Introduction

The preceding chapters in this volume have documented how welfare services in Scandinavia are changing. An insight gleaned from the chapters by Sivesind and Segaard and Saglie is how marketisation, national legislation and regulation are important drivers behind changes in the welfare mix—the composition of public, for-profit and nonprofit providers . In this chapter, I am concerned with how the users of services funded by the public sector are affected by the different providers in the welfare mix . By taking the perspective of the citizen, I document through a comparative case study analysis how the institutional sector of the provider and the use of policy instruments have relevance at the ground level of services.

A fundamental principle in western understandings of democracy is that citizens are different in all sorts of ways, and that these differences are important for the organisation of society but have no relevance when it comes to the right of all citizens to have autonomy and control over their own lives (Olsen 1990, 24). This is a fundamental feature of the Scandinavian citizenship model, where moving power as close as possible to the citizen is considered ideal (Hernes 1988; Andersen and Hoff 2001). Expectations of citizens, however, have been continuously growing over recent decades (Rothstein 1994, 232; Hvinden and Johansson 2007b).

In the face of the documented changes in governance tools and the welfare mix, it is vital to identify how Scandinavian users of public, for-profit and nonprofit providers differentially control their lives when they use public services. In developed welfare states , citizens have extensive interactions with welfare providers. Their ability to control their own lives in these meetings is, therefore, an important part of their citizenship (Andersen and Rossteutscher 2007). This aspect of service quality is a high priority in political documents on welfare policy in all Scandinavian countries (Rostgaard 2015, 4).

The concept of active citizenship can be used to analyse the consequences of welfare policy for individuals or groups in society (Hoskins 2014; Jensen and Pfau-Effinger 2005). The concept goes beyond a traditional understanding of citizenship that primarily emphasised social rights and entitlements (Marshall 1950). It emphasises possibilities for active participation through representative democracy, civil society and freedom of choice (Hvinden and Johansson 2007a). Analytically, I use the concept of active citizenship as a way of looking at the opportunities citizens have to use choice before they become users, empowerment as users at institutions and participation as users in local policy processes that frame operations at the institutions. Based on this analytic approach, the central questions of this chapter are: Do citizens exercise active citizenship differently in public, for-profit and nonprofit service providers? if so, what can explain it?

In this chapter, active citizenship is examined at institutions at the local level. Municipalities are instrumental in providing welfare services to citizens in Scandinavia to the extent that the welfare model has been said to be based on ‘welfare municipalities ’ (Kröger 1997; Kjølsrød 2005). I compare the experiences of users of municipal primary and lower secondary school and nursing homes in Norway, Denmark and Sweden. Through these comparative case studies, I examine the differences between the three institutional sectors: public, for-profit and nonprofit. I also compare the consequences of different conditions regarding the governing structures that were analysed in the preceding chapters focusing on schools and nursing homes. Therefore, in addition to the institutional sectors , the cases were selected to make it possible to compare across countries and service areas . For further information about the selection of cases, see Chap. 1.

Studies of increased marketisation and changes in the welfare mix have often focused on efficient provision and economic savings for the public purse (Domberger and Jensen 1997; Hood and Dixon 2015), or on different forms of quality such as the number of staff and use of physical restraints in elderly care (Comondore et al. 2009), and test scores in schools (Hanushek et al. 2013). Relevant to this study is research that shows how marketisation and changes in the welfare mix have impacted the relationship between citizens and the state (Clarke 2006; Clarke et al. 2007), as well as how Scandinavian countries are particularly exposed to such changes due to their tradition of universal public services (Anttonen and Meagher 2013; Kröger 1997). Judgments about the consequences of marketisation vary. Some studies have warned of deteriorating solidarity between and powerlessness of users when faced with market entrepreneurs (Christensen 2012; Eriksen and Weigård 1993). Others have pointed that the potential users have to achieve more control when they obtain consumer or customer rights (Rothstein 1998; Kumlin 2004).

The relevance of using an active citizenship approach to study this issue is accentuated by a report from the Norwegian Centre for Human Rights , which documents breaches of human rights in Norwegian nursing homes. The report identified users’ inability to make their voices heard as one explanation for unsatisfactory action to improve the citizen-rights situation (Norsk senter for menneskerettigheter 2014). Given that user power and opportunities for active citizenship are important for the quality of services, I examine these aspects in light of the local governance of services and the use of providers from different institutional sectors. To set the stage for this discussion, the following section presents and subsequently operationalises the analytic concept of active citizenship . The empirical approach used in this chapter overlaps with that used in the preceding two chapters, but a short reminder is also included before the analysis is presented.

Active Citizenship

Active citizenship is a contested concept that scholars and policymakers have used in a number of different ways (Hoskins 2014). Before using active citizenship as an analytic tool, it is necessary to first establish the concept in relation to the existing uses of the term, and to show how it is useful for the analytic purposes of this chapter.

Within the context of local service delivery, the content of publicly financed services is decided by actors in three different roles: the user and their next of kin, the staff and leaders at the institutions and the policymakers and administrators at the municipal level (Daly and Lewis 2000, 287). Users and their next of kin can influence the content of services in meetings with both staff and managers, as well as with policymakers and administrators at the municipal level. An analytic approach based on the capacity users have to exercise an active citizenship role can deepen understanding of these relations.

I use the concept of active citizenship to analyse services from the perspective of users (i.e. citizens) and to map how users can control and influence their lives when using public services. The extent to which users can influence their own lives is directly related to their potential to influence services at three different levels. First, if and how they can choose a provider before they become users. This choice also includes the option to change providers. Second, if and how they can influence the institution’s services while they are users. Third, if and how they can influence the municipality that sets the frames for the service provider. Based on this tripartite understanding of users’ capacity to control their lives in relation to service providers, I develop three dimensions of active citizenship in order to analyse differences in the capacity for active citizenship for users (and their next of kin) of public, for-profit and nonprofit welfare services: choice, empowerment and participation .

Investigating the experiences users have when interacting with welfare providers can provide insight into the functioning of the welfare model in terms of the autonomy of citizens, the division of labour, responsibility and influence. The concept of active citizenship allows us to evaluate these features or functions from the users’ point of view (Jensen and Pfau-Effinger 2005; Boje and Potucek 2011b). Although hailed as a universal and solidary welfare regime, the Nordic welfare states are also remarkably individualistic in the sense that different welfare instruments are consistently based on individual autonomy (Trägårdh 1997, 253). The welfare programmes are tied to individuals, and through them the state seeks to give individuals autonomy from alternative structures such as charities, families and employers (Trägårdh 2008). This perspective on the state’s role in the welfare society reveals a longstanding tradition of striving to expand the individuals’ control of their everyday lives, also when dependent on public transfers or services. When new instruments are used in the welfare state, individual rights can be expanded with correspondingly new duties, which is a natural process in societies with a more skilled and individualistic population both able and willing to enjoy a growing level of individual autonomy (Andersen 2005, 87).

