Social and healthcare reforms and vulnerable groups

Due to great internal and external pressures, welfare states are aiming for more flexibility and efficiency in social and healthcare service provision. From an economic perspective, the goal is to reap the benefits for social and healthcare users from increased competition, without risking deterioration of service quality due to overly aggressive cost-cutting by private providers (Hart, 2016).

Reforms have entailed a vision of change in public governance and bureaucracy, which has earlier been found to contain unnecessary regulation of markets and expensive infrastructure. The new, more pliable and more goal-oriented, adaptable public sector has come to direct its voice directly to the individual citizen, who in various situations and phases of life is given the opportunity to take responsibility over their welfare and health, choosing between different service provision alternatives (Hellman, Monni, & Alanko, 2017).

In the Nordic countries the commodification of welfare services is already limited due to the small markets and low population density. There are not enough bone fractures per day to make bone fractures a viable specialty that can be commodified profitably and be market-driven in the interest of both service providers and users. In order to achieve profitable levels of service production, people should live densely in massive cities and prioritise all their assets on consumption of services and less on, e.g., housing. Additionally, medical (and other) knowledge production has become so specialised and expensive that the next step in bone fracture research – for example stem cell cultivation and robotics – can be executed only in a few particular places in the world. All our science fiction images of tomorrow’s market-steered information society are based on enormous resources that must be added according to non-market driven principles in order to match even a fraction of our visions.

Vulnerable groups

Research has repeatedly shown that the toughest test for trialling societal costs and benefits of new coproduction procurement is inquiring into their validity for the most vulnerable populations with complex problems (e.g., Alanko, 2017). In this category we can find, for example, young people who have a long-term or recurrent situation of not being in education, employment or training (so called NEETs); mental healthcare service users; migrants with a low socioeconomic status; and marginalised drug users, such as people who inject drugs (PWID). The problems of these groups can be both complicated and entangled. Providing better services and finding the right amount and sort of support for at-risk and marginalised populations in enhancing their wellbeing and good health is often emphasised in current visions for social and healthcare reform. However, in times when the welfare state’s resources are tight, it is likely that supporting individuals’ capacities to “pull themselves together” is a more easily available path than straining the public sector with complicated and costly solutions.

There is a great need to grasp and evaluate the ethicalness and welfare state accountability in new service provision. A good start is to begin by relating Nordic welfare services to the four principle pillars of rule of law. In Finland these are: the division of power, the legal liability of the welfare state institutions, basic rights and the parity principle. Furthermore, all Nordic constitutions guarantee everybody the right to subsistence in event of unemployment and illness and adequate social and health services. Such welfare principles also guarantee that we recognise and deal with the enhanced risk of marginalisation for risk populations with complex and overlapping problems who have difficulty accessing services (e.g., Perälä, 2012). They also guarantee a certain level of welfare state accountability to its citizens.

New attempts to reform service production often lack a sensitivity for how strongly cultural values are embedded in the governance of societies. The blind spot of neoliberalism is self-reflection – and this leads to a carefree unawareness regarding the potential low quality of the governance that its powers set in motion. The fates of the most vulnerable people in society are a good measurement of how well we have succeeded.

In this issue of NAD, Lundeberg, Kvaavik, and Tokle (2019) investigate the new patterns of use of different tobacco products. The study shows that co-use of such products is especially prevalent in young people. School survey data are used in the study by Karlsson, Ekendahl, Månsson, and Raninen (2019) to investigate whether illicit drug use has become normalised in groups of Swedish youth. In an article by Pakovic, Todorovic, Santric-Milicevic, Bukumiric, and Terzic-Supic (2019) attention is turned to a Serbian adult population looking for associations between social characteristics, alcoholic beverage preferences, and binge drinking. Last but not least, the fourth article of this issue concerns the alcohol-use context of Swedish student unions – an interesting study environment, when following up the decreased alcohol consumption trend among Nordic teenagers (Strandberg, Elgán, Jägerskog, & Gripenberg, 2019).