Vocational rehabilitation in Sweden – the problem
Absence due to sickness is much higher in Sweden, Norway and the Netherlands than in Denmark, Finland, Germany, France and the United Kingdom [1]. Also, it varies much more over time in the first mentioned three countries. However, differences in composi- tion of the labour force between the countries influence the sick leave situation.
Underlying differences in the composition of the labour force (gender, age, types of industries, number of part-time workers, and employment conditions) explain about one fifth of the differences of the rate of sick leave in Sweden and the average of the countries with the lowest rate in the above-mentioned study of European countries [1].
Age seems to be the most important factor in Sweden, where a comparatively high share of employees has reached an age at which the risk of being ill is higher. Although these factors are important, the main part of the differences between the countries remains to be explained. One interesting area is the differences between countries in design of the system for financial compensation. An example is that generous compensation from public systems, as well as through occupational agreements, could lead to a higher rate of sickness absence, but other differences may also play a role [1].
Another – but related – problem in Sweden is the high rate of disability pension. This means that a period of long-term sick leave often ends with a decision by the national insurance office to grant a disability pension – and not with a decision to provide voca- tional (or medical-plus-vocational) rehabilitation aiming at resuming working life [2, 3].
Even the government considers this to be a major Swedish economic problem, leading to a too small proportion of the population gainfully employed in relation to the propor- tion living on disability allowance. The efficiency of the system for vocational rehabilita- tion is of great importance here. The effectiveness of the various rehabilitation pro- grammes provided is one important aspect, the skill in co-operation of the different rehabilitation actors is another, and also important is the proportion of long-term sick leavers who actually receives a vocational rehabilitation measure from the public sys- tem [4, 5].
J. Ekholm and K. Schüldt Ekholm
Who is responsible
for vocational rehabilitation in Sweden?
How is the vocational rehabilitation organised?
Main bodies involved in rehabilitation aiming at resuming working life
There are several actors in the area of vocational rehabilitation. Below follows a descrip- tion of the main organisations with some kind of official responsibility for vocational rehabilitation; the employers, the health and medical service, the national insurance office, employment offices, and social services [6]. In addition, the patient/client has res- ponsibilities, e.g. for actively participating in rehabilitation measures granted, and to a certain extent the patient, are supposed to be involved in the selection of rehabilitation measures.
The employer
According to Swedish law, employers have extensive responsibility for the working envi- ronment of the employees. The employer shall take into account the particular qualifica- tions of the employee for the work task, by adapting working conditions or by taking appropriate actions. The employer must ensure that there exist within the company pro- grammes for adaptation and rehabilitation. Large companies often have staff assigned for this work, but the resources of small companies vary.
In principle, the employer has responsibility for ascertaining and investigating needs of vocational rehabilitation, for the actions to be brought about, and for the financing of those actions. A governmental investigation [7] has observed that this responsibility is not clearly perceived by all employers. In reality the national social insurance office has been pressing on for the investigations to be carried through and for changes to occur.
An employer must initiate a rehabilitation investigation when: (i) an employee is on sick leave more than 4 weeks; (ii) an employee has repeated short term sick leaves; (iii) when the insured person (the employee) wants it [6].
Public organisations
The responsibility for rehabilitation in public institutions is divided into four parallel sectors: the public health and medical service of the county councils, the social service of the municipalities, the employability offices of the state, and the national social insurance system.
The health and medical service
The public health and medical service is, in addition to regular medical examination and treatment, responsible for medical rehabilitation and should occur at least to some extent
in all levels of the medical service system: specialist rehabilitation is found in some 30 public clinical departments of rehabilitation medicine located in the various counties.
The goal of rehabilitation of the public medical service is to restore functioning as far as possible in all aspects, analysing function in terms of impairments, activity limitations and participation restriction taking into account environmental factors according to the principles of International Classification of Functioning, Disability and Health – ICF [8].
The boundary line between medical rehabilitation and vocational rehabilitation is somewhat blurred because the national insurance system with its health insurance has the responsibility (and public resources) for the “working-life-oriented” rehabilitation.
Thus it has become a matter of how the definitions are made with respect to “rehabilita- tion medicine” and “working-life-oriented” rehabilitation [7]. In reality, most of the county-based bigger clinical departments of rehabilitation medicine run particular pro- grammes aiming at returning to working life and programmes for assessing working capacity, these run in parallel to or in combination with rehabilitation programmes for other purposes. Many of these activities are at least partly financed by the national health insurance and the county councils finance the other parts.
