Difficult decisions on care and services for elderly people: the dilemma of setting priorities in the welfare state

The aging of the population combined with restricted economic resources is leading to an increasing gap between care needs and care resources. The first strategy to cope with this growing disparity is often the rather non-controversial attempt to optimize the use of the resources. At some point in time, however, more crucial decisions are needed. Four levels of decision-making in the system of care services may be identified - from decisions regarding national resource allocation to decisions regarding individual users. The different conditions for making decisions and setting priorities at each level must be considered when studying the decision-making process and the consequences - including the repercussions for other levels and sectors. With Sweden as a case, four trends in decision-making can be seen: decentralization of many controversial decisions; redefining of the lines of responsibility between sectors; increasing inequality in the accessibility, cost, and quality of care; and a general lack of public discussion and debate about central welfare issues.