The Swedish mental health system. Past, present, and future

In sum, the evolution, strengths, and weaknesses of the Swedish mental health system are quite similar to mental health systems in other Western countries; early reliance on stand-alone, state psychiatric hospitals, followed by deinstitutionalization and development of largely ambulatory, community mental health care. This evolution has been complicated in Sweden by the multiple levels and system components, the state, the county councils and the municipalities. Unlike the United States, but similar to Britain, community mental health care in Sweden is provided by two systems; treatment (and forensic services) by the county councils' mental health providers, and generic services by the municipalities' social welfare system. The resulting division of roles and responsibilities creates a strong need for collaboration and coordination of activities on behalf of consumers. It can also have the unintended disincentives to serving more difficult consumers. All these difficulties not withstanding, the Swedish mental health system has made major stride in providing quality, appropriate care.     

Why community compulsion became the solution - Reforming mental health law in Sweden

The aim of this article is to understand how compulsory community care (CCC) has become a solution in mental health policy in so many different legal and social contexts during the last 20 years. The recent introduction of CCC in Sweden is used as a case in point, which is then contrasted against the processes in Norway, England/Wales and New York State.In Sweden, the issue of CCC was initiated following high-profile acts of violence. Contrary to several other states, there was agreement about the (lack of) evidence about its effectiveness. Rather than focusing on dangerousness, the government proposal about CCC was framed within an ideology of integrating the disabled. The new legislation allowed for a broad range of measures to control patients at the same time as it was presented as a means to protect positive rights for patients. Compared to previous legislation in Sweden, the scope of social control has remained largely the same, although the rationale has changed — from medical treatment via community treatment and rehabilitation, to reducing the risk of violence, and then shifting back to rehabilitation in the community.The Swedish approach to CCC is similar to Norway, while New York and England/Wales have followed different routes. Differences in ideology, social control and rights orientations can be understood with reference to the general welfare and care regimes that characterize the four states.     

The determinants of health policy, a case study: regulating safety and health at the workplace in Sweden

This article analyzes and criticizes the " technocratic " view of occupational health and safety policies, which sees the values of the personnel in "post-industrial" regulatory agencies as the most important determinant of those policies. It takes an alternate position, which explains occupational health and safety policies as primarily resulting from the different degrees of political power of the two major classes (capital and labor), and from the set of influences exerted on the regulatory agencies by the instruments (e.g., parties, unions, trade organizations) of those classes. It shows how an analysis of the historical evolution of those classes in Sweden and their conflict in both civil and political societies explains Swedish occupational health and safety policies better than a mere analysis of the regulators' views. And it concludes that the occupational health and safety policies in Sweden are not identical to those in the U.S.--as the " technocratic " theorists assume--but rather offer more protection to the workers than U.S. policies do. This situation is a result of labor having more power in Sweden than it has in the U.S. The different class formations and class behavior in the two societies are compared, and the implications of this comparison for occupational health and safety policies are discussed.     

The patient protection and affordable care act: the victory of unorthodox lawmaking

The 2010 Patient Protection and Affordable Care Act was a major legislative achievement of the 111th Congress. This law structurally reforms the US health care system by encouraging universal health care coverage through regulated competition among private insurance companies. When looking at the process for reform, what strikes an observer of US health care policy in the first place is that the Democratic majority was able to enact something in a political field characterized by strong resistance to change. This article builds on that observation. Arguments concentrate on the legislative process of the reform and support the idea that it may be partly explained by considering an evolution of US legislative institutions, mostly in the sense of a more centralized legislative process. Based on approximately one hundred semidirected interviews, I argue that the Democratic majority, building on lessons from both President Bill Clinton's health care reform attempt and the Republicans' strategy of using strong congressional leadership to pass social reforms, was able to overcome institutional constraints that have long prevented comprehensive change. A more centralized legislative process, which has been described as "unorthodox lawmaking," enabled the Democratic leadership to overcome multiple institutional and political veto players.     

