national channels. What can be done nationally is to use legislation, incentives and persuasion. That approach has had some influence, but still leaves the municipalities considerable latitude. That may be even greater in the future. Closer monitoring by local politicians, media and organizations of retirees may be beneficial, but the monitoring function requires data at the local level to compare with other municipalities and national averages. The aggregate statistical data we have used here are the best available at present. Nevertheless, they should be compared with independent data on actual needs and how they are satisfied. Furthermore, an empirical test of public policy ideally requires appropriate longitudinal data. Our crosssectional evidence must therefore be considered preliminary. So far, only a couple of rudimentary analyses have been undertaken [6,10,13]. However, there are other problems. Surveys indicate that the proportion of the aged who complain that they ‘do not get help but need it’ is surprisingly similar in various localities (3-7% of the handicapped elderly living at home) [ 141. Of course, the elderly themselves, their families and local traditions may have adapted to what is ‘normal’ and expectable. And, what is ‘normal’ and ‘decent’ health care and old age care may thus vary locally and may be far from acceptable decades henceforth and/or in other cultural and social settings. It has also been found [15], that variation inside the Nordic countries is larger than the sizable differences between them. This variation was just as large in the decades before 1985, the year for this study, and has also persisted in the years after 1985. It is understandable that inequities appear or remain when welfare programs expand, but they are less legitimate in today’s situation of financial restrictions and shrinking coverage ratios in all kinds of programs for the elderly in Sweden.

References 1

Berg, S., Branch, L., Doyle, A. and Sundstrom, G., Institutional and home-based long-term care alternatives: The 1965-1985 Swedish experience, The Gerontologist, 28 (1988) 825-829. 2 Sjukvirdens planerings- och rationahseringsinstitut, Aldreomsorg och ekonomi, Spri-rapport 164, Stockholm, 1983. 3 Johansson, L., Kommunal servicevariation, Kommundepartementet, Ds Kn 2 (1982). 4 Stjemquist, N. and Magnusson, H. Den kommunala sjiilv- styrelsen, jlmhkheten och variationema mellan kommunerna, Civildepartementet, Ds 36 (1988). 5 Sundstriim, G., and Cronholm, I., Hemtjansten: De Hldsta virdtagarna och omsorgsapparaten, Rapport f&n Institutet for gerontologi, Jiinkiiping, 1988. 6 Thorslund, M. and Wemberg, K., Aldres utnyttjande av service och v&d. En personbaserad studie i Tierp 1984, Institutionen for socialmedicin, Uppsala universitet, 1986.

186 Statskontoret, Aldreomsorg i Norden - kostnader, kvalitet, styming, KRON-projektet, Statskontoret, 34 (1987). Daatland, S.O., Sdkelys pi eldreomsorgen, Rapport 4, 1990, Norsk Gerontologisk Institutt, Oslo, 1990. Rivlin, A. and Wiener, J., Caring for the Disabled Elderly. Who Will Pay? The Brookings Institution, Washington, DC, 1988. Sundstrom, G. and Samuelsson, G. Om hjiilpformer, omsorgsresurser och kvarboende. In SO. Daatland (Ed.), Gammel i eget hjem, Nordiska ministe&det, Kiipenhamn, 1987. Sundstriim, G. and Zappolo, A., Long-term care for the elderly in Sweden. In T. Schwab (Ed.). Caring for an Aging World. International Models for Long-Term Care Financing and Delivery, McGraw-Hill Book Co., New York, 1989. 12 Thomson, D., The decline of social security: falling state support for the elderly since early Victorian times, Ageing and Society, 4 (1984) 451-482. 13 Thorslund, M., Aldres flyttningar till service och v&d, Sundsvall 1986, Institutionen for socialmedicin, Uppsala universitet, 1986. 14 Sjoberg, I., Pension&x, Rapport 43, Undersiikningen av levnadsforh~llanden, Sveriges OBiciella Statistik, Statistiska Centralby&, Stockholm, 1985.