Aging in Sweden: Local Variation, Local Control

Abstract

Aging in Sweden has been uniquely shaped by its history—most notably the long tradition of locally controlled services for older adults. We considered how local variations and local control shape the experience of aging in Sweden and organized the paper into 3 sections. First, we examine aging in Sweden along demography, economy, and housing. Next, we trace the origins and development of the Swedish welfare state to consider formal supports (service provision) and informal supports (caregiving and receipt of care). Finally, we direct researchers to additional data resources for understanding aging in Sweden in greater depth. Sweden was one of the first countries to experience rapid population aging. Quality of life for a majority of older Swedes is high. Local control permits a flexible and adaptive set of services and programs, where emphasis is placed on improving the quality and targeting of services that have already reached a plateau as a function of population and expenditures.

Aging in Sweden has been uniquely shaped by its history—most notably the long tradition of locally controlled services for older adults. The most unique outcome of this history is its highly developed Welfare State apparatus that is largely organized at a local level. For example, responsibility for old age care rests with Sweden’s 290 kommun (municipalities). To understand how these forces have shaped the experience of aging in Sweden, we organize this paper into three sections. First, we briefly outline the current status of older Swedes focusing on developments in the demographics of aging; economy, pensions, and subsidies; and housing. Second, we chart the origins and development of the welfare state in greater detail, with an emphasis on services and service utilization, and caregiving that currently organize much of the aging policy discussion in Sweden. In a final section, we provide information about some of the existing Swedish data resources available to researchers who wish to learn more about aging in Sweden.

Aging in Sweden

Demographics of Aging

A great deal is known about the demography of aging in Sweden (see Sundström, 2009 for an extensive review), and Sweden was among the first nations to experience rapid population aging. When Swedish population data were collected for the first time in 1749, the results were immediately classified as state-secrets because they were considered as politically sensitive, finding that the country had only 1.8 million inhabitants after a series of devastating wars with Russia, crop failures, and epidemics. These early records show that 6% of the population was aged 65+ at that time. During the later 1700s and the 1800s, there was rapid population increase and proletarization. The proportion of old people rose slowly to reach 8% in 1900; in absolute terms, the number of old Swedes doubled in the four decades following 1860.

Because Sweden’s population began aging prior to most other nations, it is also a leader among the oldest-old (aged 85+). Figures 1 and 2 show the percentage of the population in each municipality (kommun) aged 85+ by sex in 1987 and 2002, respectively. There has been a rapid increase in the proportion of the population aged 85 and older in a 25-year period. Substantially higher proportions of those 85 are women than men. There is also substantial variation in the proportion of the population aged 85+ by municipality with large bands of municipalities having very high proportions of the oldest-old. Data are the authors’ own calculations from Statistics Sweden (Statistiska centralbyrån, http://www.scb.se/).

Economy, Pensions, Subsidies

A majority of older Swedes enjoy financial security, with many living in fully paid single-family homes (Swedish Association of Local Authorities and Regions [SALAR], 2009). To make modern housing affordable more than 30% of older persons get housing subsidies (depending on income and cost of housing), including home owners. Reconstruction in the 1990s made pensions dependent on Swedish economic productivity, leading to unexpected cuts of about 5% to pension payments in 2012 and 2013 and prompting further demands by pensioners’ organizations for redesign. Swedish men and women retire late by international comparisons, and there is a consensus that future cohorts should continue working even longer (69 has been proposed), conflicting with present mandated (by agreements between employers and trade unions) retirement for workers by age 67. Widows’ pensions were abolished in the 1990s in the name of gender equality.

In 1950, about 5% of the gross domestic product (GDP) was public expenses spent on older persons, including pensions. Continuously rising, this ratio culminated at about 14% in the late 1980s and has not increased substantially since in relative terms but spending in absolute terms has continued to rise. Adding acute health care may add another 3%. This is a crude indicator although it may capture the historical trend. Government reports suggest rising expenses and also the need for increased self-reliance in the future.

