Lennarth Johansson

Associate Professor, School of Health and Welfare, Jönköping University

Sweden has a well-developed welfare system, providing health care, social services as well as pension and social protection to the citizens over the life course. It has been a public responsibility for centuries to care for older and disabled people. The general principle of Long-Term Care (LTC) is to provide publicly subsidised, widely available services (in kind) based on the individual’s needs, regardless of economic means and family resources, thereby removing the burden of providing services from the family[1],[2]. A basic idea behind the universalistic feature of the Swedish welfare system is to make the services affordable for the poor, but still attractive for the wealthier. As care of older people is a public responsibility, consequently there are no legal obligations or statutory requirements for adult children to provide care or economic security for their older parents. Swedish welfare state programmes are based upon individual independence; family bonds should be voluntary and not obligatory, to promote maximum independence from the family, even if you need support for your daily living[3].

In Sweden, responsibility for health care and social services is divided between three levels of government. At the national level, parliament and the government set out policy aims and directives by means of legislation, economic incentives, and supervision. The Social Ministry is responsible for both health and social care at the national level. The regions (21 in all) are responsible for the provision of health and medical care. At the local level, the (290) municipalities are legally obliged to meet the social service, home health care, and institutional care needs of older people. Regions and municipalities have a very high degree of autonomy vis-à-vis central government. At regional and local level, each region and each municipality decide, within the framework of existing legislation, over their own matters. In short, old age care is based, driven, and financed by local governments.

Regions and municipalities have elected assemblies and the right to levy taxes. The regions and municipalities may decide to what extent they will prioritise older people over other groups. Health and social care system has universal coverage and not means-tested.

The division of responsibility between national and local governments is reflected in funding responsibilities. LTC is almost totally financed by taxes. The largest share of the cost (about 85-90 percent) is covered by local taxes. The user only pays a fraction of the cost (4-6 percent). National taxes cover the remaining part of the cost (about 5 percent). The fact that health and social care services for older people are primarily funded by local taxes confirms the independent role of the local authorities, i.e., their independence of national government. The fees for home help, institutional care, and health care (including prescribed medications) have a cap, with a maximum cost for the user. This means that usually no one has to forgo health and social care due to economic reasons.

The “ageing in place” policy is the guiding policy in LTC for older people in Sweden[1]. Swedish people have a statutory right to claim service and care whenever needed. The provision of  long-term service and care is based on a single-entry system; persons in need of help turn to the municipality where they live in order to claim help. Need is determined through a needs assessment process, which is carried out by a municipal care manager. Eligibility to services is not means-tested and there are no national regulations. The municipality decides the service level, eligibility criterias and range of services provided.

Home care (home help and home health care) benefits are provided in kind and there is no cash alternative. Home help includes help with daily activities, e. g. shopping, cooking, cleaning, and laundry, but also covers personal care such as help with bathing, going to the toilet, getting dressed, and in/out of bed. There is also a comprehensive range of other municipal services, such as transportation services, meals-on-wheels, safety alarms, and assistive devices, etc. Municipalities also offer day care, often used as respite for families providing care to older people at home. In addition, there is short-term institutional care, which is often offered older persons after a hospital stay or as a respite opportunity. Most municipalities have also a carer´s counsellor that provide families with counselling, support groups and in-home respite[4].

Municipalities decide over eligibility to home help and are the major providers of LTC services. Some 17 percent of home help is run by private providers (mostly for profit), contracted by the municipalities. Out-patient health care is accessed at the primary health care centres (PHC), mostly publicly but sometimes privately run (reimbursed with public money). The region is responsible for PHC; at these centres’ health care is provided by doctors, nurses, occupational therapists, and physiotherapists, who serve the whole population, including elderly people. Municipalities also provide home health care (except in the Stockholm region). If a person needs health care but is unable to access the primary health care centres (PHC), the person can be enrolled in municipal home health care, a decision taken by the doctor at the PHC.

Since the Community Care Reform  (1992) the municipalities are responsible for all types of care homes. This concept covers nursing homes, residential care facilities such as old age homes, service houses, assisted living, and group homes for persons with dementia etc. Municipalities are the care home providers, but some 21 percent of care homes is run by private providers (mostly for profit), contracted by the municipalities, which also decide over eligibility to care homes.

Most care homes look like regular apartment houses, which is reflected in the housing standard; three quarter of all care home apartments in Sweden has 1 or 1½ room, with cooking facilities (kitchenette), a WC and shower. The residents furnish their apartment themselves to make it as home-like as possible. The resident pays a rent for the apartment, and costs for food and care.

Health care in care homes is provided by nurses and assistant nurses. Medical care is provided by the primary health care doctors. The care personnel (mainly assistant nurses and care aids) cater for daily personal care, social activities, and companionship.  The care homes have an operating manager who is responsible for administrative tasks, finances, scheduling, and rostering of care personnel. Care homes are usually staffed by a nurse at daytime during weekdays. During non-office hours and weekends there are nurses on call as well as doctors if needed.