If growing individual rights and room for influence in the implementation stage of the political process are observed, this may enhance the individualistic features of the social democratic model . At the earlier stages of social democracy, the strategy of granting cash assistance and not only benefits in kind to single mothers was an example of the belief that individuals have the right to make decisions concerning their own lives (Rothstein 1998); thus, the expansion of active citizenship can be viewed as a continuation and further development of this feature of the social democratic model. At the same time, equality in service quality is also an important value in the social democratic model. Whether these mechanisms are compatible, or whether they pull in opposing directions, is an empirical question.

The capacity for active citizenship can have wider implications. When the power of users influences the implementation of policies, the experience of the citizenry as a whole can change; small, incremental steps can, over time, change the welfare arrangement, almost as if by stealth (Hinrichs and Kangas 2003). A growth in the importance of policy implementation at the expense of electoral politics is a common finding in Scandinavian power studies (Andersen 2006, 580). Strong electoral legitimacy is a cornerstone of Scandinavian democracy, but much of this legitimacy is determined on the output side where the citizens experience the results of decisions made by policymakers, and one such important result is the public welfare services (Rothstein 2009; Gustavsen et al. 2014). What happens on this side of the democratic process is thus also important to consider.

Currently, citizen involvement in forming welfare services is becoming a critical issue in international scholarly debates (Boje and Potucek 2011b; Evers and Guillemard 2013a, 24). Evers and Guillemard (2013a) emphasised how using active citizenship as an analytic tool gives insight into the ‘responsibility mix’: the division of rights and obligations between the state, civil society and individual citizens. This division involves deciding which tasks should be assigned to different actors, and also provides a basis for normative perceptions about the suitable size of each institutional sector . In Western Europe, the governments’ redistributive role is increasingly being supplemented by attempts to motivate citizens, as the states assume the role as orchestrators of last resort. In this capacity, the states must balance their interest in the individual autonomy of citizens, commercial enterprises and other special interests in the welfare fields, with their economic goals, including social investment agendas (Evers and Guillemard 2013b). At the same time, variations in user preferences are arguably also growing as societies become more diverse (Boje and Potucek 2011a, 13; Phillips and Smith 2011). This calls for the active involvement of users and citizens in forming the content of services.

The concept of active citizenship can elucidate these developments and show how welfare states are dynamic entities in spite of their stability on many variables (Palier 2007). In using the concept, I recognise that users can seek to influence both staff at the level of local institutions and local policymakers. Active citizenship thus maps the landscape of user control and, in our case, this landscape is limited by borders established by national and EU laws, regulations and policies. Therefore, analyses focusing on active citizenship connect the individual experiences of users with overarching changes in the welfare model.

Operationalisation of Active Citizenship

Hirschman (1970) identified two main strategies for users to obtain changes from an organisation: exit and voice. The first strategy involves either exiting or threatening to exit an organisation. This will give the organisation an incentive to accommodate the wishes of users and is thus an empowering instrument for users. This strategy is related to the use of choice in my framework. The second strategy involves the use of voice by users who stay in an organisation, and who advocate changes within them. Here, users do not leave the organisation but try to produce changes by identifying aspects they believe to be unacceptable. This relates to my notions of user empowerment and participation , whereby users voice their interests at the institutional or municipal level, respectively.

In terms of choice , the central features are whether the option to choose can enhance the power of citizens as customers, and whether the available alternatives are distinctive enough to increase variation in the services offered to citizens. For choice to be an important aspect of power relations, alternatives must exist that are real options and not just formal possibilities. The most powerful action taken by a user who is dissatisfied with a service is to exit an institution altogether (Hirschman 1970). This is the solution Blomqvist and Rothstein (2008, 18) recommended for amending the asymmetrical power relationship between users and staff at the institution and the policymakers’ ultimate lack of control over policy output. In addition, letting users choose institutions can also increase the capacity for active citizenship by expanding the scope of public services. When users can choose between different institutions with their own distinctive content, the chances of getting services in line with the users’ interests and needs also increases (Smith and Grønbjerg 2006, 224). Distinctive alternatives are therefore an essential component of choice. For the citizen, a central prerequisite for exploiting a broader range of services is knowing what is available. Information is therefore also an important aspect of choice (Le Grand and Bartlett 1993). From a citizen’s perspective, the capacity for active citizenship expands when public services are more diverse and cater to minorities and other groups whose preferences and interests deviate from the majority.

Empowerment is a matter of how users and their next of kin voice their concerns about what happens at an institution and what changes they can obtain. This can take place formally or informally (Andersen 2004, 25). Arenas set up by institutions or users (e.g. user boards) comprise formal mechanisms for voice. Central to these are how they are included in the overall steering of an institution (Rose 2007). Circumstances or settings in which users can affect their situations through day-to-day interactions with staff or other official members of institutions constitute informal mechanisms for voice. Interaction between users and providers is a fundamental aspect of services, and in this sense co-production is a feature of all services (Osborne et al. 2013, 139). Since the study by Parks et al. (1981), the focus on co-production has dealt with costs for the government and the improvement of service quality (OECD 2011; Alford 2014, 300). In this study, I am more concerned with how co-production affects power relations between users and providers, as well as how users can influence services. When citizens involve themselves in institutions that are part of their everyday lives, they become ‘everyday makers’. They may have no ambition to influence what happens in the large-scale democracy, but when various individuals take steps to make changes in their close surroundings, it becomes something ‘democracy cannot afford to dismiss, neither in theory nor in practice’ (Bang and Sørensen 1999, 336).

Choice and empowerment pertain to active citizenship in the implementation of public policies. The third dimension, participation , involves participation in the development of public policies at the local level. This dimension concerns user involvement in relevant political settings and how users perceive their level of influence or their political efficacy (Andersen 2004, 25). When users influence the interpretation of public policies, they operate within politically defined frames. When they are able to influence local policymaking, they influence the frames themselves: The resources held by users when approaching the municipal level, the arenas set up to facilitate such approaches, and the responsiveness of the municipality decides the scope of this influence. The fundamental issue regarding active citizenship is that the experiences made at the institutions have real influence on policymaking. In practical terms, this is an issue of the advocacy role of institutions and individual users vis-à-vis the municipal political and administrative level. User surveys are not part of the advocacy efforts of users, but represent the only tool for the municipalities to directly collect the views of many users at the same time and are thus a relevant aspect to consider.

The definition of active citizenship covers what we may refer to as the basic level or background concept (Goertz 2006; Adcock and Collier 2001). The second level consists of the three dimensions. These dimensions are ontological in the sense that they constitute the background concept. Based on these dimensions, I developed indicators than can be evaluated. These indicators are not necessarily internally correlated, but can be functionally equivalent, which means that the strong occurrence of one indicator can substitute for the lack of occurrence of another indicator of the same dimension (Goertz 2006, 15). The qualitative data gathering process was designed to capture variations in the dimensions of active citizenship and to be able to conduct qualitative comparisons between institutions. The scores on the indicators are therefore qualitative. What is interesting is the value on one provider’s indicator as compared to the other providers. Table 6.1 illustrates the relationship between different levels of the concept.