Housing

Consistent with their general economic well-being, most older Swedes enjoy access to high quality and affordable housing (SALAR, 2009). A nationally representative survey of older persons (67+) in 1954, the world’s oldest preserved survey of that kind, made visible the substandard housing conditions and even misery of many older persons even by the standards of that time; a tenth did not even possess a dwelling of their own but lived on premises owned by former employers, and so forth. Many were helped by family, and 27% coresided with children. But surprisingly, many also got little or no informal care—contrary to common beliefs about people being more caring “in the past.” Today surveys for older adults inquire about cell phones (91% have one) and computers (6 out of 10, 65+, have an E-mail address). One in 10 older persons live part of the year in second homes or even in Spain or other sunny sites.

Origins and Development of the Swedish Welfare State

Sweden has a long tradition of public, locally financed and administered responsibility for poor, frail, sick, and older persons who cannot support themselves or get support from family. Following the Reformation in the 1500s, administration of poor relief was a highly local concern. Sweden’s approximately 2,500 parishes had an average of 300 inhabitants at that time. In 1862, these parishes were transmogrified into municipalities that continued to collect taxes for poor relief and determine the worthy recipients. This tradition is important for understanding Sweden today because it is a more financially powerful edifice established on old foundations. There were, and remain, large local variations both in how much help is provided and in the quality of that help. This high level of devolution allows local administrators to have a thorough knowledge of their catchment area. For example, one study found that Home Help workers and administrators know a lot about older people in their districts even when they are not clients of their services (Socialstyrelsen, 1996).

Continuing into the late 1940s the general policy, endorsed by central authorities, was to institutionalize older persons who today would often not be eligible for any support whatsoever and also prefer to remain in the community. Protests by the fledgling pensioners’ organization (Sveriges Pensionärsförbund [SPF], established in 1938) against these inhumane practices and the meager pensions were not heeded. Growth in community-based services began with Home Help expanding in the 1970s and 1980s other types of support like transportation services, personal alarm systems, and home-delivered meals. The proportion of older Swedes receiving social services has now plateaued. From spending about 1% of the GDP on eldercare in 1960, it grew to 2.5% in 1975 but increased only marginally after that time to approximately 2.9% today.

Use of Public Services

Home help is funded from local taxes and a complex national redistribution formula. Swedish home help began with abolition of the Poor Relief Act in 1956. Home help services grew rapidly until the 1970s as women began entering the labor force, often as home help workers. An important study by Berg, Branch, Doyle, and Sundstrom (1988) tracks changes in institutional and home-based long-term care over a 20-year period (1965–1985). Many of the changes they observed across the emergence and development of home help services through to the beginning of their contraction have been accelerated over the course of the 1990s due to economic recession (Bergmark, Parker, & Thorslund, 2000) and a shortage of home help workers (Jeths & Thorslund, 1994). Long-term care units have changed to serve more of a rehabilitation need with discharge back to the community, with nursing homes being reserved for end stage care. Despite aims of universality, comprehensiveness, and equality of access, large regional variations have been observed.

Most people in need of activity of daily living (ADL) help receive help from their family, and some of them also use public services that are means tested by income and amount of help required. Controlling for health differences, there are small class differences in the use of Home Help and other public services: After all, they are mostly paid for through taxes and clients pay just a small fraction of the actual cost. Since a few years ago a new tax deductible scheme for household services make them an economical alternative to ordinary public services, at least for the more affluent.

In 1950, there was only institutional care, covering some 6% of the older population. By 1975 that had increased to 9% in spite of the policy of home care, which at that time with Home Help covered about 16% of the older populations. These levels stagnated and began to decline in the 1980s and 1990s but have since leveled off at about 9% for Home Help and 5% for institutional care in 2011. Public spending on services for older persons has increased little after the 1990s although the resources now are used in new ways.

Sizable local variations in public services for older persons are often assumed to mean inequities in service provision and/or needs assessments. However, analysis suggests that variations largely respond to local variations in needs as defined by the combination of living alone and in need of ADL assistance, defying popular notions of equality of needs that should translate into equal service coverage. When needs are considered, most of the differences in Home Help services vanish (Davey, Johansson, Malmberg, & Sundström, 2006).

Improved capacity for self-care offset some of the service decline, but there was also a seldom noticed increase in other, less costly and “minor” but not unimportant services, such as alarm systems and transportation services. (The latter typically involves calling for a taxi, with users paying the same fee as for the local public transport.) Considering that many of the latter users do not use Home Help, total coverage rates of public old age care have been rather stable since the 1970s. Behind this apparent stability there has been a dramatic increase in the use of in end-of-life care that is not well reflected in coverage rates and similar statistics routinely used to track service utilization.

