1 Resume Legislation of disability and disability pension in the Czech Republic The purpose of my thesis is to analyse the Czech legislation of disability pension and its conditions of entitlement, and then to compare them with the situation in selected states in the European Union. I have chosen this particular topic, because a material security of disabled persons is an essential part of legislation in every developed country. This thesis is composed of seven chapters; each of them is divided into several subchapters. The first chapter characterises the pension scheme and its principles. There are explained the basic features of pension insurance, such as personal scope, period of insurance and financing. This chapter also lists benefits paid of pension insurance in the Czech Republic. The second chapter outlines the development of material security of disabled persons during previous centuries. It focuses on responsibility for persons unable to work, which has transferred from church to villages and later to state. Next chapter defines the term invalidity and points out several different looks at the concept of it. This chapter also includes the international definition formed by the World health organization. The chapter number four examines relevant Czech legislation. For entitlement to a disability...

The overall aim of this thesis was to identify factors that early in a sick leave period could illuminate people’s resources and obstacles for returning to work; factors that could predict need for professional support in the sick leave process leading to a positive outcome for the individual. This thesis consists of four studies. The studied population was living in a rural part of a northern county in Sweden, and had been on sick leave for 28 days irrespective of diagnosis. The participants have been followed for five years with different investigation methods and subgroups of participants. The thesis was initiated by sending a questionnaire to the participants; the responses were compared to groups of healthy controls. The aim was to find predictors of the likelihood of a return to work that can be identified early in a sick leave period. The main focus was on individual mental resources (Study I). The next phase involved studies of sick leave statistics obtained from the Swedish Social Insurance Office, for the study population two years before and two years after the start of the research project. The material from the sick leave statistics was analysed together with responses from the questionnaire study with Partial Least Square (PLS). This was done to search for connections between the participants and factors of concern for sick leave and returning to work in different subgroups (Study II). In-depth interviews also were conducted to explore what the participants experienced as important in their sick leave process as they progressed back to work, or to long term sick leave or disability pension (Study III). Another study investigated client files in the Swedish Social Insurance Office to describe what information that was possible to find: in terms of medical and vocational rehabilitation including assessments, predictors for the outcome of the sick leave process, and the quality of the information in the files (Study IV). The findings showed significantly lower life satisfaction and psychosocial resources in the study-group compared to the healthy controls. The PLS analysis showed that it was the impact of multiple factors that influenced the study group, and the PLS analysis could help with early prediction of the outcome. Important factors were: personal belief in an ability to work in the future, number of sick leave days in the past, diagnosis, self-evaluated symptoms, life satisfaction and sense of coherence, length of education and sector of employment, and many different consequences in daily life caused by activity limitations. The interview study confirmed these results and added the following important resources: confirmation and support, structural and contextual factors, and participation in the sick leave process. Ideal-types were crystallized that can be identified in the early phases of the sick leave process. The client file study showed that some information was possible to find but a majority of the wanted information was limited why an improvement on the quality of documentation is suggested to give better basis for the files.

The main objective of this thesis is to analyse if and to what extent changes in the labour market can be regarded as a factor influencing the risk of becoming a disabil­ity pensioner. Disability pension is a social security program operating in the nexus of work and welfare and is provided to people who, due to medical reasons, are limited in their work ability. The data material analysed consists of information about all individuals who received disability pension in 1988 (54 000) and 1993 (62 000) in Sweden. Samples fremi the non-pensioner population formed control- groups. The data collected covers mainly social and occupational background of the individuals. The first step in the analyses addressed the question of causes of disability pen­sion in general. This part showed that the causes must be seen in a multifactorial perspective. Individual, structural and institutional factors have significant impact on the relative risk of becoming a disability pensioner. An increased relative risk was associated with low educational background, immigration and broken marriages. However, the variables that had the strongest effect were age, health and position in the labour market i.e. social class and occupation. It became obvious that one im­portant mechanism explaining the impact of occupation was exposition of work environment conditions. The second step in the analyses focused on labour market change as a risk-factor. The results showed a negative correlation between employment change rates and disability pension. Individuals in occupations and industries with decreasing num­ber of emplyoees had an increased relative risk. It became clear that especially un­skilled workers and employees with a peripheral position were affected by this factor. This was especially true for women. The female labour market is to a large extent dependent on the public service sector and the reductions within this sector have resulted in an increased frequency of disability pensioning. To conclude, the study has shown that disability pension in Sweden is deeply embedded in the labour market and the occupational structure in Sweden. This can be explained both as a consequence of characteristics that accompany certain posi­tions at the labour market and as an effect of how the labour market develops. / digitalisering@umu