Experiences of coercion during investigation and treatment

According to Swedish legislation (LVM) compulsory treatment shall be decided on if someone, due to ongoing abuse of alcohol, drugs or volatile solvents, is in need of care to overcome abuse and if a voluntary intervention is not possible. Very little research has been conducted in Sweden on this particular legislation with regard to the clients' experiences of entire process from assessment to aftercare. We interviewed 74 subjects who were being assessed prior to the court's decision on involuntary care (n=39), or with previous experience of assessment and involuntary care (n=35). The assessment group more often reported having the opportunity to express their opinions to the social worker during the assessment period (55% vs. 21%, p<.05) and they were more positive towards the final decision (60% vs. 24%, p<.05). In spite of the law, 18% were not contacted by the social services while in coercive treatment. The clients who did meet with a social worker, often described the conferences as more of a perfunctory nature with a lack of focus on the actual situation and aftercare planning. This study points at a need of studying the subjects' experiences of the whole continuum of the coercive process: from the investigation, to treatment and to aftercare. It also points at the need for new instruments to be developed covering all aspects of the coercive process and in particular the period of investigation prior to the decision on involuntary care.     

Reform, change, and continuity in Finnish health care

This article describes some essential aspects of the Finnish political and governmental system and the evolution of the basic institutional elements of the health care system. We examine the developments that gave rise to a series of health care reforms and reform proposals in the late 1980s and early 1990s and relate them to changes in health care expenditure, structure, and performance. Finally, we discuss the relationship between policy changes, reforms, and health system changes and the strength of neo-institutional theory in explaining both continuity and change. Much of the change in Finnish health care can be explained by institutional path dependency. The tradition of strong but small local authorities and the lack of legitimate democratic regional authorities as well as the coexistence of a dominant Beveridge-style health system with a marginal Bismarckian element explain the specific path of Finnish health care reform. Public responsibility for health care has been decentralized to smaller local authorities (known as municipalities) more than in any other country. Even an exceptionally deep economic recession in the early 1990s did not lead to systems change; rather, the economic imperative was met by the traditional centralized policy pattern. Some of the developments of the 1990s are, however, difficult to explain by institutional theory. Thus, there is a need for testing alternative theories as well.     

Swedish quantitative criminology in the 1990s: A brief overview

Quantitative criminology research published in Sweden in the 1990s is reviewed and put in the context of major Swedish traditions in quantitative criminological research. Sweden has a strong tradition in sophisticated longitudinal and ecological research which continues into the 1990s. Other traditionally prominent areas of Swedish quantitative research include studies of crime trends, violence, and youth criminality. Traditionally Swedish quantitative criminology has been dominated by studies using official statistics and criminal records as data. In the 1990s there has been a significant upswing in survey studies, motivated partly by an increased interest in questions of etiology and crime prevention. More fundamental research on the causes of crime, including new longitudinal studies, and more evaluations of crime prevention initiatives are needed.     

A democratic responsiveness approach to real reform: an exploration of health care systems' resilience

Real reforms attempt to change how health care is financed and how it is rationed. Three main explanations have been offered to explain why such reforms are so difficult: institutional gridlock, path dependency, and societal preferences. The latter posits that choices made regarding the health care system in a given country reflect the broader societal set of values in that country and that as a result public resistance to real reform may more accurately reflect citizens' personal convictions, self-interest, or even active social choices. "Conscientious objectors" may do more to derail reform than previously recognized.     

Legal Aid in the Eye of a Storm: Rationing, Contracting, and a New Institutionalism

This article discusses possible rationales underlying a legal aid system through an articulation of theories of distribution in the legal services market, considers the idea of prioritization and planning or, in the political vernacular, rationing of public funding, and addresses the impact of economic and social theories of the professions on legal aid structures. Finally, the emerging concepts of 'new-institutionalism' and 'new public management' are introduced to indicate the organizational and sociological complexity of reforming the legal services market. Each of these threads illustrate competing values and institutional influence on publicly funded legal services. Bureaucratic rules mix with professional and economic incentives to articulate entitlement to public money in a predominantly private forum. Drawing on research in the field of rationing health care, sociological and economic work on legal services, and organizational theories, it will be demonstrated that conceptual, policy, and research tools need to play closer attention to this competition of values.     

Worlds we have lost and worlds we may regain: Two centuries of changes in the life course in Sweden

The article seeks to place into historical context the familial changes in “post-industrial” Sweden during the past two decades, by comparing them with general characterizations (based on documented life-course experiences) of the traditional Swedish agrarian society (before 1800), the transitional society (c. 1800–1870), and the industrial society (c. 1870–1980). Familial lives in traditional Swedish society tended to be stable. By contrast, during the agrarian-to-industrial transition, stability gave way to opportunity and unpredictability. In industrial society, especially since World War II, stability became once again the hallmark, because of general governmental social policy. Because in the current postindus trial phase structural alteration cannot easily be distinguished from shortterm fluctuations. Even as families cope with rapid change, familiarity with past traditions can be useful for identifying possible alternative outcomes.     