Table 6.1 Active citizenship , dimensions, and empirical indicators
Full size table

For each dimension, I developed indicators that allow for the observation of variations as well as comparisons. For the dimension of choice , I looked at the capacity users have to choose a provider when they initially become users of a service and to what degree they may exit an institution. I developed two indicators for this dimension. First, I assessed if the opportunity to choose and exit providers is important for power relations. Choice gives power to users if municipal or institutional representatives report changing the content of a service in order to avoid user exits or attract more users. Likewise, users’ perception of exit as a tool for obtaining changes indicates that they have power as opposed to situations where there is no exit opportunity. There is a continuum between no exit opportunity and full exit opportunity. Second, I evaluated whether the opportunity for choice leads to a wider range of services for citizens. If users are able to choose alternatives that constitute distinct services from those offered by public providers, the entire scope of public service becomes broader. When public services can cover a broader range of citizen preferences, the capacity for active citizenship is expanded.

Indicators of empowerment focus on two forms of user influence. First, I mapped how user boards take part in steering and influencing the activities of institutions. The accessibility of user boards and their level of influence are central components of this measure. Second, I examined how users experience the opportunities they have to obtain changes through day-to-day interactions with other users.

I evaluated participation by looking at arenas where users have access to decision makers at the municipal level, and I examined how representatives and decision makers perceived user influence in these arenas. I also looked at municipal interest organisations, like councils for the elderly, which channel the interests of users toward the municipal level. In some cases, these channels were missing altogether.

The Importance of Individual Characteristics of Staff and Users

Even if the institutional sector of a provider matters for active citizenship , it is not the only factor explaining variations in active citizenship. The actions of individuals who operate within the frames of institutions make up the capacity for active citizenship. The capacity for active citizenship is affected by which sector an institution belongs to because it frames the decision making of its leaders, staff and users (Thornton et al. 2012). How individuals choose to use the flexibility that exists within the frames influences much of the variation between institutions. If nonprofit institutions generally have more space than public institutions to promote empowerment, institutional leaders at public institutions can still, due to their individual abilities, empower users more than leaders of nonprofit institutions. Accordingly, what this study sets out to reveal are differences in the potential for active citizenship that exist between the different types of providers. This potential is sometimes exploited fully, while at other times we can only speak of latent control of everyday life.

In addition to variations in how leaders and staff at providers exploit the capacity for active citizenship within their institutional frames, user characteristics are another factor to consider when evaluating active citizenship (Bang et al. 2000). When it comes to welfare services, one central characteristic is the health of users. Users of nursing homes have health problems that make it difficult for many of them to exploit the capacity for active citizenship. This renders users unable to seek more active citizenship and makes facilitating more active citizenship less relevant for providers. In the school sector, the parents of students are primarily the ones who enjoy active citizenship . They are often able and willing to pursue as much influence as they can obtain.

The latent or potential capacity for active citizenship says something about how users can influence services. Some users do not wish to be active citizens, but their interest in good services is nevertheless just as acute as any other citizen. If the capacity for active citizenship leads to some citizens being able to obtain better services than others, then this constitutes a relevant aspect of the analysis. At the same time, opportunities for user influence can also be important for those who do not actively use it at any given time. The existence of such channels for influence is like ‘security valves’ in the system. They may not be in use at all times, and they may seem insignificant on a day-to-day basis, but they can make a huge difference once users feel that things need to change.

Data and Methodology

The empirical analysis in this chapter is based on the same material as in the preceding chapters. I will therefore not repeat all of the details of the design, which are presented in the appendix to Chap. 1. In each country, we selected two municipalities (plus a third municipality in Norway where only schools were studied). In each municipality, one public institution and one nonpublic institution were compared in both the school and the nursing home sectors. National experts in each country carried out the qualitative investigation with a shared field guide as the basis for data gathering. The primary sources of data were semi-structured interviews and focus groups. In total, we conducted 35 interviews in Denmark , 21 in Sweden, and 57 in Norway . These data were triangulated with studies of central documents in the investigated municipalities and institutions, in addition to local user surveys where relevant. There is no room for statistical generalisations from these case studies, but they do highlight some mechanisms that help us understand conditions that expand the capacity for active citizenship .

Analysis and Findings

For each service area , I analysed the different dimensions of active citizenship —choice, empowerment and participation —across the analytic dimensions by country and institutional sector . I start by presenting an analysis of the nursing home sector in the three countries before turning to an analysis of the school sector in the same three countries.

Nursing Homes

Choice —Diversity in Services and Exit Opportunities for Users?

In the Norwegian and Swedish municipalities, the users of nursing homes do not have user choice because the municipalities allocate citizens to the nursing homes. Users can request certain homes, but due to excess demand, they must normally take the first slot that opens. The consequence of this system can be frustrating for users. The daughter of a user in Norway explains:

I was at the counter at the grocery store when my phone rang. The person tells me: your mother can have a place [in the nursing home] now, but you must decide within an hour. You know what I felt, I was so angry. Am I supposed to turn everything upside down? We had applied many months before and then we get one hour to change your life, take it, or leave it. […] Am I supposed to take this decision without talking to her? (Interview, user representative, municipal nursing home, Norway)

Since 2005, Danes have had user choice between nursing homes in the same municipality. The poor health of users means that the choice is mainly exercised by their next of kin. The effectiveness of this right is limited by the lack of a sufficient number of nursing home places. When a slot in a nursing home opens up, a user will typically take that slot. Thus, in spite of the formal user choice opportunity in Denmark , actual differences between the Scandinavian countries in terms of user choice in nursing homes are negligible.

Even if users are not free to choose nursing homes , they can make requests. As much as possible, all municipalities claim to try to accommodate user requests. Interviewees from different positions stress geography as the most important factor for users. The leader at one of the Danish diaconal nursing homes sums up the importance of geography:

I believe geography is most important. I wish I could say that it is because of us, but it is not. People live in this area, and of course, they want to stay because here is where they have their social environment and their children. When they first are here, they are happy to be here, and their children are happy. Yet it is mostly geography, no doubt. We can see the same with ourselves. No matter where we live, we do not want to move to the other side of the country if we were to move to a nursing home. We want to be in a well-known, safe environment where we belong. (Interview, site manager, nonprofit nursing home, Denmark)

Even though some of the studied municipalities have introduced open tenders, there are no differences between municipalities in terms of how nursing homes compete to attract users. There is thus no sense of competition between the different options and no exit opportunity that could affect power relations. The staff and leaders at the different nursing homes did not perceive of themselves as providers who attract users in a market.

The lack of user choice also complicates the opportunities nonpublic providers have for providing services distinct from those of the public sector. With the high demand for nursing home slots, municipalities want all available nursing homes to provide a uniform service so that deciding which homes to allocate users to is a non-issue. Since the interviewees specified geographic proximity to their home or their relatives’ homes as the primary factor in requesting a particular nursing home, it is in their interest that the nursing homes do not represent different concepts, as they do not want to risk that the closest nursing home does not provide a service that suits them.

