Objectives and measures
On 1 February, the Swedish government classified COVID-19 as a disease that constitutes a danger to society, opening the possibility of extraordinary communicable disease control measures (Prime Minister’s Office 6 April 2020).
The overall objective of the Government’s efforts has been to reduce the pace of the COVID-19 virus’s spread: to ‘flatten the curve’ so that large numbers of people do not become ill at the same time. It has also been considered important to introduce the right measure at the right time, to achieve the best possible impact and the measures taken to reduce the pace of the virus’s spread need to be weighed against their effects on society and public health in general. The crisis may continue for a long time, and for the measures to work, people need to understand and accept them. The measures were implemented gradually, rather than lock down first and then open gradually.
When the corona virus gained foothold in Sweden, the government and the Public Health Agency acted less restrictive compared to other countries. Childcare and primary schools are still open, much like restaurants, cafes, hairdressers, and stores. The Swedish way of doing things met with great interest internationally and has received support also from unexpected direction but has also met a lot of criticism. If this strategy has been acceptable will surely be studied extensively in the future, but so far the number of deaths per million in the corona pandemic is much higher in Sweden than in the neighboring countries Denmark, Norway, and Finland, but lower than in for example Belgium, Great Britain Italy, and Spain.
The Swedish government has from the start relied on the assessments of the Public Health Agency, which is not part of the government. It is the recommendations of this agency that the Swedish government follows, and the parliament has been supporting. The recommendations have largely been for guidelines and advice and similar to those in other countries: isolate yourself if you even have the mildest symptoms, keep physical distance, follow rigorous personal hygiene measures, work from home if possible, do not travel within the country if you don’t have to, and if you are 70 or over limit close contact with other people (Krisinformation 2020).
These are just recommendation, but there are also some restrictions, which have changed over time and will be changed also in the future. Sweden started forbidding gatherings of more than 500 people, which later changed to 50 people. Secondary schools and universities have been closed, restaurants and cafes are only allowed to serve people sitting at separate tables, with a distance between them and inspections are now taking place to see that these restrictions are upheld.
The situation today is that the number of confirmed cases of COVID-19 is decreasing and that all monitoring systems show a continued decreasing dispersion, despite testing still being on a high level. Two days last week there were no new confirmed cases in intensive care, which is the first time since the middle of March. The number of people who die has been decreasing for some time.
It took time before politicians, agencies and media in Sweden understood that elderly care was central for the development of the corona pandemic. Up until the 8 March 2020 almost 75,000 articles about corona/COVID-19 were published in Swedish media (Szebehely et al. 2020). Of those less than 1 per cent was about elderly care. However, later elderly care became at the top of the agenda because many of those who have died, died in elderly care. Ninety percent of those who have died have been 70 years or older and more men than women have died. How the virus found its way into elderly care is not clear. It is being investigated. To visit special housing for elderly was forbidden early in the crisis, and it has been strongly recommended not to visit elderly parents or grandparents also early on.
Most elderly take care of themselves, but some also need help from others, a partner, relatives, or employees in elderly care. Public elderly care is provided in special housing and as home care. Care assistants and assistant nurses for elderly are the most common occupations in Sweden (Statistics Sweden 2020a). They are also very female-dominated and many foreign-born women work there.
Elderly care in Sweden is funded by municipal taxes and government grants. Only about 4 per cent of the cost is financed by patient charges (Sweden 2020). Recipients should be able to choose whether they want their home help or special housing to be provided by public or private operators. An agreement guarantees that the elderly is covered by the same regulations and fees that apply to municipal care facilities. The municipality always has overall responsibility.
The most common services provided to the elderly in 2019, were security alarm, food distribution, home help service and special housing (Socialstyrelsen 2020). Of those services home help and special housing are of most interest here. Of those 65 years or older, 10 percent of the women and 6 percent of the men had home care, 5 per cent of the women and 3 per cent of the men live in special housing. More women than men have home care and live in special housing, the reason is that women are older than men, but also that older men are taken care of at home by a younger wife.
Problems in elderly care
Problems in elderly care has been discussed for a long time. Why corona-19 has spread in elderly care and why so many who live in elderly care have been affected are discussed intensively, and in the future, there will certainly be a lot of research about this. Many reasons are put forward and new ones are coming forward and it will take a long time before we have the full picture, if ever.
However, many point out that the working conditions for the employees in elderly care might be part of the problem. Even before the corona pandemic assistant nurses and care assistants in home care and special housing for elderly were on sick leave to a higher extent than other occupations (Socialstyrelsen 2020). Sick leave means that temporarily employed and substitutes are replacing ordinary staff. This impairs the basis for continuity among the employees, which is of importance for quality in care. Continuity means that the elderly to greatest possible extent are cared for by the same employees. Continuity in home care can be described by measuring “number of different home care employees who help the elderly person in 14 days”. Measured this way the continuity has deteriorated.
Another reason for lack of continuity in elderly care is the large share of fixed-term employment. According to Swedish Radio around 40 per cent of the employees in the municipality elderly care in Stockholm are on fixed-term employment and paid by the hour (Kommunal 2020). Stockholm is the area worst hit by corona-19 in Sweden.
Assistant nurses and care assistants are as pointed out very big occupations consisting to a very high extent of women. Of which many have children. This is one important reason why preschool (1−6 years) and elementary school did not close in Sweden. Over 90 per cent of the preschool children are in preschool. Statistics Sweden estimated that to close down preschools and elementary schools would influence more than 115,000 persons with children 0−12 years who work in care sectors, which is almost one third of all who work in care (Statistics Sweden 2020b).