Deinstitutionalization and Its Impact on Swedish Corrections

The dominant approach in Swedish corrections is to deinstitutionalize as many offenders as possible. This started in the 1960's when Sweden decided that rehabilitation, and secondarily deterrence, would be the overriding goals of its correctional program. This has remained true despite the statistical evidence indicating that the goal of rehabilitation has not been achieved to any significant extent. The dominant belief in Sweden is that prison is harmful and counterproductive when the overall aim is to reintegrate the offender into society.     

Compulsory psychiatric care in Sweden: development 1979-2002 and area variation

As in many other countries, the Swedish legislation on compulsory psychiatric care has been revised several times during the last four decades. Great regional differences within the country in the use of compulsory psychiatric care have been reported. The aims of this study were to describe the development of compulsory psychiatric care in Sweden 1979-2002, and to analyse differences between two groups of counties, one group with high and one with low civil commitment rates, in terms of psychiatric care structure, resources and processes. Data on civil commitments and forensic psychiatric care in Sweden 1979-2002 were collected from public statistics. At least one responsible person in leading position (administrative manager or chief psychiatrist) in each of the included counties was interviewed. The total number of involuntarily hospitalised patients decreased about 80% between censuses in 1979 and 2002, but the rates of forensic patients were unchanged. No clear-cut differences were found in the analyses of structure, resources and processes of psychiatric services between counties with high and counties with low levels of compulsory care. The equality before the law may be questioned. The importance of leadership is emphasised for future analyses.     

Ethnic politics, policy fragmentation, and dependent health care access in California

One out of every six nonelderly Americans without health insurance lives in California. The problem of access to competent and dependable health care is especially problematic among the state's minority, and especially Hispanic, population. Because one-third of the country's Hispanics live in California, how this state deals with health access issues will affect the practice and progress toward universal care in the nation as a whole. Expanding health care access to California's dependent population will involve overcoming a number of well-known administrative and fiscal obstacles, including an underfunded, highly fragmented public health care system that has developed incrementally and incoherently over decades. However, a key to understanding the problem of access to health care in California involves a story of how ethnic conflict and partisan politics often conspire to deny or discourage access for eligible women and children.     

Juvenile Crime Trends in Post-War Europe

In the literature, two models - routine activity and social control - are most often used in attempts to account for a continuous upward trend in the number of juvenile offenders during the post-war period. In Sweden, contrary to what we might expect given these models, the number of juvenile offenders has been stable, and may even have decreased, over the last 25 years. This article will present an analysis of juvenile crime trends in West European countries during the post-war period (1950-1995). A sensible way to begin a comparative study is to take advantage of the analyses already carried out by researchers in the relevant countries. Besides the official crime statistics this study also uses alternative statistics, that is, self-report studies and victim surveys. An obvious advantage with these surveys is that they are independent of the relevant country's judicial system and official statistics. The availability of data played an important part in the choice of countries to be included. In addition, contacts were established with researchers and research centres in most countries covered by the study.     

Health care financing reforms in Germany: the case for rethinking the evolutionary approach to reforms

Health care reform has been a perpetual issue in German politics since reunification. Reform initially focused on restructuring the health care system of the former East Germany. It has subsequently focused on questioning whether the financing of the German social health insurance (SHI) system is sustainable, in light of economic malaise that characterized the 1990s and heightened global competition. In this article, we document twelve significant attempts to reform health care financing in Germany and critically appraise them according to the principles of solidarity and subsidiarity on which SHI systems were built. While the reforms in the aggregate offered the prospect of addressing the challenges faced by the system, the modest results of the reforms and remaining deficiencies of the system underscore the limitations of the evolutionary approach to reforms. This suggests that reformers should consider a more revolutionary approach.     