The social services
The Social Services of a municipality is responsible for the residents’ potential to live in the society, irrespective of reason for the problems. Support of various kinds including economic support is given. By tradition, the Social Services also have particular respon- sibility for drug and alcohol addicts and people with chronic psychiatric disease and social problems. Even if rehabilitation is not explicitly a responsibility for Social Services, rehabilitation aimed at some kind of working situation is often a goal in the planning, since it can end dependence on allowances from the Social Services [6].
The employment office
An employment office is responsible for rehabilitation of the unemployed. Their main task is to help healthy people get jobs. However, the major employment offices have spe- cial units – employability institutes – for the additional task of supporting unemployed people with moderate or light disability to find, obtain, and maintain a job. The activi- ties of these offices include the testing of working capacity, guidance about job seeking, and organising opportunities to be a trainee or apprentice, or other training situations.
Even if the normal labour market is the normal long-term goal, an employment office also has the option of placing a person in sheltered employment [6].
The task of Samhall AB, which is a big governmentally owned company with units spread all over the country, is to provide meaningful jobs which will develop potential for persons seeking a job through the employment office or its employability institutes, and who have been unable to get a job on the normal labour market due to disability related to physical, psychiatric, intellectual, or abuse problems. The group of companies provides adapted work places [6].
The National Insurance office
In addition to supplying insured persons with a variety of allowances, the National Insurance Office is responsible for the co-operation between the various rehabilitation actors. Other responsibilities are to initiate rehabilitation measures and supervise over other vocational rehabilitation actors. The National Insurance Office has a great number of local offices and has responsibility for the decision as to whether the person receives a sickness allowance, rehabilitation allowance, or disability pension, using doctors’ certifi- cates and other medical reports as a basis. The National Insurance Office may purchase rehabilitation services to enable a sick leaver to resume work. Such services may include investigations of functioning or measures aiming at facilitating return to working life (e.g. education or measures to increase function or minimize disability) [6].
How is the access to the vocational rehabilitation organized?
In principle, all persons in the country between 18 and 65 years of age are covered by the national health insurance (with only a few exceptions) and all manpower with sick leave has the possibility (but not the right) to receive vocational rehabilitation. The request for vocational rehabilitation can come from different sources, most often from the patient’s physician. The doctor’s certificate form allows the insurance office of easily informing about a need of vocational rehabilitation for resuming work. The employer, the patient, or an officer of the insurance office can also suggest that vocational rehabilitation is needed.
In principle the employer has to initiate a request for rehabilitation (but in reality this does not regularly occur at present). If the person is unemployed the insurance office per- forms this function. If the local national insurance office approves the rehabilitation need of the patient, and economic resources exist, the next step is that a plan for rehabilitation is prepared at the insurance office. The proportion of patients with rehabilitation needs who receives a vocational rehabilitation measure varies over time and places, depending on the current economic resources and a sufficiency of staff to find and purchase the rehabilitation measures. At present, about one fifth of the patients who are in need of vocational rehabilitation receive it, at least in some measure [4, 5, 7]. That proportion can, of course, be altered depending on political decisions and/or state of the market [9].
Accident and health insurance companies and reimbursements of clients
The private accident insurance provides economic protection after acute injury and inva- lidity. In principle it adds to the public insurance system, and may cover costs for medical care, medicaments, damage to cloth or spectacles, compensation for pain and suffering, scars and deformities, medical and economic invalidity or costs for a funeral.
This kind of insurance can be taken out individually or collectively, e.g. at the work place. Four criteria must be fulfilled for an injury to be defined as an accident. It must be an injury that has occurred involuntarily as a consequence of a sudden external event.
Trouble as a consequence of overload, e.g. heavy lifting, is not regarded as injury due to accident [10].
Private health insurance schemes are supplementary to the public insurance system, and give reimbursement commensurate with the reduction of the working capacity that it has led to a doctor’s certificate of illness, granted temporary disability pension or per- manent disability pension. Since morbidity increases with age, the cost of insurance pre- mium markedly increases too. At a great age it is often not economically worthwhile to take out a health insurance. The insurance companies usually have the age of 59 years as the upper limit for taking out a health insurance [11].