In order, for the corona virus not to spread, people were asked to isolate themselves even if they only had the mildest symptoms, and if possible, to work from home. Employees in elderly care cannot work from home, but they should stay home even if only slightly ill since older people are at greater risk of serious illness. Sick employees should not return to work for at least two days after recovering.
Ordinarily, in the event of illness there is an insurance against loss of income in Sweden. Before the corona virus, the first day of illness was a qualifying day for which no compensation was paid. A doctor’s certificate was required from the eighth day of sickness. In general, sickness benefit amounted to a compensation level of 80 per cent. If a person is sick for more than 14 days, the employer must report to the Social Insurance Agency, and they will then pay the sickness benefit.
However, early on the government decided, in order to reduce the risk of spreading the infection, and to induce everyone with the slightest symptoms to stay at home, and keep people economically harmless, the qualifying day was scrapped and so was the need for a medical certificate for the first 14 days of sickness to reduce the pressure on health care services (Ministry of Health and Social Affairs 15 March 2020). These temporary rules are valid until 30 September.
Ordinarily the sickness compensation is related to your income, but in this case the compensation is flat rate since it was believed that otherwise it would be too much work for the Social Insurance Agency to calculate how much each person should have. There have been complaints that the compensation is too low. It has been raised from SEK 700 (USD 70) to SEK 804 (USD 80) (Ministry of Finance 7 May 2020).
The abolished qualifying day and the recommendations around sickness absence from the Public Health Agency of Sweden had great effect. During one week in April almost twice as many persons as normal applied for sickness allowance. The Social Insurance Agency believes this is related to COVID-19 (SVT 9 April 2020).
The less common Disease Carrier Allowance, which can be paid to persons who is or might be infected by a generally dangerous sickness, increased. In January less than ten persons per week applied, one week in April 470 applied and in March the number have been higher than usual.
Additionally, a parent can stay at home taking care of a sick child and receive temporary parental benefit from the Social Insurance Agency for a maximum of 120 days. The child needs to be under 12 years of age and a doctor’s certificate was required after the 8th day. A parent may also receive compensation if there is a specific suspicion that the child is spreading infection.
From 25 April there is temporary legislation, where parents will get approximately 90 per cent of the temporary parental benefit when staying at home with an ill child and there is no need to submit a doctor’s certificate if the child is ill or infected for more than seven days.
The Swedish Social Insurance Agency experienced a significant increase in the payments of temporary parental benefit in the three first months 2020. The Agency believes that the reasons for the increase mainly are that society has been more careful when a child is considered sick when there is a pandemic (Social Insurance Agency 2020).
While compensation for income loss when permanent employees became sick, even with mild symptoms, encouraged them to stay home in order not to spread the virus and to spare the elderly, for the fixed-term employees it is harder to say no to a job since they might not get any sick allowance. A fixed-term employee paid by the hour only gets paid compensation when sick for the hours she/he should have worked. The employee must prove that she/he should have worked to apply for compensation, which might be difficult. This probably meant that employees with permanent contracts in elderly care went on sick leave, and to replace them came fixed-term employees with unclear employment, which meant more people and less continuity. Additionally, the fixed-term employees might work in different sections and different accommodations and thereby also meet many elderlies. A fixed-term employee might also be more reluctant to be “difficult” since it might mean missing job opportunities in the future.
In order, to stop the corona virus education, knowledge and competence is needed. To know how to handle questions about infection and protective equipment. When many employees are on fixed-term contracts and paid by the hour it means less continuity. There have been several conflicts between employers and employees in elderly care of how to handle infected elderly and what is reasonable protection equipment. If you are employed by the hour it is harder to make demands on the work environment and protection.
It can be argued that elderly care is an undervalued part of society’s care apparatus. Employees in elderly care, of which a very big majority is women, have low status and problematic working conditions. It is heavy work and underpaid and absence because of sickness and occupational injuries are more common than in most other occupations. The qualifications needed for the work are often underestimated and many have precarious employment.
Improving working conditions in elderly care
The COVID-19 pandemic has affected an already strained staffing situation for health and social care, not least in care of the elderly. At the same time, employment has declined in many other sectors because of redundancy notices and job cuts. To improve the supply of staff and make it more attractive to seek jobs in care of the elderly, a boost for care of the elderly is being implemented that means that employees in care of the elderly will be offered paid education and training during working hours (Ministry of Finance 12 May 2020).
For those who require it, it will be possible to combine employment with training to become nursing assistants or auxiliary nurses during paid working hours. Central government will finance the costs for the time the employee is absent due to studies. The initiative is in line with a proposal presented by the Swedish Association of Local Authorities and Regions and the Swedish Municipal Workers’ Union, which made the assessment that 10 000 people could be included.
To ensure that there are sufficient education and training places, the Government is also injecting funds so that 10 000 people can attend education and training focused on health and social care at regional vocational adult education institutions during the fourth quarter of 2020 if they study part-time. These places will be wholly funded by central government in 2020. Municipalities will fund 30 per cent of the education and training places that are sought for 2021.
In addition to this, it is proposed that folk high school vocational education and training be expanded with approximately 1 000 new half-year places in 2020, also with a focus on health and social care. It is proposed that central government wholly funds this expansion and no regional co-financing will be needed.
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Kommunal (2020) ”Hög sjukfrånvaro i Stockholms äldreomsorg”https://www.kommunal.se/sok?keys=h%C3%B6g+sjukfr%C3%A5nvaro+i+stockholm
Ministry of Finance (7 May 2020) Reinforced measures for employees and businesses. Available at:https://www.government.se/press-releases/2020/05/reinforced-measures-for-employees-and-businesses/
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