During the last decades, Swedish policy makers have implemented various marketization reforms into the public welfare sector in order to make it more cost-efficient and to improve its quality. The aim of this dissertation is to investigate what implications this marketization trend has had for the organization of Swedish eldercare. In particular, the research question addressed is how marketization reforms such as privatized provision, increased competition, and user choice have transformed the relationship between the service users, the professionals, and the state. To answer the research question, four articles are presented in the dissertation, each corresponding to a separate empirical investigation. Together, the articles demonstrate that the increased reliance on marketization in Swedish eldercare has made it more difficult for the local authorities to directly control the quality of the services, since it reduces their ability to allocate public resources and expects them to govern the provision of eldercare through the entering of contracts. This development has also implied that service users themselves become increasingly responsible for ensuring that the quality of their care is high. Moreover, the articles show that the increased reliance on audit by the national government and its agencies has tended to undermine the professionalization of eldercare staff, thereby limiting their autonomy and ability to ensure service quality. As a whole, the dissertation contributes with a more comprehensive understanding of how marketization has altered the organization of Swedish eldercare and under what conditions it might undermine the goals of social equality and ensuring that all citizens have equal access to good quality care.

This study aimed to examine the reasoning among first line managers concerning the law from 2012 which gives older couples the right to continue living together even when only one of them needs special housing for service and care. We used a qualitative method with data collected through individual semi-structured interviews with six care managers in different municipalities in Sweden. The theoretical approach and interpretative framework for the analysis consisted of Michael Lipsky’s theory of street-level bureaucracy, Roine Johansson’s swedish adaption of this theory and Max Weber’s theory about social actions. We found that there was little variation in how the interviewed care managers used the law and the guidelines to support the work in the organisation rather than seeking individually based solutions for the elderly. The main conclusion of our study was that the law concerning the cohabitation guarantee for elderly has made little difference.

根據衛生署資料顯示，民國八十六年時，台灣地區六十五歲以上老年人口保險總數占總保險人口的8.95%，然而醫療費用卻占總醫療費用的27.09%，此現象跟台灣社會邁入高齡化之後，疾病型態慢性化的傾向有密切關係。在此情形之下，除了醫療服務需求，更迫切的是後續性的長期照護需求。個人長期照護的支出中，約有85%~90%是屬於生活照顧的部分，只有10%~15%屬於醫療照護的支出。全民健保財務之推估基礎，原係以急性醫療保健服務為主，長期照護服務給付歸由理論上屬急性醫療性質之全民健保給付略顯牽強，因此，長期照護服務建立其自給自足的財務體系有其必要性。 目前世界各地人口老化的趨勢使得長期照護的需求逐漸增加，不少國家為平衡公共部門、區域社會與家計間費用負擔，已紛紛建立長期照護服務體系。歸納已被採行的財源籌措方式，計有1.強制性健康保險(statutory health insurance)；2.租稅融通支應社會福利；3.儲金帳戶制度(saving account)；4.自付額(out-of-pocket payments)；5.宗教慈善團體。或者可由以上五類為基準，進行不同程度的搭配採行。現階段我國可行之財源籌措方式可分為以下數類：1.以社會保險方式辦理：2.以社會福利方式辦理：3.以商業保險方式辦理：4.以國民年金搭配其它方式辦理。 本研究首先對長期照護費用進行估算，推估方式將採取分別估算我國長期照護人數以及每人每年長期照護費用，在結合兩者得出1999年至2041年之長期照護費用估計，並觀察長期照護費用占該年度GDP比例。在2001年(民國90年)長期照護費用約為246億元，占該年GDP的0.23%；在2040年為8,791億元，占GDP的0.73%。 本論文討論的長期照護財源籌措方式包括社會保險、租稅融通、國民年金給付自付部分長期照護費用、年金及社會保險結合以及其它方式等。在社會保險方式之下，觀察被保險人、保險對象以及有酬就業者的主要工作收入負擔長期照護保險費用的程度和能力。其中保險對象在40、45和50歲以上負擔的三個方案，將分別在15、10和5年後，達到每月負擔1,000元左右。 租稅融通方式當中，將觀察長期照護經費占總稅收、社會福利支出以及歲出預歲的比例，以及各稅目的負擔情況，以了解政府經濟財政對長期照護經費的負擔能力。發現長期照護以社會福利方式開辦，採取稅收方式融通長期照護費用，加徵的稅額將占總稅收的1.5%左右(以1997,1998資料計算)；並且會使總稅收占GDP比例增加0.23%-0.24%。 以國民年金給付來自付部分長期照護費用方式當中，本研究發現，國民年金的調整條件符合「至少達到每月平均消費水準50%」的方案中，該國民年金給付對於長期照護費用的支應具降低總費用負擔6%至28%的效果。 另外，研究發現以國民年金結合社會保險方式，65歲以上被保險人之保險費，以國民年金給付來支付，則所支付的長期照護保險費總額，占國民年金的總額比例為1/5至1/20之間呈現遞減的狀態。顯示此方式對國民年金而言具可負擔性及可行性，並且可達到政府以移轉支付來補助長期照護保險費，減輕年輕保險對象之保險費用負擔的效果。