There is a large range of assistive devices available to support older and disabled people to live an independent life. There are individually prescribed aids, such as crutches, walkers, wheelchairs, and safety alarms. There is also the option of having your home adapted. For example, you can get help installing a shower instead of a bathtub, toilet seat raisers and handrails in your bathroom. A third type of aids are technical work aids, to facilitate care work, e.g., a patient lift makes it easier for the staff when a person needs to be helped in and out of bed.

Digital technologies, to support independency and to make the home care work easier is rapidly expanding. For example, safety alarms with a GPS function, makes it possible to track e.g., persons with dementia who can’t find their way home. The use of a web camera installed in the older persons´ bedroom, is currently being  used in both private homes and care homes. Daily “visits” can also be carried out via digital contact. Another example is the medication reminder that helps the older person to take medication “on time”.

Access to welfare technologies is decided by the municipalities after e.g., an occupational therapist has assessed the needs. Some aids are offered free of charge, others you have to pay a certain fee, as they are regarded as a loan (e.g., a walker). Safety alarms come with a monthly fee paid by the user. Technical work aids are usually financed by the municipality.

Care personnel in LTC consists primarily of assistant nurses and care aids, as well as nurses. Both in home help and in care homes, assistant nurses make up the largest staff group among permanently employed care personnel. Temporary employees also include a large group of care aids. Home health care is provided by a separate municipal organisation, with nurses, occupational therapists, and physiotherapists, who provide health care in the person’s home. In home health care, there is also a large number of assistant nurses responsible for home visits to older people e.g., helping them take their prescribed medication. There are no official statistics on staff in older people’s care, and therefore there is no information on e.g., staffing and staff density in LTC.

Municipal LTC has had problems with recruiting and retaining staff who have the necessary training for a long time[5],[6]. In 2023, a new law was introduced that regulates the profession of assistant nurses, and the education required to work as an assistant nurse, which is nowadays seen as the desirable training when working in old age care.

The government have taken several initiatives to address the staffing shortages in the municipalities.  A well-received national initiative is  “Äldreomsorgslyftet– a “boost for care of older people”. It offers employees in LTC paid education and training during working hours. The government finances the costs for the time the employee is absent for studies. This governmental program started in 2020 and have been prolonged several times and present it is running until 2024.

There is an ongoing development to secure systems for information transfer between different forms of care and authorities. The exchange of information between Sweden’s 21 regions and 290 municipalities is still severely limited for personnel, as there are confidentiality barriers between different principals and authorities and between private and publicly run older care.

However, in  2023, a new law came into force on coherent documentation for care providers[7]. The new law means that care providers can gain access to personal data directly or in other electronic ways from other care and social care providers. Furthermore, a non-confidential provision is included in the Publicity and Confidentiality Act. It means that the social service confidentiality does not prevent information about certain efforts under the Social Services Act being handed over from one authority to another authority in the same municipality.

The policy direction in LTC – ageing in place – has now an added focus on self-care, health promotion and preventive care interventions. Consequently, the new initiatives developed in LTC, have all in common that they are focused on helping older people to stay at home, even if they need extensive care and supervision. One example is the mobile hospital team, responsible for (hospital) care in the individual’s home. For the patient, enrolment means that more advanced care can be provided at home, that a doctor is available around the clock and access to immediate admission to hospital in the event of a possible deterioration. This is described as “virtual care places”, where modern digital technology can maintain the same level of patient safety as in a hospital – an example of “digi-physic” care.

The pre-hospital care “merges” with mobile care in the home, i.e., ambulance care and emergency teams. One example is the “single responder” or nurse’s car; a nurse  with an emergency-registered passenger car, equipped like an ambulance but without a stretcher, that can make rapid interventions. PHC also have mobile teams, which are often used, as the hospital teams, to monitor the health of older people living at home.  In municipal LTC, “digi -physic” care has also made inroads, although not to the same extent as in healthcare. The municipalities offer, for example, medication reminders, camera surveillance both day and night, and digital work aids for care personnel.

The recent decades service coverage in LTC has been shrinking, albeit it is still high compared to other countries. The reduction of hospital beds and  beds in care homes  have resulted in a tightening of eligibility, especially to municipal care homes[8],[9],[10].

There is an equity problem that is” built in” in the Swedish LTC system. As each municipality decide on eligibility and service levels, there are differences between the municipalities how care needs are assessed, eligibility and what services provided. That is, two people with equal care needs, may be offered a place in a care home in one municipality, while in a neighbouring municipality would be offered more hours of home help.

The issue of effectiveness is always  debated and e.g., one motive for the increased market competition in LTC to increase the effectiveness in service delivery – yet with unproven results[11]. Another strategy is the use of digital technologies, for example, medication reminders, camera surveillance both day and night, and digital aids for staff.