The unintended consequences of New Zealand's primary health care reforms

In 2001, the New Zealand government commenced a program to reform the organization of publicly funded primary care services. While there have been several positive results of this reform, including the reduction of patient co-payments and the extension of the range of primary care services, the government's program was a hastily implemented attempt to place primary care, the delivery of which is dominated by private doctors, under firm state control. It was also an attempt to override preexisting arrangements. As such, the government succeeded in its goal of establishing new primary health organizations (PHOs), but there were also significant unintended consequences. As detailed in this article, these consequences include (1) the creation of a labyrinthine funding and organizational system with a variable capacity to deliver on the government's reform objectives, (2) an increase in the power and scope of preexisting doctor organizations combined with a government unable to wrest control over the setting of patient co-payment levels, and (3) an emerging lack of clarity about future directions for the primary health care sector.     

Sweden in 1930 and the 1930 census

The primary goal of censuses has always been to collect reliable information on the state’s population and provide a basis for governmental decision-making. This study examines the categories used in the 1930 census and links them to the context in which they were generated. We treat the census as a tool of state power, which can be discerned from the definitions of its categories and the way in which statistics are collected and used. The guiding question of the study was “how does the 1930 census differ from previous censuses and how can these differences and changes be explained?” We find that as in earlier censuses, Statistics Sweden used extracts from the parish books on the individual level to collect information for the 1930 census, but also used diverse supplementary sources including tax registers, income tax returns and language surveys. Thus, unlike in most countries, Sweden did not send out census takers or questionnaires to the population. Many of the new or updated variables we see in the 1930 census such as income, wealth, and number of children born, can be related to the political and social debate concerning the poor working class and the establishment of the welfare state. The inclusion of categories such as ethnicity, religion, and foreign nationality can be seen as part of a normative approach wanting to control, monitor and correct deviant elements of the Swedish population.

Sweden has several extraordinary longitudinal population databases built on the country’s excellent parish registers dating back to the 18th century. While the Swedish censuses have rarely been used as sources of data for historical analysis, this work demonstrates that the 1930 census has great potential to support new research.     

The European parliament and co‐decision: A rejoinder to Tsebelis and Garrett

The primary aim of this article is to analyse the question ‘How do the longest serving Swedish parliamentarians view change in the Riksdag?’ The article is in three parts: the first sets out a framework for analysing parliamentary change comprising six main ‘dimensions of change’ which are then briefly applied to the Swedish case. The second section presents an academic perspective on parliamentary change in Sweden by reference to the analytical framework set out in part one. The final section concentrates on the Riksdag veterans’ perceptions of parliamentary change.     

The changing process and politics of health policy in Korea

Korea recently introduced three major health care reforms: in financing (1999), pharmaceuticals (2000), and provider payment (2001). In these three reforms, new government policies merged more than 350 health insurance societies into a single payer, separated drug prescribing by physicians from dispensing by pharmacists, and attempted to introduce a new prospective payment system. This essay compares the three reforms in Korea and draws important lessons about the country's changing process and politics of health care policy. The change of government, the president's keen interest in health policy, and democratization in the public policy process toward a more pluralist context opened a policy window for reform. Civic groups played an active role in the policy process by shaping the proposals for reform-a major change from the previous policy process that was dominated by government bureaucrats. The three reforms also showed important differences in the role of interest groups. Strong support by the rural population and labor unions contributed to the financing reform. In the pharmaceutical reform, which was a big threat to physician income, the president and civic groups succeeded in quickly setting the reform agenda; the medical profession was unable to block the adoption of the reform but their strikes influenced the content of the reform during implementation. Physician strikes also helped block the implementation of the payment reform. Future reform efforts in Korea will need to consider the political management of vested interest groups and the design of strategies for both scope and sequencing of policy reforms.     

The hunt for an elusive crime – an analysis of Swedish measures to combat sex trafficking

Sex trafficking has been described as an enormous, serious and growing problem that must be combatted, but also as a moral panic based on a very small number of cases. This article explores the measures that have been proposed to combat sex trafficking by politicians, the national police and the National Council for Crime Prevention in Sweden between 2007 and 2017. The analysis shows that sex trafficking is partly used by the actors to justify their own work. The measures that all three actors describe as central are crime victim support, co-operation, information, education and expanded legislation. The underlying problems associated with sex trafficking, according to the three actors, appear to be prostitution, drug use and foreign women crossing Swedish borders. Much of the responsibility for the provision of information and education is delegated from government agencies to a wide range of actors. This desire for comprehensive societal engagement stands in stark contrast to the small number of sex trafficking cases in Sweden. The measures to combat sex trafficking are thus largely characterized by the hunt for an elusive crime.