Therefore, when municipalities present information about their nursing homes , they do not point to substantive differences, since effectively there are none. In some cases, municipalities do not even differentiate between public and nonpublic options on their websites. The administrative leader of one of the municipalities suggested that citizens do not know which nursing homes are public and which are nonpublic, a claim which underscores how difficult it is for users to choose providers based on institutional sectors.

Still, leaders at all the nonprofit nursing homes stressed that they found their nursing home to be distinct from the public option. All nonprofit nursing homes in our study were faith-based. Their Christian values are demonstrated in how they operate, albeit with respect for non-Christian residents. Since their users have not specifically chosen Christian nursing homes , administrators cannot impose their faith on them. As the leader of one of the Danish nursing homes put it:

It is the diaconal, the spiritual care, that is in focus. A good thing about spiritual care is that it is not measurable. It is lovely that we have one field where one cannot measure everything. Because how do you measure that we have read the Lord’s Prayer today? […] for me the importance of this has increased over the years as I have experienced that the elderly want this. They need the space for reflection that spiritual care provides. In reality, this is mostly about reflection. (Interview, site manager, nonprofit nursing home, Denmark)

The user representatives at this nursing home share this view, but point out the conditions for the employees, and not the users, when referring to the particular diaconal institution. They found that the diaconal respect for individuals makes the nursing home a good employer, but they do not find that the diaconal basis of the nursing home affects the content of the care.

The staff members also recognised the particular aspects of spiritual care, but qualified them by claiming that represented minor differences:

Well, I do not know what to say, but I do not notice the big difference. I simply do not. Of course, there is worship in the afternoon. Moreover, we have the services. I do not know if this is more than in other nursing homes, but in my daily life, I do not notice any difference. (Interview, staff member, nonprofit nursing home, Denmark)

The for-profit nursing homes do not have the same inherent alternative values as the public option. The Norwegian for-profit nursing home still claims to be distinctive by employing a ‘service concept’ imported from the hotel business branch of the firm. Interestingly, none of the users, staff or municipal representatives found that the for-profit nursing home demonstrated any distinctiveness from public institutions.

Yet, the importance of institutional sectors for local policymakers is evident. One of the Swedish municipalities has gone the furthest by introducing market mechanisms. It uses tenders to allocate contracts, and within the public structure, it has an autonomous unit that operates like a provider entity. The Conservative leadership in the municipality allocates contracts to it because they regard having a public option as ‘important for the user choice’. It is difficult to understand this reasoning as the users cannot themselves choose institutions, and the municipalities themselves claim there are no substantive differences. At the same time, it recognises the potential differences between different institutional sectors. In addition, by having providers from different institutional sectors, this municipality has benchmarks that can be useful for assessing the different providers.

In conclusion, the regulatory regime of nonpublic nursing homes gives some freedom to operate according to local institutional initiatives. It is, however, unclear if this room for local initiatives is bigger for nonpublic than for public institutions. The lack of user choice means that there is no power based on opportunities users might have to exit a provider.

Empowerment —How Users Can Influence at an Institution

All nursing homes in this study have tried, with or without success, to establish user boards. In all cases, the formal arenas for user involvement in nursing homes are based on the participation of relatives. Eighty percent of nursing home users in Norway suffer from dementia (Haugen and Engedal 2005), and reports from staff and municipalities suggest the situation is similar in Denmark and Sweden.

When it comes to the functioning of user boards, there is no systematic difference between homes belonging to different sectors. The functioning of user boards is in all cases somewhat up to the users themselves. As one Norwegian municipal manager puts it:

User board, it is almost dangerous to say, because we had a project, you may have heard about it, at the municipal nursing home. It was very dependent on some vital persons to run it on such an advanced scale as they expected. When these persons no longer had their loved ones at the nursing home, the user board, I will not put it explicitly, was transformed into a friend’s organisation [that encourages volunteer efforts]. (Interview, administrative leader, municipality, Norway)

The situation today is that the user board mostly coordinates volunteer activities and does not play an important role in the steering of institutions, even though they are sometimes consulted.

In Denmark, both nonprofit nursing homes have closed their user boards due to lack of interest from relatives; the same thing has happened to both nursing homes in one municipality in Sweden. The lack of user boards in the municipality does not concern any of the leaders of the institutions, but they find it somewhat frustrating that there are no relatives willing to contribute: ‘I understand completely [that people have busy lives], but we have 52 residents, it should be possible to find 3–4 persons’ (Interview, site manager, municipal nursing home, Sweden).

At the same time, there have been successful attempts to establish user boards. In the for-profit nursing home in Norway , the leader of the user board believed that the leader of the institution felt threatened by how the user board interfered in how the institution was run, implying that the user board’s influence was real. In this municipality, municipal guidelines instruct the head of the nursing home to discuss important plans and changes with the user board before making final decisions. When initiatives come from user representatives, they normally concern detailed aspects of care, not the long-term development of the institutions themselves. Likewise, in Denmark , a municipal leader describes the importance of their user board:

It is a demand that we involve the next of kin and the residents in what happens, and why should we change something that works? Therefore, we will keep our user board and we will keep elections for who can be in it. We have elections almost every time because there are more people running than we need in the board. We do not have any problems getting people to participate in the board, and as the representatives from the staff say: ‘everyone should experience a user-next of kin board.’ Imagine all our old users who are immobile and can almost do nothing, and then they appear [in the board meetings] with pen and pencil. (Interview, site manager, municipal nursing home, Denmark)

Generally, the interviewees agreed that there were variations over time in the nursing homes, but the willingness and ability of the user board members to take an active role explains these variations. Accordingly, it is difficult to conclude that variations in the functioning of user boards can be attributed to the institutional sector.

The interviewees cited day-to-day contacts as the most important route for obtaining changes on behalf of users. Most users in all institutions were content with the possibility of exerting influence via this channel. The exception were those who would have liked more services, such as follow-ups from physiotherapists, which are limited due to cost issues. This exemplifies how changes with budgetary consequences are difficult to obtain, while other changes are easier to achieve. Changes in budgetary frames are decided at the municipal level. To obtain these sorts of changes, users need to try to participate in arenas which channel their interests to this level.

Some interviewees among the staff and leadership at nonprofit nursing homes pointed to increased flexibility outside of the public hierarchy, which allows more adaptation to user needs. It seems difficult, however, to infer if this is an effect of ownership or of variation in how nursing homes exploit their ability to manoeuvre. Users at public institutions were also happy with the possibilities they had to influence services, as illustrated by a user at a municipal institution:

I find that both leaders we have here are very open to us in the user-next of kin board. In addition, I have the impression that they are very open to all the users and want to do a lot to make sure this is a good place to live. (Interview, user representative, municipal nursing home, Denmark)

There is no contradiction between collective and individual empowerment, but there is the perception that individual empowerment can compensate for a lack of collective empowerment. One leader of a nursing home found that the lack of a user board was no problem because of individual empowerment:

This is why one does not miss the user board. One has good contact with them [the relatives] and they come here to visit. The nurse and the designated contact staff talk to the relatives and ask if they have any questions. (Interview, site manager, municipal nursing home, Sweden)

On the other hand, we were unable to collect data from users with the most fragile health. There is, therefore, a risk that their interests are not as well represented as the interests of those who can articulate themselves better. It is not possible to affirmatively conclude that providers belonging to a specific institutional sector have better levels of individual empowerment.

