Privatization of social services: quality differences in Swedish elderly care

One of the major policy trends in recent decades has been the privatization of social services. This trend has also reached Sweden, a welfare state with health care and social service sectors that previously had almost no private providers. One of the most affected areas is elderly care, i.e. home-help services and residential care provided to citizens older than 65 years, where the proportion of private providers increased from 1% in 1990 to 16% in 2010. The ongoing privatization in Sweden and many other countries has raised important questions regarding the consequences of this policy transformation. In this paper, we present a cross-sectional study comparing the quality of services in private and public elderly care. Using statistics from 2007 displaying a variety of quality dimensions covering over 99% of all elderly care residents in Sweden, we were able to show that privatization is indeed associated with significant quality differences. Structural quality factors such as the number of employees per resident was significantly smaller (-9%) in private elderly care. On the other hand, the proportion of residents participating in the formulation of their care plan (+7%), the proportion of elderly with a reasonable duration between evening meal and breakfast (+15%), and the proportion of elderly offered different food alternatives (+26%) were significantly in favour of private contractors. Our conclusion is that private care providers seem to emphasize service aspects rather than structural prerequisites for good care.     

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

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.     

The 2019 Health Basic Law in Portugal: Political arguments from the left and right

The Portuguese National Health Service (NHS) was established in 1979. Since its inception, the relationship of the NHS with private-for-profit and private-non-profit organisations has been controversially discussed between left and right-wing political parties, and this has also led also to academic debate. In 1990, a Health Basic Law was approved by right-wing parties, which allowed public-private partnerships (PPPs) in the health system and led to an increased role of the private sector in health care provision. During the 2015 general elections, the role of PPPs in the health system was an important topic of discussion, with all left-wing parties calling for an end of PPPs in the NHS. In 2019, after two years of intense political controversies, left-wing parties supporting the minority socialist government approved a new Health Basic Law. This paper analyses the process of policy formulation, tracing the process of adoption and the views of the main political parties involved.Although some parties wished to eliminate PPPs and to mandate that services in the NHS should be provided exclusively by public providers, this was not included in the final version of the law. Nevertheless, the new Health Basic Law re-enhances the central role of the NHS in the health system, clarifying that the private and non-profit sectors should only play a complementary role.     

Cost containment and the backdraft of competition policies.

This article offers an explanation of why governments and other purchasers found competition policies attractive, and it summarizes a set of new case studies. Faced with economic slowdown and the need to retrench social services, governments felt their legitimacy threatened and sought a new approach that would legitimize controlling costs. Starting in the 1980s, a group of pro-capitalist "moral entrepreneurs" launched an international business movement focused on reducing waste in governmental and welfare services through competition and privatization. Political leaders in a number of the developed industrialized countries enthusiastically embraced "managed competition" as a way to control the costs of health care services and to make them more accountable. The dangers of implementation and the extensive market failures that are ever-present in medicine, however, led most governments to pull back. Most nations that implemented competition policies experienced a political backdraft of protest from patients and providers that swept them out of office.     

Elderly care policy, formal and informal care. The Swedish case

This paper discusses the consequences of a 'greying' Sweden with respect to the present Swedish policy for the care of the elderly and the role of the family as care provider for the elderly. The present system of elderly welfare is questioned, based on demographic facts, a review of the service systems and research findings. The tentative conclusions are two-fold. Firstly, present trends point to a shift in the Swedish welfare model, from a publicly financed and run elderly care system to a mixed model based on public, private and voluntary resources. Secondly, the fact that the informal care system functions as the main provider of services for the elderly, means that the development and implementation of support programmes for the family caregivers is of crucial importance for the future. The challenge for the 1990s, then, is to improve conditions for informal carers in order to enlarge the caring capacity of the community.     

Reforming foodservice in elderly care: National actions and local outcomes

Aim

The aim was to explore the outcome, on a local level, of steering, organisation and practices of elderly care foodservice by Swedish municipalities, and changes relative to national actions.

Methods

A survey using a web‐based questionnaire about elderly care foodservice targeting all Swedish municipalities (n = 290) was conducted in 2006 and 2013/2014. The questionnaire included the topics: organisation of foodservice, its practice in elderly care and steering devices such as guidelines and policies. Based on the share of a rural population, municipalities were divided into groups: rural (≥50%), urban (<50%) and city (≤20%).