Recent years have seen some rationing of services. Recipients of home help receive less support, and the needs of those receiving support are greater than in the past. There is considerable variation in how municipalities have responded to these changes. Some areas try to preserve coverage rates (percentage of elders receiving supports) whereas others provide services more intensively to smaller proportions of the older population (Davey, Savla, Zarit, Sundström, & Malmberg, 2007; Savla et al., 2008). There have also been changes in institutional care. Longitudinally, in 1950, about 15% of older persons ended up in institutional care—today more than 50%. Altogether about 80% of older persons use social services before they pass away. The general public, and regrettably also professionals and responsible politicians, only visualize the declining coverage rates. Complaints about less accessible services are common, as are complaints about quality problems. Surveys on client satisfaction usually show that about 80% or more of clients of Home Help and institutional care are overall happy with their service, although the validity of these measures as indicators of quality has been challenged. Indicators of quality at the municipal level cover measures such as staffing ratios and training, place of death, pain relief at the end of life, overmedication, and use of psychopharmaceuticals (also in the general older adult population), also vary by location (Davey et al., 2007; Trydegård & Thorslund, 2001). It is noteworthy that there is no straightforward connection between quality, efficiency, and productivity as suggested by these indicators and cost variables (SALAR, 2009).

Historically, older people who used poor relief and, later, public services often lacked functional family members and/or lived alone and were poor. To some extent this is still true, particularly for the use of institutional care. For example, the never-married (and consequently often childless) are still overrepresented in places providing institutional care. About 5%–6% of older people (65+) in the 1950s were institutionalized and this increased before retreating back to 5% in 2012. Rates at this level were not unusual in earlier centuries but could vary a good deal locally. An alternative to institutionalization is the home help services that expanded rapidly in the 1960s. These services had and have a much less visible class bias. The working class use home help services more often in old age than middle- and upperclass older adults, but Swedish analyses indicate that this is mostly due to class differences in functional capacity and living arrangements. Elders using home help were often helped by their family as well and vice versa (Socialstyrelsen, 2000, 2006). It seems that class gradients may have become attenuated, with public services focusing on the oldest and frailest, who often suffer from dementia.

Caregiving and Receipt of Care

Surveys in Sweden show a consistent decline in need for ADL help among older adults from 32% to 22% between 1989 and 2009 (Fors, Lennartsson, Agahi, Parker, & Thorslund, 2013) although other studies give a less favorable image of how needs have evolved (Parker & Thorslund, 2007). There is no evidence of decreasing help from family and other informal caregivers in Sweden, if their input is related to decreasing needs during this time period. Trends in public Home Help are similar. Access to informal care at large has increased during this period because more older people today have available kin than in the early 1950s (Sundström, 2009). Analyses show that probability of receiving informal help increases with the number of close relatives, but so does the risk of becoming a caregiver as well (Socialstyrelsen, 2006).

Older people are not only recipients of help and care. About one fifth of older Swedes are caregivers. Absolute numbers of older family caregivers increase as the number of people “at risk” for becoming caregivers is increasing, and more of them are married or partnered. Surveys on caregiving and helping at large suggest a general increase in informal care in Sweden since the early 1990s with partner caregivers assuming the heaviest commitments. Increase in caregiving may be associated with cutbacks in services and also reflect older persons having more close family like spouses and off-spring (SALAR, 2009)

Since 2009 municipalities are mandated to provide support for caregivers, and many municipalities have hired “caregiver consultants.” Previous fears that local authorities would be “flooded” by needy caregivers have not materialized. With the exception of spouse caregivers, utilization of these support programs is often quite low and caregivers are more likely to prefer continued quality services for the care recipient over support for themselves (Socialstyrelsen, 2009).

Swedish data indicate that men and women are equally likely to provide care for their partners in old age. Because men often experience more “abrupt” deaths and shorter and less severe spells of frailty, the total volume of care provided by men and women comes out to be about the same (Socialstyrelsen, 2004). It is noteworthy that most old people will have used public home help before they move to an institution or before they die in the community.