Youth unemployment is an increasing burden on societies around the world. This prospective, register-based cohort study examined the relationship between unemployment and sickness absence, disability pension, death and future unemployment among youth in Sweden. A comparison was also made between immigrants and native Swedes. Another aim was to see if Active Labour Market Programs (ALMPs) and attained education moderated the outcomes. The baseline year was 1992, a year of severe economic downturn. The follow-up period was from 1993 to 2007, divided into three 5-year periods. The study group of 199,623 individuals comprised all immigrants born between 1968 and 1972 who immigrated before 1990 (25,607) and a random sample of native Swedes in the same age range (174,016). Individuals with unemployment benefit in 1990-1991, disability pension in 1990-1992 or severe disorders leading to hospitalization in 1990-1992 were excluded in order to minimize selection bias. Those who were unemployed in 1992 had elevated risk, measured as odds ratios, of ≥60 days of sickness absence, disability pension, ≥100 days of unemployment and all, except native Swedish women, had elevated risk of death during follow-up. The risk of future unemployment declined until the last follow-up period, while the elevated risk of future sickness absence was about the same in all three follow-up periods. Higher level of education at baseline decreased the risk of future unemployment. Individuals participating in ALMPs had an increased risk of future unemployment, and immigrant women had an increased risk of sickness absence, compared to non-participating individuals. Attained education between 1993 and 1997 decreased the risk of future unemployment and decreased the risk of sickness absence among immigrants. The risk of both future unemployment and future sickness absence increased with the length of unemployment in 1992. Immigrants had higher risk of unemployment both at baseline and follow-up compared with native Swedes, but followed the pattern of native Swedes when unemployed. The conclusion are that exposure to unemployment are associated with elevated risk of future unemployment, sickness absence, disability pension and death fifteen years after exposure. To a society this will mean substantial costs in the form of increased welfare payments and loss of productivity and tax income. Selection to unemployment by individuals already sick, may explain part of the association between unemployment and the studied outcomes.

This thesis investigates ‘the doing’ of the Swedish social insurance program Activity Compensation (AC). AC is an example of disability policies in Western welfare states. These policies have two goals: to ensure financial security and to promote social participation. In 2003 AC replaced Early Retirement Pension for persons aged 19 to 29 years and who, for medical reasons, have reduced work capacity. Three features characterize AC. Young adults are differentiated in a separate system. For them, benefits are time-limited. Benefits include an established right to participate in activities. Doing AC is studied bottom-up. Interviews with two actor groups have provided the empirical base: 1) persons accorded AC and medically certified to have an anxiety and/or a depression diagnosis and 2) the respective administrator(s) at the Swedish Social Insurance Agency. National legislative preparatory texts and legal documents complete the data. The conclusions of this study are three-fold addressing goal displacement and non-contact. Firstly, a discursive change in respect to the denotation of social participation within the politics of principle has appeared throughout OECD countries over the last decennium. This goal displacement obscures the goal of economic security emphasizing the profitability of work. AC explicitly manifests this change in establishing a right to activity participation for beneficiaries. This displacement is without full impact in the politics of practice when actors’ experience of doing AC is examined. Financial security remains the foremost goal in the local politics of practice mirroring the initial function of safeguard for those with reduced work capacity due to certified illness. Relating to this lexical displacement, the study concludes that social participation is revealed as a goal to be realized in a specific form, salaried employment, within a distinct arena, the labor market. Values such as life-quality are neglected as regulatory efforts to get persons on the track to work have been underscored. Finally, the prescribed contact between the insured young adults and their administrator(s) is not consistently present. This contact is a necessary condition for the intended planning of activities to take place. When non-contact prevails, the established regulatory right to participate in activities can not materialize.