Results

The response rate from municipalities was 80% in 2006 and 56% in 2013/2014; 45% participated in both surveys. The results showed increased use of local food policies (P = 0.03) and meal choice (P < 0.001), while access to clinical/community dietitians declined (P = 0.01) between the surveys. In home‐help services, daily delivered cook‐serve meals declined (P < 0.001) and chilled meals delivered three times a week increased (P = 0.002) between the surveys. City municipalities used private foodservice organisations the most (P < 0.001), and reported reduced use of cook‐serve systems in favour of chilled. In rural municipalities, the use of public providers (98%) and a cook‐serve system (94%) were firmly established. Urban municipalities were placed between the other groups.

Conclusions

National actions such as soft governance and benchmarking appear largely to determine local level outcomes. However, conditions for adapting these measures vary between municipality groups. While efficiency enhancing trends were prominent, questions remain whether national actions should be expanded beyond performance to also examine their consequences.     

Conspiracy beliefs and distrust of science predicts reluctance of vaccine uptake of politically right-wing citizens

It is not uncommon for conspiracy theories to have a political agenda, some conspiracies are more endorsed by the political left-wing than the political right-wing and vice-versa. Conspiracy theories quickly flourished as the COVID-19 pandemic emerged and this may have been an underlying factor in a reluctance by some in following public health policies such as the wearing of face masks. In the present study, we surveyed a community sample of 1358 adults just prior to the COVID-19 vaccine rollout in Aotearoa New Zealand. Our first aim was to determine whether one’s political orientation, whether they are politically left- or right-wing, would be predictive of an individual’s belief in conspiracy theories and determine whether this relationship can be exacerbated by a distrust in science. The second aim was to determine how such a relationship could explain an individual’s vaccine hesitancy. Our results supported that indeed those that identify as right-wing tended to have higher hesitancy associated with taking the COVID-19 vaccine. However, we demonstrated that this association, in part, can be explained by a corresponding belief in COVID-19 related conspiracies. Interestingly, such a relationship only emerged in the presence of a general distrust in science. In other words, if a right-wing individual has at least a moderate trust in science, they demonstrated similarly low endorsement of COVID-19 conspiracies as their left-wing counterparts. Mitigating the right-wing endorsement of COVID-19 conspiracies then aligned with a reduction in vaccine hesitancy. Our findings indicated that public interventions seeking to increase trust in science may mitigate right-wing endorsement of conspiracy theories and thus lead to a more unified and positive response to public health behaviours such as vaccination.     

Indonesian heath care and the economic crisis: is managed care the needed reform?

The ramifications of the current economic crisis are being felt throughout Asia, but problems are particularly acute in Indonesia; in the midst of high inflation and unemployment the government is considering expanding managed care reform. In this paper, we discuss the impact of the recent economic crisis on the health sector in Indonesia, and analyze the potential for implementing effective reform following the managed care model. The health sector is discussed, highlighting pre-existing problems in the health care supply environment. The determinants of the economic crisis are summarized, and the broad impacts of the crisis to date on the health sector are assessed. Next the prospects for success of current managed-care reform proposals are examined in some detail: viability of expanded managed care reform measures are assessed in light of the continuing crisis and its likely impacts on the consumers and suppliers of health care. Analysis of the potential impact of the continuing crisis focuses on key participants in health care reform: households, the government, and private health care providers. In conclusion the potential viability of managed care appears poor, given the current economic, political, and institutional conditions and likely future impacts, and suggest some alternative reform measures.     

Co‐production of community mental health services: Organising the interplay between public services and civil society in Denmark

Co‐production involves knowledge and skills based on both lived experiences of citizens and professionally training of staff. In Europe, co‐production is viewed as an essential tool for meeting the demographic, political and economic challenges of welfare states. However, co‐production is facing challenges because public services and civil society are rooted in two very different logics. These challenges are typically encountered by provider organisations and their staff who must convert policies and strategies into practice. Denmark is a welfare state with a strong public services sector and a relatively low involvement of volunteers. The aim of this study was to investigate how provider organisations and their staff navigate between the two logics. The present analysis is a critical case study of two municipalities selected from seven participating municipalities, for their maximum diversity. The study setting was the Community Families programme, which aim to support the social network of mental health users by offering regular contact with selected private families/individuals. The task of the municipalities was to initiate and support Community Families. The analysis built on qualitative data generated at the organisational level in the seven participating municipalities. Within the two “case study” municipalities, qualitative interviews were conducted with front‐line co‐ordinators (six) and line managers (two). The interviews were recorded, transcribed verbatim and coded using the software program NVivo. The results confirm the central role played by staff and identify a close interplay between public services and civil society logics as essential for the organisation of co‐production. Corresponding objectives, activities and collaborative relations of provider organisations are keys for facilitating the co‐productive practice of individual staff. Organised in this way, co‐production can succeed even in a mental health setting associated with social stigma and in a welfare state dominated by public services.     