Organisation of financial compensation for loss of earnings in case of accidents or illness
In the case of falling ill, or having an accident, the patient reports to the employer and to the regional social insurance office (of the national insurance system). The first week of sick leave is certified by the patient him/herself. On the 8th day a doctor’s certificate must be available at the public regional social insurance office for the sick leave to be conti- nued. At present, the employer pays sickness benefit the first 2 weeks, (except the first day that is not paid at all) and 15% of full sickness allowance until it is finalized. The (public) national health insurance pays 85% from the third week and on, and in principle, the sickness allowance is unlimited in time in Sweden. Part-time sick listing is possible with 25%, 50%, 75% and full. Self-employed persons, too, can use the national health insurance at varying levels of compensations related to their payment.
The level of benefit from the national health insurance may vary due to varying poli- tical decisions and is at present 80% of the salary up to a ceiling (maximum salary 494 euros per week). The benefit is taxed. During the first two weeks sickness payment from the employer, it may be at the same level as the public payment, but is more often set by agreements concluded between employer and employee.
Organization of disability pensions in case of accidents or illness
Usually after some time (e.g. one year) the regional social insurance office suggests a change from sickness allowance to temporary disability pension. The patient’s physician is contacted to give an opinion on the patient’s working capacity. The regional social insurance office then decides about granting temporary disability pension and the num- ber of years (one or two) until the next assessment. During this period of time rehabili- tation measures are supposed to take place [9].
At the next assessment working capacity is evaluated again. If full working capacity is not achieved the regional social insurance office decides once more whether it will be continued temporary disability pension or a move to permanent disability pension.
Permanent disability pension can be at different levels – 25%, 50%, 75% and full pension.
The payment is substantially lower than that for sickness allowance. The level of both tem- porary and permanent disability pension is calculated in a way similar to that for old age pension depending on, for example, the total number of years of gainful employment[9].
References
1. Socialdepartementet (the Ministry of Health and Social Affairs) (2003) Den svenska sju- kan II – regelverk och försäkringsmedicinska bedömningar i åtta länder. (in Swedish with English summary) (The Swedish disease II - rules and regulations and assessments of working capacity in eight countries). (Group of authors: Mikaelsson B, Ekholm J, Kärrholm J, Murray R, Sandberg T, Söderberg J, Nyman K) Governmental report. Socialdepatementet Ds 2003: 63, www.regeringen.se/propositioner/sou/pdf/remiss.pdf
2. Selander J (1999) Unemployed sick-leavers and vocational rehabilitation. PhD Thesis.
Karolinska Institutet (Section of Rehabilitation Medicine, Dept. of Public Health Sciences) Stockholm, Sweden
3. Marnetoft S-U (2000) Vocational Rehabilitation of unemployed sick-listed people in a Swedish rural area. PhD Thesis. Karolinska Institutet (Section of Rehabilitation Medicine, Dept. of Public Health Sciences) Stockholm, Sweden
4. Marnetoft S-U, Selander J, Bergroth A, Ekholm J (1997) The unemployed sick-listed and their vocational rehabilitation. Internat J of Rehabil Research 20: 245-53
5. Selander J, Marnetoft S-U, Bergroth A and Ekholm J (1998) The process of vocational reha- bilitation for employed and unemployed people on sick-leave: employed vs unemployed people in Stockholm compared with circumstances in rural Jämtland, Sweden. Scand J Rehabil Med 30: 55-60
6. Ekholm J (2002) Försäkringsmedicin och rehabilitering (Insurance Medicine and Rehabilitation) In: Järvholm B, Olofsson C (eds): Försäkringsmedicin (Insurance Medicine).
Studentlitteratur, Lund, 2002 (in Swedish)
7. SOU, Socialdepartementet (2002) Rehabilitering till arbete. En reform med individen i cen- trum (Rehabilitation to work. A reform with the individual in the centre) (In Swedish). SOU 2000: 78. Fritzes, Stockholm
8. WHO (2001) International Classification of Functioning, Disability and Health – ICF. WHO, Geneva
9. Olofsson C & Mikaelsson B (2002) Regelverk och administrativa processer (Rules and regu- lations and administrative processes) In: Järvholm B, Olofsson C (eds): Försäkringsmedicin (Insurance Medicine). Studentlitteratur, Lund, 2002 (in Swedish)
10. Netz P (2002) Olycksfalls- och trafikförsäkring. (Accident and trafic insurance) In: Järvholm B, Olofsson C (eds): Försäkringsmedicin (Insurance Medicine). Studentlitteratur, Lund, 2002 (in Swedish)
11. Perman E (2002) Privat försäkring – nyteckning (Private insurance - taking out an insurance) In: Järvholm B, Olofsson C (eds): Försäkringsmedicin (Insurance Medicine).
Studentlitteratur, Lund, 2002 (in Swedish)