Background: In Sweden, as well as in most Western countries, sickness absence is a major public health problem that has increased in recent years. This is a complex phenomenon related not only to ill health factors, but also to other factors on the levels of the individual, the family, the workplace, and the society. Most studies of sickness absence are cross sectional, which makes it difficult to investigate aetiological factors. A longitudinal study design is preferable, because sick-leave spells can have a long duration and are often due to chronic or recurrent disorders. Objectives: The aim of the present research was to conduct a pilot study to gain further information about factors associated with sickness absence and disability pension, perceptions of contacts with rehabilitation professionals, and self-rated health over time among younger persons initially on sick leave with low-back, neck, or shoulder diagnoses. Material and methods: An eleven-year prospective cohort study of all individuals who, in 1985, were aged 25–34 years, lived in the municipality of Linköping, Sweden, and had a sick-leave spell ≥ 28 days with low-back, neck, or shoulder diagnoses (n = 213, 61% women). The following information was obtained from registers: number of sick-leave days and spells in 1982–1984; diagnosis and demographical data in 1985 (age, sex, occupation, citizenship, marital status, and income); data on each sick-leave period (date, full/part time), disability pension (date, diagnoses, temporary/permanent, full/part time); emigration (date), and death (date, cause) from 1985 to 1 September 1996. In 1996, a questionnaire was sent to members of the cohort (response rate 73%). Different measures were used to analyse sickness absence and disability pension over the eleven-year period, possible risk factors for disability pension were tested by Cox regression, and possible factors predicting future low levels of sickness absence were tested by logistic regression. Based on the questionnaire perceptions of encounters with rehabilitation professionals were analysed with factor analyses and linear regression, and the so called health-line (a method to collect data on self-rated health over time) was tested, and the results were compared with data on sickness absence and disability ension. Results: The members of the cohort turned out to be a high-risk group for disability pension. After 11 years, 26% of the women and 14% of the men had been granted such benefits, mainly due to musculoskeletal diagnoses, but also with psychiatric diagnoses for half of the men and 17% of the women. Full-time pension was granted more often to men than to women. The women had higher levels of sickness absence. An extended Cox regression model proved suitable for prediction of disability pension. Taking citizenship and long-term sickness absence into consideration, the women had a 1.9 times higher risk of being granted disability pension than the men. Predictors for future low levels of sickness absence were a history of low sickness absence, having a white-collar job, and being married. These associations were not discerned when a pathogenic approach was used, which implies that factors other than the opposite risk factor for disability pension are associated with future low sickness absence. Three dimensions of the individuals’ contacts with professionals were identified: supportive treatment, distant treatment, and empowering treatment. Women perceived both social insurance officers and health care professionals as more supportive than the men did. Contact with social insurance officers was experienced as more supportive and empowering by persons on disability pension than by those not receiving such benefits. Data collected using the health-line (i.e., self-rated health from 1985 to 1995) was correlated with data on annual mean number of sick-leave days and days on disability pension. No tendency to recall bias was noted. Conclusions: Additional research is needed to elucidate the situation of women on sick leave with low-back, neck, and shoulder diagnoses. Further testing and practical application of statistical and epidemiological models for analysing sickness absence and disability pension data should be carried out to ascertain the validity and usefulness of such models. / On the day of the public defence the status of the article I was: Submitted; article III was: Accepted; article IV was: Submitted and article V was: In press.