Participation—How User Experiences are Translated to the Municipal Level

The dimension of participation is where the biggest differences between the three countries were observed. In all three countries, local politicians stressed that they wanted input from users, and they all gave users and other citizens access to their meetings. The differences observed included how local policymakers actively invited users to provide their input and how users sought to directly influence the municipal level.

One thing the Scandinavian countries have in common is municipal elderly councils or associations that speak on their behalf. One example from Norway shows how interactions between this type of council and nonpublic providers can be mutually reinforcing, as the council uses the professional expertise of the nonprofit nursing home to strengthen their arguments with the municipality. The leader of the nonprofit nursing home explains:

They are quite good at approaching us, perhaps because they see that we think somewhat differently in certain areas, and then they ask. I let them know if I want to try out something […] and when big issues for the council for the elderly arise, it is obvious that we discuss them. What are the needs? They have many opinions themselves, but sometimes I think they need some help with some additional arguments. (Interview, site manager, for-profit nursing home, Norway)

The presence of a nonprofit nursing home thereby empowers the elderly in the municipality by giving them access to professional opinions that may challenge the municipal structure.

In Norway , both nonpublic nursing homes are integrated with the public system when it comes to this issue. The public and nonpublic nursing homes administer the same user surveys, which thus have the same potential for leading to changes in all institutional sectors. One of the municipalities holds annual meetings between user boards and the relevant committee in the municipal council. Opinions differ between municipal representatives and users in regards to how constructive these meetings are. Both the administrative and political leadership were very clear, as in this statement from the administrative leader:

The dialogue meetings are the basis for the budget process. The CEO of the municipality has the results as the fundament of the priorities in the strategic plans. He often uses the input from these dialogue processes when he suggests future focuses and priorities. That is what can happen, and it does not happen seldom. (Interview, administrative leader, municipality, Norway)

Users, on the other hand, were more sceptical:

Afterward, we concluded that [the meeting] had little commitment. The politicians said something, we said something, but there were no minutes of the meeting. Moreover, many issues were raised that had no place in the municipal budget. (Interview, user representatives, municipal nursing home, Norway)

It seems like users had no information about the consequences of the meeting and had no way of knowing how their input could make an impact. In this sense, they might have more influence than they make use of or realise.

In Denmark , at both the nonprofit and municipal nursing homes, the user boards have had an active role in defending the interests of the nursing homes in relation to the municipality. There are examples from both forms of nursing homes of incidents where active lobbying from the user boards has prevented municipal budget cuts. The leader of a municipal nursing home gives a telling example of the role the user board can play:

At one point, in 2010, it was suggested by politicians that our kitchen should close, and that we should get food from Aulum [a central kitchen] like the other nursing homes. I must say, at that time we had some fine next of kins. They are the ones we can thank for having our kitchen today. That is for sure. They were present at the town hall, sent letters to the editors of newspapers, and called politicians. They were the ones who did the job. (Interview, site manager, municipal nursing home, Denmark)

This clearly shows how the user board takes responsibility for the nursing home in its relations with the municipality. Interestingly, the nonprofit nursing home chose to stand outside of the public structure, but users still found it natural to lobby the municipal level when they wanted changes. The leader of the user board gives one example:

I told the leadership at one point: we have to write a letter and send it to all the members of the city council because I do not think they know what is going on here […] and that is what we did, and then – I promise – things started to happen. I spoke on the phone with some of the members of the council and they did not know what they had said yes to. (Interview, user representative, nonprofit nursing home, Denmark)

As we can see from these examples, the fight for resources is what interviewees at the nursing homes pointed to when describing their external role, and this role is the same for both public and nonprofit nursing homes. It is up to the nursing homes themselves to be active in approaching the municipal level, since there are no formal arenas where representatives from the user boards can interact directly with municipal leaders.

In Sweden, politicians practice an ‘open door’ policy where committee meetings are open to the public, and citizens are welcome to make statements to politicians. Politicians report that few citizens use this opportunity, but they still believe it is a good way of promoting transparency in the municipality. In addition, both municipalities have politicians dedicated to following up with the different nursing homes and keeping in touch with the user boards, where these exist.

The more prominent form of citizen involvement in Sweden is through councils for the elderly that influence local policymaking. They have no formal ties to users of the nursing homes and do not work differently with institutions based on their institutional sector . In sum, Sweden has fewer formal routes for user participation in municipal policy formulation.

Table 6.2 summarises the findings for active citizenship in the nursing home sector. The table shows that there are small differences between the different institutional sectors as well as between countries. For citizens, their ability to control services did not vary that much across different institutions in Scandinavia.

Table 6.2 Active citizenship in the nursing home sector
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Schools

Choice —Diversity in Services and Exit Opportunities for Users?

All countries have user choice where families are free to select nonpublic schools. In Sweden, these schools can come from all three institutional sectors . In Denmark , nonpublic schools that receive public funding must be self-owned and thus nonprofit. In Norway , nonpublic schools that receive public funding may not distribute profits or channel funds out of the schools in any way. All income from the state and user fees must benefit the students. These regulations entail that practically all nonpublic schools in Norway are nonprofit. In all municipalities, families have a local school where they belong to and have the right to attend. To choose to attend a nonpublic school thus represents an active choice to exit this local alternative. How much the families use this opportunity varies. In one Danish municipality, only 56% of students attended their local schools; while in Norwegian municipalities, more than 90% of students attended their local schools.

In Norway , the main motivation for selecting a nonprofit school are the special services they offer. For the religion-based nonprofit schools, the view of this parent is typical: ‘The Christian influence and the values we have, they get them both at school and at home; the values we have, they get them at school also’ (Interview, parent, nonprofit school, Norway). The other schools, which have alternative approaches to teaching as their basis, point to their holistic approach to each student and relaxed approach to testing and competition as examples of their special qualities.

At the same time, there was a large minority of families whose choices were not determined by the schools’ conceptual framework. Rather, they actively make a choice away from the public schools. These families shared a negative experience with the public schools, and approached nonprofit schools as a last resort. One mother gives a telling example about her daughter:

She has had some difficulty concentrating throughout her schooling. As parents, we have seen it, but the school has not taken it seriously and handled it as we wanted. In the end, the girl practically perished. It was a matter of surviving. (Interview, parent, nonprofit school, Norway)

In Denmark , which has a bigger share of students in nonprofit schools, there are many reasons for choosing a specific school. The distinctiveness of a school is one reason among several, and the importance of this factor varies substantially. One parent who found the distinctiveness of a school to be of great importance states:

No, it is not my experience that to go to a nonprofit school is a conscious decision. Unfortunately, seen from my perspective, I experience that at least in the grade of my youngest child, that in selecting the school many think it is a for-profit school [something that does not exist in Denmark]. At least it is a negative choice, away from the public school. (Interview, parent, nonprofit school, Denmark)

Disappointment about the lack of conviction on the part of some parents was shared by teachers who found that there were two kinds of families: the classical ‘nonprofit family’ that treasures the distinctiveness of nonprofit schools, and the kind of family that seeks an alternative to public school with little concern for the actual content of the alternative. In order for this latter group to be pleased with a nonprofit school, deviation from public schools cannot be too pronounced. The share of students attending nonprofit schools seems to reflect how much these schools deviate from the public option.