Research and Data Resources on Aging in Sweden

Compared with many countries, Sweden has a long history of gerontological research, including a number of influential longitudinal studies. After a hesitant start in the 1960s, gerontology got off the ground in 1970 with the publicly financed Institute of Gerontology (IFG) in Jönköping (today part of the local university). Somewhat later this Jönköping county council initiative was followed in Lund and Stockholm. Noteworthy early research initiatives included the H70 study (Steen & Djurfeldt, 1993) begun in 1970 in Gothenburg, a longitudinal study of 70-year-olds, which found dramatic improvements of functional health in new cohorts, who are becoming more active in all aspects covered (except church going), including sexual activities. This was a starting point for the longitudinal gerontological studies that are a hallmark for Swedish gerontology. Other longitudinal data sets include studies of octogenarians (OCTO, OCTO2; e.g., Zarit, Femia, Gatz, & Johansson, 1999) and nonagenarians (NONA; e.g., Wikby, Johansson, Olsson, Löfgren, Nilsson, & Ferguson, 2002) at the IFG, Sweold (Brattberg, Parker, & Thorslund, 1996) and the Kungsholmen study (Wang, Karp, Winblad, & Fratiglioni, 2002) of the 80+ at the Aging Research Center (Stockholm), the SATSA (Swedish Adoption Twin Study of Aging; Gold, Malmberg, McClearn, Pedersen, & Berg, 2002; Lichtenstein, Pedersen, & McClearn, 1992) at Karolinska Institute, for several years funded by U.S. National Institutes of Health, and the Betula study (Nilsson et al., 2000) of cognitive aging and memory changes in old age at Umeå university. Umeå University also hosts the important historical population database that follows individuals and families since the mid-1700s, which is useful also for studies on aging. Additional important studies include the Swedish National study on Aging and Care (SNAC; Lagergren et al., 2004) and the Swedish Centenarian Study (Samuelsson et al., 1997). Sweden also participates in the Survey of Health, Ageing and Retirement in Europe (SHARE, http://www.share-project.org/), a multidisciplinary, cross-national panel database on health, socioeconomic status, social, and family networks with four biennial waves of data collection harmonized with the U.S. Health and Retirement Study, beginning from a baseline wave in 2004.

Governmental funding in the 1980s supported three universities to establish behavioral gerontological research. In Gothenburg a chair in psychology was inaugurated, in Uppsala a chair in sociology and in Stockholm a chair in social work, all directed towards old age. Lately a number of centers tied to universities have emerged. Especially successful is the ARC (Aging Research Center), a collaboration between Karolinska Institute (KI) and Stockholm university, which, among other things, is the home of a Swedish center for dementia research. At KI the department for epidemiological medicine and biostatistics administrates the Swedish twin register, a gerontological success story in Sweden and internationally. Other research centers tied to universities are Centre for Ageing and Supportive Environments (CASE) at Lund university and National Institute for the Study of Ageing and Later Life (NISAL) at Linköping university.

This year the Swedish government has made massive funding available for program support to research about aging and health and related issues. Also a very large (SEK 1 billion+) private fund has been established to support gerontological research. Swedish aging research has often been motivated (and publicly financed) to tackle applied topics such as reasons for institutionalization, factors behind dementia, and designing better dementia care. The renewed interest in support of gerontology may further improve our understanding of aging and old age.

Statistics Sweden (Statistiska centralbyrån, http://www.scb.se/) provides data for a wide range of population and industrial characteristics on an annual basis and provides data export and some limited mapping features. The National Board of Health and Welfare (Socialstyrelsen, http://www.socialstyrelsen.se/) provides a number of reports on health, illness and disability on the Swedish population. Most community services, including elder care, are organized at the municipal level. The Swedish Association of Local Authorities and Regions (Sveriges Kommuner och Landsting, http://www.skl.se/) provides a wide range of reports and data on Swedish local government.

Conclusion

Aging in Sweden has been almost uniquely shaped by its history—most notably the long tradition of locally controlled services for older adults. Careful study of aging in Sweden has important implications for advancing our knowledge in gerontology. Sweden is well ahead of many other countries in terms of both population aging and the development of aging-related policies and services. For this reason, there are many reasons why gerontologists from other countries should know more about Sweden and its agile adaptations to an independent aging population.

Acknowledgments

Dr. Davey was supported by grants from the National Institute of Health (R03AG023301, R01HD069769, R21CA158877, R01AG13180, R01CA158361) and United States Department of Agriculture (PENR-2010-04643, PENR-2011-04489).

References

Author notes