This dissertation studies factors that predict use of public eldercare, informal care, and purchase of private services in relation to an individual’s needs, social network characteristics, and sociodemographic factors. A further purpose is to examine whether use of public eldercare is correlated to receipt of informal care and purchase of private services in the Swedish welfare state. The dissertation is based on the Kungsholmen Study, a population-based longitudinal study. Studies I–III used cross-sectional data from community-dwelling people aged 81-100 and examined (I) gender, (II) marital and parental status, and (III) dementia and depressive symptoms as predictors of use of home help. Study IV analyzed factors related to moving into institutional care and receipt of home help from 1994/96 to 2000. The majority of support provided to elders living in the community comes from informal sources, even among people living alone. There was considerable overlap between home help and informal care. When all sources of care were considered, childless individuals had comparatively lower odds of receiving care. Factors predicting use of public eldercare and informal care differed depending on whether or not elders coresided. No gender differences in use of formal and informal care were found when controlling for household composition. Living alone, dementia, need of help with household chores, and walking limitations increased the likelihood of using public eldercare. Coresidence, informal care from outside the household, and use of private services decreased the likelihood. Depressive symptoms increased the likelihood of receiving home help and institutionalization when using longitudinal data, but not in the cross-sectional studies. Educational level was of importance and interacted with several factors; persons with higher levels of education were advantaged. Very few people moved into institutional care without previously having received home help services. Essentially the same factors that predicted receipt of home help services also predicted institutionalization.

The aim of this study was to increase the knowledge about if and how the National Value System’s goal of a life with dignity for the elderly pervades the work in home care organisations. The study was based on a qualitative research method and was conducted through interviews with professional care givers in home care organisations, there were five individual interviews and one pair interview. The background for this study was the National Value System for the eldercare that was introduced in 2011. The theory of New Public Management and the concept of Rationality of Caring were used to analyse the result. New Public Management introduces a strategy of competition tendering by signing deals with the company that give the best offer, in order to increase the quality and efficiency of organisations. An important part of New Public Management is that the leaders in organisations have control of what is happening in the organisation in order to further increase the quality and efficiency. The Rationality of Caring is about having the care recipients’ needs and wishes as a primary force of action. The study shows that professional care givers work in a way that promotes a life with dignity for the elderly and that they act with a rationality of caring, but the rationality that rules the organisations in which they work precludes their way of working. The Politicians definition of rationality, which is about the efficiency and quality that can be measured, is the one that is prioritized. It also shows that the organisation priorities small time-consumption and standardized services in order to increase the efficiency. It is found that the professional caregivers perceive that the demand for documentation and other administrative tasks has increased and as a result of this the elderly does not receive the time they have been granted.

Background: In 1946, a proposal was made for a law on national pensions with the aim of reforming the pension system and giving pensioners better finances, which later was implemented at 1948. The theory of the social determinants of health suggests that income is an important factor that has an impact on health. The study aim was therefore to investigate whether the general pension reform implemented in 1948 could account for any differences in death rates for those aged 67 and older, and the research question was to examine if there was change in death rates for those aged 67 and older after 1948 that could be explained by an increase in income from the pension reform  Method: The study design was a quantitative inductive method. Data used in the study was death rates for those aged 67-90 years in Sweden between 1933-1962, as well as statistics from the Statistical Yearbook for Sweden to obtain data on income from the pension system. To investigate whether the pension reform has had any significant effects on the health of people of old ages, an interrupted time series analysis was used to measure changes in death rates for those aged 67-90 years between 1933 and 1962 in Sweden.  Results and conclusion: The results showed that there was an increase in the average pension by 461% for men and 442% for women between the years of 1947 and 1948. The study suggests that for women there was a significant change in death rates since the reform started, but that the reform of 1948 might not have had a significant effect on men’s death rates. Overall my study indicates that the changes in death rates for women in the pension age in 1948 and after could be explained by an increase in income from the pension reform, and that the pension reform seems to be a sustained policy effect that have accumulated over time.