Nonprofit schools take active measures to defend their distinctiveness . They vary in terms of their particular type of distinctiveness, but share an emphasis on the collective, which is an important finding in our case study schools. In these schools, parents are expected to be involved in different aspects related to their operation. One headmaster made it a point to be explicit about this expectation in his first conversation with potential parents in order to maintain loyalty to the principles of the school:

I know that I have scared away parents and they have simply said: it is so much collectivity and participation ; it is simply not us. (Interview, site manager, nonprofit school, Denmark)

In the same way that nonprofit values are important for some of the families who choose this kind of school, values also underpin the decision to select municipal schools. Denmark has traditionally had many nonpublic schools, which has caused some parents to rally around the public option. One parent at a municipal school explained: ‘When we moved here we were aware that there was a nonprofit school here, but in our family we are by principle against opting against the public school’ (Interview, parent, public school, Denmark). This parent went on to describe the effect on social integration when students from different families in the same neighbourhood attend the same local school; something he contrasted with nonprofit schools, where he found that the group of parents were more homogeneous. In sum, the motivation for choosing a specific school can be based on values in both public and nonprofit schools.

Interestingly, for-profit schools in Sweden are not perceived as offering something substantively different when it comes to teaching methodology, religion or ideology. Here, when families make their initial decision, geography is the most important factor. In addition, the administrative leader in one municipality mentioned other factors that were revealed in an internal investigation in the municipality. What was surprising was that the profiles of the nonpublic schools, like a special orientation toward sports, were hardly mentioned by the parents. Instead, they mentioned quality, group pressure and opting out of the public option.

Moreover, the lack of distinctiveness between Swedish schools makes changing between them an available option for families that do not want something substantively different from their local schools, and this creates a competitive dynamic. In all Swedish schools, staff members report that parents use the threat of changing schools when arguing their case. According to the schools themselves, changing schools is more of a problem for students than it is for schools, as it does not occur often enough to affect the schools but can be disruptive for students. Still, the schools reported that their operation was dependent on attracting students, and headmasters in different schools reported that they believed that competition inspired them to remain competitive: ‘We feel the competition and that has made us clearer and better’ (Interview, site manager, public school, Sweden).

A similar effect was seen in Denmark , where competitive pressure is growing. The number of students in Denmark is set to decrease in coming years since the total number of children in each generation is getting smaller. In combination with substantial reforms to public schools that have increased the number of lessons given per week, a competitive environment has been created where leaders of both types of schools must make active choices in order to stay competitive. A statement by a teacher at a nonprofit school exemplifies this trend:

We tell ourselves that we are a collective and such things, and that is obviously true, but it is also a business. We need some customers in the shop; if not, there is no money to run the collective. So yes, we are in competition with local municipal schools to attract students. I do not find that there is any bad blood between the two institutions, but it is something we have to deal with – e.g., with the new reforms and the new number of lessons a week, we need to be on par with local public schools. I strongly doubt that this is needed for nonprofit schools in more densely populated areas. (Interview, staff member, nonprofit school, Denmark)

In spite of the blunt admission that competition is altering how schools are run, this teacher concluded that the distinctiveness of the school can be preserved: ‘That is exactly what we fear, but I doubt it. The big challenge is to follow the development while at the same time not becoming too similar. I do not really think so because there are certain things that make us unique’ (Interview, staff member, nonprofit school, Denmark).

In Norway , competition between public and nonprofit schools is an unfamiliar concept. Families choose nonprofit schools primarily because they give them services better suited to their preferences. Interestingly, although some parents expressed discontent with public schools, none used the exit option as a tool for obtaining change at their former public schools. Moreover, headmasters at the schools did not regard the threat of exit as a potential instrument for students to obtain changes. One headmaster at a public school pointed out that they tried to keep their students and would accommodate them to avoid changes, but that it was to a certain degree unavoidable. At the same time, more students enter the school than leave it, as the headmaster observes: ‘It is not always we get star students, to speak plainly. Often there is ‘something’ when you change school’ (Interview, site manager, public school, Norway). This suggests that often it is the weaker, more demanding students who change schools, especially when the change is between public schools, since these families do not seek distinctiveness or wish to opt out of public school. Since these students demand many resources, it might not be beneficial for schools to attract them in the first place.

Information is pivotal for parents to make an active choice when choosing schools and making use of the alternatives they have. Differences in this sense reflect the tradition of school types in the different countries. In Denmark , the law requires all nonprofit schools to publish their values on their websites, but as the preceding quote demonstrates, parents are sometimes still uninformed about the schools before they approach them directly. In Norway , there are no such rules, but nonprofit schools belong to three categories: Christian, Montessori and Waldorf (Steiner), and most families that consider opting out of public school have an idea about what they consist of. There is no information readily available about them though, so one can speculate that more families would be interested in the nonprofit option if they knew what they had to offer. In Sweden, schools from different institutional sectors have less distinctive profiles, so such information is deemed irrelevant. However, parents actively searching for information can find quality indicators, such as results from user surveys and test results from the schools.

A different aspect of choice seems to involve a contradiction between giving users power through exit opportunities and broadening services. If there is to be a level of competition that moves power from the institution to the user, services cannot be too distinctive. If different actors cater to different students, many families will only find one suitable institution for themselves. This empowers them as they do find good options, but it does not give them improved opportunities for asking for changes from the institutions.

Generally, the opportunity for choice is associated with somewhat different effects in the three countries. In Norway and Denmark, which only allow nonprofit schools, choice spurs the development of schools that are distinct from the public option. In Sweden, there is less variation between schools across institutional sectors ; one can, however, observe competition between schools, which is also increasingly seen in Denmark but is absent from Norway.

Empowerment —How Users Can Influence at an Institution

Parents have more influence in schools than users and their relatives have in nursing homes . This is partly because students and parents are more willing to use their latent influence, and partly because of laws giving parents more influence in schools. All three Scandinavian countries have laws that govern the composition of user boards in public schools and the issues about which they must be consulted.

In the selected municipal schools, user boards function as arenas where representatives for the parents obtain relevant information and provide input on general issues. Parents typically describe them as places ‘where we can give input’. The headmasters who also attend these meetings share this description. When asked to give an example of a case where a user board has had influence, the headmaster mentioned work done on IT solutions, but then qualified the statement by adding, ‘It is not completely true because I had already decided to make these changes. But it is good to use the parents as support when I argue with the teachers, even if it is not always a good argument’ (Interview, site manager, public school, Norway ). This latter example illustrates how collective empowerment can have real, albeit limited, effects. The Swedish for-profit schools function practically the same way as public schools in this regard.

