Freedom of Choice and Gender Equality in Swedish Home-Based Elderly Care

Annette Thornquist

Introduction

In Sweden, as in many other countries, gender equality must be integrated into all policy areas and regular operations. As this gender mainstreaming strategy was launched in the mid-1990s - during a time of public-sector deregulation, marketization and retrenchments - it has also been linked with economic objectives (Callerstig and Lindholm 2011; Callerstig 2014; Jacquot 2010).1 The Swedish Act on System of Choice in the Public Sector (LOV) provides an example of such interlinked economic and gender-equality policy objectives. The Act, which came into force in 2009, aimed to regulate and promote the exposure of primary healthcare and social care and services to private competition through customer/user choice. Choice in this sense means that users of tax-financed welfare services are entitled to choose between the public service provider and external providers authorized by the public principal. This reform, which was highly prioritized by the centreright coalition government in office between the general elections of 2006 and 2014, would not only foster freedom of choice for the users, but also create a market for female entrepreneurs. While the regions (formerly county councils) have been obliged to operate LOV in primary healthcare since 2010, the municipalities can use the reform voluntarily in social care and services for the elderly and for people with functional impairments, as an alternative to competitive bidding under the Act on Public Procurement (LOU).2 In July 2020, 160 of the 290 municipalities in Sweden had introduced LOV. In 157 of these municipalities, the reform was being applied to home-based elderly care, which is the municipal sector in which the reform has predominantly been implemented (SALAR 2020). The present chapter focuses on this sector.

Aim and Theoretical Approach

The aim of this chapter is to discuss the relationship between the economic and gender equality objectives in the freedom of choice reform.

The questions asked are: 1) what was the normative conception of gender equality implied in the reform; and 2) how have the gender equality objective been realized in home-based elderly care? The analysis is based on an intersectional approach in combination with a centre-periphery perspective. In addition, I use precarious employment as a multidimensional analytical concept. Theoretically, the purpose is to illustrate the benefit of integrating these three perspectives.

The intersectional perspective helps to reveal and explain how social structures, normative processes and patterns of behaviour create inequalities based on gender, as well as on class, ethnicity, age and other social categorizations. This approach does not question the benefit of using social categories analytically, but helps to contextualize the relevance of these categorizations and accentuate their interconnection (Lykke 2003; de los Reyes and Mulinari, 2005; McCall 2005; Acker

2012) . In this chapter, the intersectional perspective helps to identify and interpret the normative conception of gender equality implied in the LOV reform, as well as the meaning of diversity. Like the notions of gender equality and gender mainstreaming, the meaning of diversity may also vary, depending on how it is communicated, and whether it is linked with other purposes (de los Reyes 2001; Walby 2005; Ahmed 2007). I also use the intersectional perspective for a critical discussion of the social implications of the reform in working life.

The second analytical perspective is the centre-periphery divide. Nyhlen and Giritli Nygren (2015) and Giritli Nygren and Nyhlen (2017) use this perspective in their analyses of the implementation of the national Swedish elderly care policy in rural areas. I relate to their research, and I also use the centre-periphery metaphor to illustrate distinguishing practices in the labour market, such as segregation and segmentation (Deakin 2013).

Regarding the notion of precarious employment, I use Lewchuk et al.’s (2003: 23) definition: ‘a cumulative combination of atypical employment contracts, limited social benefits, poor statutory entitlements, job insecurity, short tenure and low wages’. However, I prefer to add another factor, namely a poor working environment. The cumulative aspect lies in the fact that these factors are interlinked and mutually reinforcing. This multi-dimensional definition corresponds well with the intersectional perspective, which also stresses the importance of multidimensional and cumulative processes.

The connection between these three perspectives appears even in a brief presentation of the character of the Swedish labour market in elderly care, which is segregated by gender and increasingly also by ethnicity, especially in metropolitan areas. In elderly care, 91% of auxiliary nurses are women (Statistics Sweden 2020). In a survey of workers in the Swedish Municipal Workers’ Union (Kommunal) in 2012 (Wondmeneh

2013) , foreign-born workers accounted for 24% in elderly care. In the

Freedom of Choice and Gender Equality in Swedish 233 county council of Stockholm, however, the proportion was twice as high. The study also showed that the share of fixed-term and hourly employment was considerably higher among foreign-born workers than among Swedish-born workers. In contrast, Giertz and Jonson’s (2018) study based on the same dataset reveals no significant differences between immigrants and Swedish-born workers in how they perceived their working conditions. What is certain, however, is that non-unionized workers, who were not represented in these surveys, are more at risk of precarious employment. In the public sector in 2019, union density among foreign-born blue-collar workers was 65%, compared with 75% among Swedish-born workers. In addition, the general decline in union density during the period 2006-2019 was much higher (26 percentage points compared with 13 points) for the two categories (Kjellberg 2020: 51-53).

Material and Methodology

This chapter draws on an analysis of preparatory works3 for the LOV reform, and especially the report from the government-appointed investigation behind the legislative proposal (Swedish Government 2008a), including the government’s directive for this investigation (Swedish Government 2007), comment letters on the report and the government bill (Swedish Government 2008b). I also refer to relevant research in this field, including my previous studies published in Swedish (Thórnquist 2013, 2014). The former study, which concerned the consequences of LOV in working life, comprised 15 in-depth interviews with social partners, municipal officials and private providers in three municipalities that had introduced LOV into home-based elderly care in 2009. Analysis of the development up to 2020 is based on official statistics, reports and other documents from government agencies, municipalities and the social partners. In addition, I carried out five follow-up interviews in the summer of 2019 with representatives of Kommunal at the national and local level, with the Swedish Association of Local Authorities and Regions (SALAR), and with the local authority in one municipality featured in my 2013 study. In this municipality, where many small and medium-large actors contracted under LOV have provided domestic services to the elderly for the last ten years, there have been problems with security fraud and ‘unhealthy competition’, i.e. competition based on poor working conditions.

 
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