Home care for older people in Sweden: a universal model in transition

Abstract

One aspect of universalism in Swedish eldercare services is that publicly financed and publicly provided services have been both affordable for the poor and attractive enough to be preferred by the middle class. This article identifies two trends in home care for older people in Sweden: a decline in the coverage of publicly funded services and their increasing marketisation. We explore the mechanisms behind these trends by reviewing policy documents and official reports, and discuss the distributional consequences of the changes by analysing two data sets from Statistics Sweden: the Swedish Level of Living surveys from 1988/1989 and 2004/2005 and a database on all users of tax deductions on household and care services in 2009. The analysis shows that the decline of tax-funded home care is not the result of changing eldercare legislation and was not intended by national policy-makers. Rather the decline was caused by a complex interplay of decision-making at central and local levels, resulting in stricter municipal targeting. The trend towards marketisation has been more clearly intended by national policy-makers. Legislative changes have opened up tax-funded services to private provision, and a customer-choice (voucher) model and a tax deduction for household- and care services have been introduced. As a result of declining tax-funded home-care services, older persons with lower education increasingly receive family care, while those with higher education are more likely to buy private services. The combination of income-related user fees, customer-choice models and the tax deduction has created an incentive for high-income older persons to turn to the market instead of using public home-care services. Thus, Swedish home care, as a universal welfare service, is now under threat and may become increasingly dominated by groups with less education and lower income which, in turn, could jeopardise the quality of care.