Background: The Social Insurance is part of the Swedish welfare system that is intended to create economic security for citizens in the event of unemployment, sickness, functional disability, and old age. The Swedish sickness‐benefit insurance is based on the standard insurance principle meaning that sickness benefits are related to level of lost income. The increasing number of sick listed people and people with disability pension (DPs) in Sweden may lead to marginalisation of individuals as they are not part of the labour market. The government has decided that the number of sick‐listed people should be halved by 2008, which means a tougher judgment of the applications for sick leave compensation. To be qualified for sickness benefit the disease has to impair the work ability in relation to the specific demands of the work of that person. The evaluation of the work ability in a percentage is an important element with regard to the policy on disability. The social insurance officers (SIOs) who are assessing the work ability are dependent on judgments from the physicians as expertise, and the guidelines in the social insurance act. The eligibility criteria for DP and the process of dealing with applications for DP is scarcely studied. Objectives: The overall aim of the thesis was to explore demographic and health differences between those, who were granted and those, who were not granted disability pension. The second aim was to study how the process from applications to decisions on disability pensions were executed and perceived by the social insurance offices and to elucidate their working conditions during the decision process. Material and methods: The first two studies explored differences between those granted DP and those not granted DP. Study I was a register‐based retrospective case‐control study carried out in the area of a county in Sweden. The cases were all individuals rejected a full disability pension 1999‐2000, in all 99 cases. Controls were every tenth person who was granted a full DP during the same period, 198 controls. Determinants were recorded from the Social Insurance (SI). In study II demographic data and medical diagnoses were obtained from the SI records. Data concerning self‐reported health, HRQoL, social networks and use of health care were collected by a postal questionnaire. The study objects were the same as in study I. In study III and IV indepth interviews were carried through to study the social insurance officers’ perspective on the process from application to decision on disabilitypensions as well as their experiences of prerequisites and hindrances in their work with DP applications. The transcribed data were analysed by an inductive content analysis. Results: Unemployment, living in the main municipality and age below 50 years were determinants for rejection of DP. Medical status as described in the Social Insurance records had less association with the outcome. There are variations in praxis of rejection of applicants between social insurance boards in different geographical areas due to other reasons than medical. The nDP group had more often multiple diagnoses, and lower self‐reported health and HRQoL compared to those granted DP. Those not granted DP also had significantly smaller social networks. The SIOs perceived that they had to make rapid decisions within a limited time frame, based on limited information, mainly on the basis of incomplete medical certificates, and with no firm criteria for the regulations on the individual case level. Communication among the various authorities as employment offices and social services suffered from lack of common goaldirected strategy. In study IV the SIOs described their working conditions when executing the applications for DP. The SIOs perceived recurrent changes in rules and regulations as frustrating as they at the same time had to face the client. The large number of clients prevented them from being able to offer clients activities and support them in the way they were supposed to do. The SIOs powerful position and how their discretion was implemented made them feel responsible for performing their work well. SIOs are to be considered as typical street‐level bureaucrats as they have to perform their work between the policy, rules and clients. Conclusions: The individuals had an increased risk to be rejected DP if they were younger than 50 years, unemployed, and lived in the main city. No evident differences in medical diagnoses were found between the groups. The results indicate that there may be other reasons than medical in praxis. Contrary to expectations, those not granted DP do not seem to have better health, but rather to suffer from more sickness than those, who were granted DP. Unemployment leads to inability to qualify for compensation and benefits that are associated with participation on the labour market. The group not granted disability pension appears to be a disadvantaged group in need for a co‐ordination between different parts of the social welfare system. The different perspectives were perceived as obvious obstacles in the communication between professionals in the welfare system as they had other goals and demands. Clients, that have comprehensive problems and are in need of coordinated measures from many authorities to get entrance to the labour market still suffer from lack of coordination. One question is how the different public officers use their discretion when handling clients and how the cooperation can be improved. / The electronic version of the printed dissertation is a corrected version.

Background. In Sweden 10 percent (550,000) of the labour force, aged 18 to 65 years are disability pensioners and about four percent are on sick leave. The knowledge of the course from healthy individual to disability pensioner is not well known and was the theme of this thesis. Objectives, Material and Methods. The aims of the thesis were to follow the study population regarding sickness absence, health care utilisation, quality of life, and survival. Population based data including 14,538 women and men from three cities in Sweden were used, of whom 1,952 were granted a disability pension at baseline or received one during follow up. Register data, including sickness spells, health care utilisation, and mortality data during 30 years of follow up, and questionnaire data including socio-economic and quality of life data were used. Results. The most powerful determinant for being granted a disability pension was cumulative annual sick leave days, more powerful than all other tested determinants together. The degree of explanation for all determinants combined was 96%. Health care utilisation among disability pensioners continued to be high also after disability pension, 2.3 times higher for hospital admissions and 8 times higher for primary health case appointments than among referents. Disability pensioners had lower quality of life than non-pensioners and old age pensioners. For those who became disability pensioners after the baseline measurements quality of life measures decreased progressively until disability pension was granted and were then stabilised on a low level. During follow up 525 (7.6%) subjects died. Compared with subjects who did not become disability pensioners the hazards ratio was 2.78 among women and 3.43 among men, even when the effect of a number of other outcome affecting variables were taken into account. The mortality differences were not explained by underlying disease. Conclusions. The risk of disability pension may be predicted but only late in the course of events. Disability pensioners continue to have a high level of health care utilisation, and have a worse quality of life development and a higher mortality rate than non-pensioners. Given the unfavourable outcome of disability pension, other means of managing the reduced work capacity might be considered.