This study explores how municipalities in Sweden interpret and apply the Social Services Act in their provision of eldercare, specifically in their original place of residence, which has been their responsibility since the 1992 elder care reform. Despite a national ambition for equal eldercare provision, municipalities have significant flexibility in shaping their own guidelines based on local conditions. The study contains a content analysis of 23 communal guidelineswhich were selected based on the municipalities’ size, geographic location, and population patterns. The guidelines were analyzed using Max Weber's concept of bureaucratization and identity theory. Notably, a significant proportion of the analyzed guidelines contain explicit time intervals for the home care interventions that are typically provided within the municipality. The study's key findings highlight substantial variations in these interventions across municipalities, encompassing differences in the types of interventions offered, as well as variations in their frequency and designated time intervals. It is reasonable to assert that the variations in home care interventions identified in this study bear significant consequences for older adults that seek home care, depending on their municipality of residence. This paper highlights the significant importance of guidelines in shaping the variations in home care services across different municipalities. It also seeks to promote further research and encourage broader discussions on the governance of eldercare in Sweden.

Syftet med denna studie är att belysa hur upplevelsen gällande dokumentation bland personal inom hemvården ser ut. Detta gjordes genom en kvalitativ studie med sex slumpmässigt utvalda ur personalen på tre arbetsplatser inom en medelstor stad i Sverige. Den huvudsakliga faktorn som formar upplevelsen gällande dokumentationen bland personal tenderer att vara hur arbetstiden är fördelad, då ingen specifik tid till detta finns utsatt i deras schema. Detta verkar vara ett stressmoment bland personalen. Vikten av kunskap, både gällande möjligheten till att använda de redskap som finns tillgängliga inom arbetsplatsen samt tillräckliga språkkunskaper för att ordentligt kunna dokumentera har även nämnts som viktiga faktorer. Tillgängligheten av verktyg, främst datorer visade sig ha en stor inverkan på personalens upplevelser gällande tiden. En annan faktor som pekades ut var arbetsklimatet, som var påverkat av det stöd som erbjöds från personalgrupp och enhetschef vid problem gällande dokumentationen. Den sista större faktorn gällande upplevelsen av dokumentationen visade sig vara att den ger en trygghet, något som skyddar både personal och brukare. För att vidare belysa resultaten av denna studie, användes två teorier, KASAM (Känsla av sammanhang) och systemteorin. / The purpose of this study is to shed some light regarding the experiences among personnel within home care services about documentation as a work activity. This is done by a quality study with six randomly selected personnel for an interview from three workplaces within a medium sized city in Sweden. The result of this study shows a pattern among the participants in certain areas. The primary factor that shapes the experience regarding documentation among personnel tend to be how the working time is distributed, since no specific time set aside for documentation only in the schedule. This tends to be a stress factor amongst the personnel. The importance of knowledge, both regarding the ability to use the tools available within the workplace and the language skill needed to properly document has been mentioned as important factors. The accessibility of tools, primary computers has a major impact on the experience of time amongst the personnel. Another factor that was pointed out was the working climate, which was affected by the support offered by both other personnel and head of unit should problems regarding documentation arise. And lastly a major factor regarding the experience about documentation turned out to be the safety it gives regarding the rule of law, which protected both the personnel and patients. To further shed light regarding the results of this study, two theories were applied, “sense of coherence” and systems theory.

The purpose of the study is to gain an understanding and to contribute with new knowledge on how unit managers in elderly care, manage the competence of assistant nurses. Furthermore, the study discusses what type of challenges assistant nurses might encounter. In their work, due to the increasing age. amongst residents in Sweden. Assistant nurses in Swedish elderly homes make a great effort to increase the quality of life for elderly people. However, in the long term unit managers in elder care will need to increase their amount of staff and also increase their unit of assistant nurses work competence. This is to give elderly people an even higher quality of care since the demands in healthcare are increasing in society and also people's life span is longer than before. Through semistructured qualitative interviews with eight unit managers in the elderly care field from the southern part of Sweden. We discovered that there are three types of competences unit managers define as an important source for working as an assistant nurse which are: language, technology and mental illness. Results show that unit managers have different ways to increase the competence of their staff, but it differs depending on what county they are in.

Homecare work is commonly described as a job involving high workload. Homecare in Sweden is affected by difficulties regarding recruiting and retaining employees. The aim of this study is to analyze the relationship between workload and the homecare employee's intention to quit their work. Workload is examined based on three dimensions: temporal, physical and relational workload. Result from frequency analysis shows that workload exists in all three dimensions. The physical dimension shows the highest percentage of workload of all three dimensions. Results from multiple logistic regressions shows that eight of nine examined variables increases the odds of homecare employee's intention to quit their work. The only examined variable that does not increase the odds is to feel inadequate regarding the care recipient’s needs. The results indicate, with the help of the effort-reward imbalance model, that there is an imbalance between homecare workers' efforts and rewards. Furthermore, the findings suggest that improvements regarding homecare employees' work situation are needed such as rewarding employees more for their efforts.