Managed care as a platform for cross-system integration

Following the significant industrialization of private health care, managed care strategies for reducing costs are beginning to enter the public sector. Privatization of public mental health dollars is already a reality in some states and a growing possibility in many others. Changes in the financial management of behavioral health care are a source of concern for providers, advocates, and clients who desire services that are consistent with the core values of an integrated system of care. This article reviews the core values of the system of care for children and families, recent changes in the continuum of care for children with severe emotional disorders, and basic principles and strategies of managed care. It is proposed that system-of-care values and managed care principles are not mutually exclusive. In fact, a judicious combination of system-of-care values and private sector management strategies may facilitate cross-system integration of services for children and youth. An example of a private, nonprofit corporation designed to manage public sector dollars across child welfare, juvenile justice, and mental health/alcohol and drug addiction systems is presented.     

Unhealthy European health policy.

The European Union claims that the defense of its welfare state is one of today's most important challenges. This article analyzes whether the European governments and the European Union really pursue a policy that strengthens their health and social security systems, or one that is in itself a threat to health and social security. After a summary of the origin and evolution of the European health systems, the authors pinpoint underlying reasons for reform and demonstrate how, since the 1990s, the European Union has built a strict financial and political straitjacket, forcing these systems to carry out privatization and cutbacks. Reform measures can be divided into three interdependent categories: (1) the increasing influence of governments on health care organization, to enable restructuring; (2) measures aimed at reducing public expenses, including higher financial contributions by patients and restrictions on the range of services provided; and (3) measures that establish competition and hidden or open privatization of services and insurance systems. Through these mechanisms public expenses are reduced while private health care expenses (and private profits) rise freely. Ongoing European health care reforms thus struggle with the contradictions between responding to growing collective needs and securing or increasing private profits.     

Health care provider choice and utilization among the elderly in a state in Brazil: a structural model.

OBJECTIVES: Current demographic trends point to the need for understanding the health challenges facing the elderly in Latin America today. This study assessed whether health care provider choice and household income impact utilization and health among the elderly in Brazil. METHODS: Using a sample taken in 1995 in southern Brazil, a structural model was used to estimate the parameters of a function that represents the choice of health care provider, controlled for health care services utilization and a health production function. The dependent variable for the production function was self-assessed health. These two functions were structurally linked by introducing the probability of choosing a private over a public provider in the health production function as an added explanatory variable. With this structural linkage, the production function assessed how much the selection of a public versus a private provider affects health, while controlling for the possibility that individuals with poorer health have a tendency to prefer one or other health care provider. RESULTS: Health care services utilization by the elderly was constrained by two factors: the number of providers at the municipality level and household income. The elderly who live in municipalities with a greater number of public, outpatient clinics and providers were more likely to use the public system. Patients who used the public health care system had lower self-assessed health status than those using the private system. This result is valid even after controlling for demographic variables and morbidity. CONCLUSIONS: Brazil's public health system does not adequately provide for the health needs of the elderly population. Policy recommendations include further investments in the public health care infrastructure, full implementation of the National Plan for Elderly Health, and developing new programs for effective geriatric consultations at the primary care level.     

Changes in managed care activity in outpatient substance abuse treatment organizations, 1995–2000

Using nationally representative data from 1995 and 2000, this study examines trends in managed care penetration and activity among outpatient drug treatment organizations in the United States. Further, it investigates how managed care activity varies across different types of treatment providers and for public and private managed care programs. Overall, managed care activity has increased, with a greater proportion of units having managed care arrangements and a larger percentage of clients covered by managed care. In general, public managed care activity has increased and private managed care activity has decreased. Treatment providers report that they have fewer managed care arrangements, which may reflect consolidation in the managed behavioral care sector. Finally, growth in managed care among outpatient substance abuse treatment units affiliated with hospitals and mental health centers may signal a preference for providers that can effectively link substance abuse treatment with medical and social service provision, or, alternatively, that linkages with such organizations may provide the size necessary to assume the risks associated with managed care contracts.     

Privatization in French health politics: few projects and little outcome

The author presents the main features of the organization of the French health care system, revealing an important mixture of public and private actors and institutions and a large number of political restraints that oppose resistance to privatization. In spite of traditional references to "liberal medicine" and recurrent debates opposing public and private intervention, neither the doctors nor the political decision makers have really supported the few projects that have been proposed for privatization or liberalization of health care. On the contrary, the cost-control policy introduced growing State intervention and new management methods into the health care sector, whose actors were not used to it. The privatization and liberalization debates appear as a rhetoric necessary to accommodate these difficult changes.     