The thesis entitled "Comparison of the social security system in the Czech Republic and Slovakia in relation to persons with disabilities" focuses on a comparison of social security systems for persons with disabilities in the Czech Republic and in the Slovak Republic. The thesis, conceived as a theoretical study, is divided into six main chapters where two objectives were defined: ,,To describe the social security system of persons with disabilities in the Czech Republic and Slovakia" and ,,To identify the differences in the systems of social security of people with disabilities in the Czech Republic and Slovakia". Study and analysis of the documents and then comparison of the information gathered there of were used as the research methods. The chapter focusing on social security in the Czech Republic and Slovakia in the years 1945 and 1992 describes, in particular, the gradual state paternalism in the field of social security and the passive position of the citizens in this system. In the context of the given topic, it was also important to determine that the social security system under the socialist government did not address the situation of the poor, the unemployed and particularly the persons with disabilities. The final part of this chapter outlines social reform after 1989, which on the one hand restored rights of the citizens and their responsibility for their lives and, on the other hand also defined and suggested solutions of non-existent social situations in the socialist period. An interesting finding that differences of opinion on the progress of the economy transformation and social reforms might have been one of the reasons that contributed to the dissolution of the Czechoslovak Federation was established. Chapters 3 and 4 describe the social security systems for PWD (person with disabilities) in the Czech Republic and Slovakia. The conditions for a disablement pension entitlement, method of assessing disablement, method of calculation, amount of a pension, etc. were described firstin each of these chapters. In addition, specific allowances for persons with disabilities in the Czech Republic and Slovakia, including the DID card, and finally social services for PWD, their types, providers, financing, quality assessment, etc. were outlined. Chapter 5 and sub-chapters compare disability pensions, allowances and social services in both countries. The comparison is based on the data included in Chapters 3 and 4 describing both of the social security schemes for PWD, on expert opinions and the author´s own experiences. The end of Chapter 5 emphasizes the main problems of both systems. Their solution was suggested. Chapter 6 summarizes the results of the comparison.

This study occupies itself with legal aspects of invalidity from youth. It represents an issue that is very significant from the social point of view although not regulated as single problem by law. However the whole theme infiltrates to another specific fields: social insurance, assessment medicine, psychology, juristic section, medicinal issue, ethics, upbringing and special pedagogy in a broad meaning. Current Czech law regulation of theme concerning benefits for persons with long-term unfavorable health state is based on concept of full and partial invalidity pension as benefits within pension insurance scheme and pension increase for incapacity (helplessness). Generally full and partial invalidity pension benefits originate from reduction of gainful activity and reaching of relevant time period of pension insurance. According to a survey it is evident that number of awarded full and partial invalidity pensions has increased in {\clqq}Jihočeský`` region. Respecting diagnostic flags structure the greatest occurrence of full invalidity pensions from youth has been recorded in group of intermediate cephalonia. Solving of social insurance of the elderly is planned under the pension reform at the present. The main goal of invalidity pension is permission to live as close as possible to normal state thus to face up to a handicap and to secure appropriate family, social and work life. In fine we could deduce that there should be confirmation of obligatory conversion of full invalidity pension to old-age pension when reaching retirement age within Czech pension reform. In my study I have focused on some factors decisive for occurrence of full or partial invalidity. It represents socially significant problems in broad range of relations that establish or could establish. Long-term loss or reduction of ability to work have negative impact not only on individuals but also affect social status of their families and thus negatively influence the whole society. Exclusion from work process traumatizes young people. Pension benefits provided to the disabled from youth are not deduced from tolled premiums. That is the reason I think this should be solved out of the pension insurance system as well as pension increase for incapacity (helplessness). Costs on these benefits would be compensated by state budget within pension insurance system in the near future with perspective of transmission of these benefits to other social scheme. In this connection it is necessary to emphasize that mankind should be made sure that there is basic perception and crucial aim of social welfare in focusing on level and quality of life of individuals and their families not affected by unfavorable social or economic influences as well as their health state and well-being that will not be compounded by diseases and injuries. This fact will substantially affect the strategy of modern social policy.