Formal arrangements give parents more influence over nonprofit schools. The law guarantees their representation in the school board, and in reality, they dominate user boards as the primary stakeholders in the institutions. In municipal schools, the municipal administration makes important decisions, such as hiring headmasters, adopting budgets and planning long-term strategies for the schools. In nonprofit schools, the board makes these decisions.

Indeed, one parent member of the school board questioned if he had too much power: ‘That was probably what surprised me the most: that as a board member you are so much involved. In many ways, it is a great responsibility. One does not have any other qualifications to be in the board other than the fact that you are a parent’ (Interview, user representative, nonprofit school, Denmark ). This overwhelming feeling can come from overall administrative and economic responsibility, not all of which impacts teaching directly. At the same time, overarching decisions regarding values, teaching philosophies and school–parent cooperation are decided at this level. One example of how administrative decisions play an important role is the nonprofit school that experienced a cutback in public transfers and then decided to increase the number of students in each class and not raise the fees. The parents themselves took this decision through to the school board.

A parent who was one of the founders of a nonprofit school illustrates the importance of parental influence in nonprofit schools. She explains that parental influence was an important reason why she helped established the school:

It is the real opportunity the parents have to have influence on the content in the school […] We saw that this teaching methodology, and that one could do this under the auspices of the parents, gives opportunities that you want as an active parent. To participate in creating something that in many ways is better then what you had to begin with. (Interview, user representative, nonprofit school, Norway)

There seems to be universal agreement that the room for influence is greater in nonprofit schools, both in principle and in reality. One Swedish public school demonstrates, however, that there is no determinism in this relationship. Here the school board makes the major decisions. The board consists of staff and parents, but the parents have the majority of the votes and the chairman. The parents show real interest in the board, and the headmaster states that the present board was elected with about 100 votes, a figure that makes up the lion’s share of parents at the school.

Yet, informal contact between teachers and parents is the more important form of influence. A reason for this is that in spite of its strong legal backing, there is still some doubt about how the user board should function, as one board member explains:

It happens in cases with complaints about teachers, grades or something else; I am very unsure about what the user board can say about professional matters. We have no role. We have no competence to speak about the teaching methodology. However, as a parent, you have the right and the duty to follow up on the teaching of your child … and the teacher and all that, but as a user board, I do not know. (Interview, user representative, public school, Norway)

Regarding informal contact, there are smaller differences between public and nonpublic schools. Both have structures in place to allow students’ and parents’ voices to be heard, and there is a shared understanding among interviewees from different groups that these structures are useful and available. In the public schools, users and staff do not experience any lack of user involvement . They stress that personal contact between teachers and parents is fluid, and that the school is receptive to input from parents. The relationship between teachers and parents is important, and personal chemistry is not dependent on one type of institutional sector.

Yet, the flexibility of the structures can be different. Nonprofit schools are based on an ideology that entails more user input and different teaching methods than in for-profit and public schools. A teacher at a nonprofit school explains the difference:

That is the major, decisive difference from the public school. The children are involved in what goals we have for them and what ambitions we have for their development. We continuously set goals on three levels: the professional, the personal, and the social. They are themselves involved, so the old concept of self-management exudes from our school. (Interview, staff member, nonprofit school, Denmark)

One part of the explanation for more room for user empowerment, both individual and collective, at nonprofit schools stems from how these schools use test scores and measurable indicators in their governance. These schools generally have a relaxed approach to tests, unlike for-profit and public schools. A headmaster at a public school explains:

Then comes the PISA-test that tells people: ‘You do not perform well enough. This is simply too bad’. Then there is even more focus on us not having enough projects, themes and 1000 other things. We must stick to the book. Oh, now I am harsh, but sometimes it annoys me that one governs [the school] this way and thus kills some of the creativity. (Interview, site manager, public school, Denmark)

With more emphasis on PISA scores and quantifiable goals, there is less room for influence from parents. From all municipalities, increased emphasis on these measures was reported, and the same can be said of for-profit schools. In this regard, nonprofit schools are in a freer position. These schools are not part of a bigger structure and thus have fewer limits to making changes based on user input. On the other hand, one of the for-profit firms has an ombudsman at the level of the firm. Students and teachers can report incidents and situations to the ombudsman, who is tasked with making sure the school follows up appropriately on reports that the school is not performing according to standards. This gives users an extra outlet to reach out to if they are unhappy with the school’s services.

Participation—How User Experiences are Translated to the Municipal Level

Just as the participatory role of relatives varies between countries in the nursing home sector, parental participation in the school sector is the dimension which exhibits the greatest differences between Scandinavian countries.

In Norway , all municipalities have mechanisms in place for conveying the opinions of students and their parents to the municipal level. Chief among them is that in all municipalities a municipal-level body exists which consists of selected parents from different schools. In one municipality, the leader of this body is paid by the municipality to enable her to spend sufficient time to efficiently promote the voice of the parents. Asked whether such leaders are able to influence school policy, one leader remarks: ‘Yes. That is my experience. I find that they are very interested in our opinions’. The same message comes from other municipalities. Debates about issues that are not strictly related to school policy but concern wider elements of municipal policies for the young also find a place in this body. In one municipality, an advisory committee exists for ‘family and child protection’ where representatives of school parents meet. The parents therefore have the opportunity to influence a range of municipal policies. Even though no formal power is allocated to these bodies, politicians, administrative leaders and parents agree that they exert real influence.

In addition, a municipal politician is also present at meetings at each school. This is meant to inform local policymakers about the operations of different schools, and the law requires it. How this provision functions varies substantially, as some politicians eagerly participate in school meetings while others are seldom present. Variations seem to be solely based on the level of personal enthusiasm of individual politicians.

In Norwegian nonprofit schools, state law requires a local politician to participate as an observer in their user boards. The interest levels of these politicians also vary, but in all cases they have less room for formal influence. Nonprofit schools are controversial in some parts of the municipalities, among some administrative leaders who find interaction and competition with nonprofits to be ‘a hassle and an annoyance’ and among some politicians who hold a more ideological approach. This partly explains why nonprofit schools are excluded from municipal arenas with policymaking influence, even when these include wider perspectives than just school policies. Nonprofit schools see this as a negative since they feel unrecognised and unheard. As one mother says: ‘It is an underlying factor that we are an outsider in the municipality. I think that feels very negative for the teachers. It takes so long to get accepted’ (Interview, user representative, public school, Norway).