The Swedish health care system--an economist's view

This article compares the organization of the Swedish health care system with that in three other countries, the U.S., the U.K., and Canada, focussing on three main areas: (1) the provision and financing (public or private) of health insurance, including the question of the quality of the insurance protection offered; (2) the organization of the production of health services, and the economic incentives on the system's decision-makers (doctors, hospital managers, politicians, etc.). Possible answers are suggested to the question why one country (the U.K.) is able to provide health care to its population at an average cost considerably below that of the others: Differences in the quality of the insurance protection and health services; in the incentives on the system managers to exercise cost control; and in the incentives on service providers such as physicians, to consider cost-effectiveness when making treatment decisions. An attempt is made to suggest lessons for health care reform in Sweden and elsewhere.     

Public and private imperatives of Greek health policies

Health care in Greece has historically developed into a multi-tier system, a mosaic of public and private providers of services covering the members of occupational social insurance organizations. In 1983 PASOK's socialist government established a unified National Health System. The aim was to arrest the growth of the private sector and promote the public sector to a dominant position. The socialist legislation has recently been reviewed by a conservative government that aims at a competitive mixed market of public and private providers. The growth of private health care, however, is not solely a matter of political support but also of new opportunities for profitable investments that arise from a shrinking public sector under economic and fiscal constraints.     

Public health, privatization, and market populism: a time for reflection

The political, social, and economic ideology fueling the movement toward privatization in health care may be characterized as "market populism." Whether or not public health agencies retain their traditional roles in personal health services delivery, these organizations must serve as the predominant external source for quality monitoring, oversight, enforcement, and advocacy for communities in an environment that regards the private market as a panacea.     

Politics and health in eight European countries: A comparative study of mortality decline under social democracies and right-wing governments

Recent publications have argued that the welfare state is an important determinant of population health, and that social democracy in office and higher levels of health expenditure promote health progress. In the period 1950–2000, Greece, Portugal, and Spain were the poorest market economies in Europe, with a fragmented system of welfare provision, and many years of military or authoritarian right-wing regimes. In contrast, the five Nordic countries were the richest market economies in Europe, governed mostly by center or center-left coalitions often including the social democratic parties, and having a generous and universal welfare state. In spite of the socioeconomic and political differences, and a large gap between the five Nordic and the three southern nations in levels of health in 1950, population health indicators converged among these eight countries. Mean decadal gains in longevity of Portugal and Spain between 1950 and 2000 were almost three times greater than gains in Denmark, and about twice as great as those in Iceland, Norway and Sweden during the same period. All this raises serious doubts regarding the hypothesis that the political regime, the political party in office, the level of health care spending, and the type of welfare state exert major influences on population health. Either these factors are not major determinants of mortality decline, or their impact on population health in Nordic countries was more than offset by other health-promoting factors present in Southern Europe.     

Infection control and changing health-care delivery systems

In the past, health care was delivered mainly in acute-care facilities. Today, health care is delivered in hospital, outpatient, transitional care, long-term care, rehabilitative care, home, and private office settings. Measures to reduce health-care costs include decreasing the number of hospitals and the length of patient stays, increasing outpatient and home care, and increasing long-term care for the elderly. The home-care industry and managed care have become major providers of health care. The role of specialists in health-care epidemiology has changed accordingly.     

Medicaid managed care for mental health services: the survival of safety net institutions in rural settings

Few accounts document the rural context of mental health safety net institutions (SNIs), especially as they respond to changing public policies. Embedded in wider processes of welfare state restructuring, privatization has transformed state Medicaid systems nationwide. We carried out an ethnographic study in two rural, culturally distinct regions of New Mexico to assess the effects of Medicaid managed care (MMC) and the implications for future reform. After 160 interviews and participant observation at SNIs, we analyzed data through iterative coding procedures. SNIs responded to MMC by nonparticipation, partnering, downsizing, and tapping into alternative funding sources. Numerous barriers impaired access under MMC: service fragmentation, transportation, lack of cultural and linguistic competency, Medicaid enrollment, stigma, and immigration status. By privatizing Medicaid and contracting with for-profit managed care organizations, the state placed additional responsibilities on "disciplined" providers and clients. Managed care models might compromise the rural mental health safety net unless the serious gaps and limitations are addressed in existing services and funding.