The quality in LTC is under constant debate and after the pandemic it has been highlighted by several reports, criticizing the municipalities especially for lack of trained staff for staffing levels that are too low. Also, staff, especially in the metropolitan regions, don´t have enough skills in the Swedish language. However, yearly customers satisfaction studies both in home care and care homes, generally show a high level of satisfaction among the users – albeit the response rate is very low[12].

Finally, Swedish LTC is battling with the aftermath of the Covid-19 pandemic when the resilience in LTC was badly shaken. Both the regions and municipalities on the one hand is struggling with  recruiting and retaining care personnel and on the other hand to finance  expected health and social care services.

In their review, the Corona commission[13],[14] pointed out structural weaknesses of the LTC system that negatively affected the system’s ability to respond to the COVID-19 pandemic . “The Commission’s overarching assessment can be simply summed up as follows[…] the factor that has had the greatest impact on the number of cases of illness and deaths from COVID-19 in Swedish residential care is structural shortcomings that have been well-known for a long time. These shortcomings have led to residential care being unprepared and ill-equipped to handle a pandemic. Staff employed in the elderly care sector were largely left by themselves to tackle the crisis”. About responsibility for the shortcomings: “The ultimate responsibility for these shortcomings’ rests with the Government in power – and with the previous governments that also possessed this information. The Government governs the Realm and should therefore have taken the necessary initiatives to ensure that elderly care was better equipped to deal with a crisis of this nature” [1],[15],[16].

To address the structural shortcomings identified during the COVID-19 pandemic, the present government launched two governmental investigations in June 2023. The first addresses whether the national government should take over the responsibility for health care from the regions and the second is to investigate whether the municipalities should have a statutory right to employ doctors.

Johansson L. (2023) Long-Term Care System Profile: Sweden. Global Observatory of Long-Term Care, Care Policy & Evaluation Centre, London School of Economics and Political Science. https://goltc.org/system-profile/sweden/

[1] Johansson, L. & Schön, P. (2021). MC COVID-19: Sweden. Country report to EU project on Mechanisms of Coordination between health and social care policy in 15 European countries.  www.ilpn.uk

[2] Janlöv, N., Blume, S., Glenngård, AH., Hanspers, K., Anell, A. & Merkur. S. (2023). Sweden: Health system review. Health Systems in Transition, 2023; 25(3): i–198.

[3] Schön, P. & Johansson, L. (2016). European Social Policy Network. Thematic report On work-life balance measures for persons of working age with dependent relatives. Sweden 2016. Report. EU network of independent experts on social inclusion. Brussels: European Commission: European Union.

[4] Johansson, L. & Schön, P. (2017). Supporting carers. Policy summary: Sweden. Cequa LTC Network, www.cequa.uk.

[5] Huupponen, M. (2021). On the Corona Frontline. The Experiences of Care Workers in Sweden. Kommunal & Arena idé. Friedrich Ebert Stiftung.

[6] Strandell, R. (2019). Care workers under pressure – A comparison of the work situation in Swedish home care 2005 and 2015. Health & Social Care in the Community, 28, p. 137–147.

[7] SFS2022:913. Lag om sammanhållen vård och omsorgsdokumentation. [Act on coherent care and service documentation, 2022: 913] (in Swedish).

[8] Szebehely, M. & Trydegård, G. (2012). Home care for older people in Sweden: A universal model in transition. Health & Social Care in the Community, 20(3), 300–309.

[9] Szebehely, M. & Meagher, G. (2018). Nordic eldercare – Weak universalism becoming weaker? Journal of European Social Policy, 28(3), 294–308. https://doi.org/10.1177/0958928717735062

[10] Ulmanen, P. & Szebehely, M. (2015). From the state to the family or to the market?  Consequences of reduced residential care in Sweden. International Journal of Social Welfare, 24, 1, 81-92.

[11] Meagher, G. & Szebehely, M. (Eds.). (2013). Marketisation in Nordic eldercare: a research report on legislation, oversight, extent, and consequences. Stockholm Studies in Social Work 30. Department of Social Work: Stockholm Uni­versity.

[12] Johansson, L. & Schön, P. (2018). Quality and cost-effectiveness in long-term care and dependency prevention.  Cequa LTC Network, www.cequa.uk.

[13] Goverment report (2020). Äldreomsorgen under pandemin. Delbetänkande från Coronakommissionen SOU 2020:80 [Elderly Care during the pandemic. Interim report from the Corona Commission SOU 2020:80] (in Swedish). https://coronakommissionen.com/

[14] Summary SOU 2020: 80. The elderly care in the pandemic (in English). https://www.government.se/contentassets/2b394e1186714875bf29991b4552b374/summary-of-sou-2020_80-elderly-care-during-the-pandemic.pdf

[15] Szebehely, M. (2020). The impact of COVID-19 on long-term care in Sweden. LTCcovid.org, Long-Term Care Policy Network, CPEC-LSE, 22 July 2020.

[16] Szebehely, M. (2021). International experiences of Covid-19 in care homes. Sub-report to the report Elder care during the pandemic. https://coronakommissionen.com/ accessed 24 May 2021.

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