Like in Norway , the external role of collective user bodies in Danish public and nonprofit schools is the opposite of its internal role. Municipal schools are more active in their relationship with municipalities. They provide input at local hearings, write open letters to editors of local newspapers and work directly with local politicians. Most of the time their goal is to make visible the need for funding at the schools. Indeed, one parent pointed to this form of lobbying effort vis-à-vis the municipality as the most important task of the school board:

Formally, we do not have much influence. Some of the things we have done the last few years are related to traffic and other things where we try to influence the municipality through different channels than the ones available to the leaders in the school. We can approach the politicians directly, that is something the leaders cannot do. They must go through their superiors. In situations where we want to put pressure on their superiors, we approach the politicians […] I see it as one of our most important roles, that we can speak the case of the school. The leadership of the school is part of the municipality and must fall in line. If the municipality makes a decision, they must loyally carry it out. We are not bound by this. We can speak the case of the school. (Interview, representative, public school, Denmark)

In nonprofit schools, user boards play a lesser external role. This is partly because headmasters have more freedom to occupy this role since they are not part of the municipal hierarchy. The loyalty of headmasters is, therefore, more clearly defined as belonging to the schools. Another reason for the limited external role of nonprofits schools is that they receive very little attention from municipalities. However, this is a natural consequence of nonprofit students opting out of the municipal option, and municipalities have limited opportunities for steering. On the other hand, about 30% of students in Faaborg Midtfyn, less in Herning, attend nonprofit schools, which consequently means that local politicians are only informed about a limited portion of the educational system in the municipality. This is something that users of nonprofit schools find frustrating: ‘No, there is no attention from the politicians. That is my impression. Neither when I am here at the school nor when I am at work [in the local newspaper] do I get the impression that the politicians are concerned about the nonprofit schools’ (Interview, user representative, nonprofit school, Denmark ). This stands in stark contrast to the experiences expressed by public school users.

In Sweden, contact between users and local policymakers is less organised. User influence on the municipal level is not all that different from influential channels available to other citizens, such as elections, local political parties and direct approaches to politicians.

Information about schools typically flows through the headmaster in the municipal hierarchy, and direct contact is not formally organised, except from user surveys which are subject to scrutiny at the municipal level. Parents have every opportunity to make further contact with politicians. In municipalities, meetings of the political committee responsible for schools are open events where all citizens can attend. In reality, few citizens use this opportunity. To make politicians better informed about situations at the schools, a politician from the municipality is present at user board meetings of all municipal schools. This makes local politicians more informed about public schools than nonpublic schools, an imbalance which reflects where politicians have room for influence.

There are few initiatives from parents that seek changes at the municipal level. In one municipality, some parents expressed discontent with the lack of opportunities to express their voices in relation to a large overhaul of the school structure. According to politicians, the opportunity to ‘vote with the feet’ and change schools, should amend this problem.

Table 6.3 summarises the findings from the school sector. As is evident from the table, this service area displays more differentiation between different institutional sectors . Nonprofit institutions, in particular, tend to be associated with more potential for user control through choice and empowerment , while users of public institutions tend to participate more in policy influencing.

Table 6.3 Active citizenship in the school sector
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How Can We Explain Different Potentials for Active Citizenship?

To make the comparison between service areas easier to grasp, Table 6.4 compares the shared findings from schools and nursing homes.

Table 6.4 Key variations in nursing homes and schools
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This table illustrates some patterns of similarities and differences across the analytic dimensions. In the following sections, I will identify the most important aspects of these patterns for the different dimensions of active citizenship . By analysing variations and consistencies across countries, institutional sectors and service areas , I am also able to suggest some mechanisms that could expand or limit the capacity for active citizenship.

Choice—The Importance of Capacity in Supply

Two mechanisms that contribute to explaining differences between service areas are the functioning of user choice and the importance of passing a threshold in capacity. In Danish municipalities, the nursing home sector formally has user choice , whereas their counterparts in Norway and Sweden do not. Potential nursing home users in Norway and Sweden can ask for a specific nursing home , but public bureaucrats make the final decision. In reality, the lack of available nursing home slots restrains Danish user choice, so user experience in the nursing home sector is very much the same across all three countries. Nursing homes are an area for cost reduction, something that together with the recalibration of the elderly care structure results in insufficient capacity (Hermansen and Gautun 2011). The consequence is that every new available space in nursing homes—public, for-profit or nonprofit—is immediately filled. Variations between nursing homes cannot be too large since one cannot know the preferences, interests and needs of users. In addition, users mentioned geography and proximity to home and family as the most important considerations when reporting preferences for nursing homes . Thus, it becomes problematic if the local nursing home has a profile that does not match a potential user. Moreover, users can be temporarily admitted to a nursing home before getting a permanent place elsewhere. This means that differences between institutions cannot be too large. From the users’ perspective, the lack of capacity makes any talk of choice irrelevant, as this user representative from Norway explains:

My mother in law was diagnosed with dementia in 2001, it almost killed me, and she lived next door. He [my husband] worked in Sweden and I had to take care of her in all ways. Then we were so ‘lucky’ to be rude, that she fell and broke her upper femur. She had surgery and was granted a short time stay [in a nursing home] and after much begging, she got a place at [name of nursing home]. […] It is not like you will get a place when you need it. (Interview, user representative, for-profit nursing home, Norway)

When users experience a shortage of available places at nursing homes , it is impossible for them to make demands regarding a single nursing home in particular. In the above example, the user was first temporarily admitted to one institution before being moved to a permanent one; this underlines the need for different institutions to have limited variation in terms of content. We found similar examples in different institutions and municipalities in all three countries. Given this situation, there are no credible nursing home alternatives for users and their next of kin, and thus exit opportunities are not available to them either.

The contrast with the school sector is striking. Municipalities in all three countries are responsible for providing enough school places for all children. Students automatically belong to their local school unless they actively seek out a different school. Nonpublic schools represent an addition to this system, as their establishment is not dependent on approval from municipalities, but is decided instead at a national level by meeting certain criteria. Unlike nursing homes, all children are entitled to a place in school. Inability to meet the necessary capacity is therefore not an option. In reality, nonpublic schools secure a certain level of overcapacity of school places since the public schools must accept students that want to return from a nonpublic school. This makes the choice option real and gives families the opportunity to choose which schools they like best and to change schools when appropriate. Thus, nonprofit schools develop distinctiveness without these characteristics being forced upon anyone.

Empowerment —Nonprofit Schools Use Administrative Freedom to Empower Users

In this investigation, the main finding regarding empowerment is that users of nonprofit schools enjoy more empowerment than users of other types of schools and nursing homes. This can be explained by the administrative freedom afforded to nonprofit schools. Legal instruments and formal arrangements at the national and municipal level also contribute to explaining levels of empowerment. Individual forms of empowerment are perceived as more important for users than collective forms of empowerment.

It is a reasonable assumption that limited access to user choice would inspire nursing homes to develop their own instruments for empowerment. This is not the case, and generally speaking, schools have more empowered users. In schools, there is no shortage of volunteers to participate in user boards. Their role also has stronger legal backing, and on certain issues, school leaders must consult user boards before making final decisions. The role of user boards is in most cases well established, and users do not reflect much on their power. They generally share the feeling that they have influence and that this makes it worth their time. The collective influence of the user board varies, but it is a shared feature that users exploit this arena when they have strongly held opinions on issues.

In nursing homes , there are small differences in terms of empowerment between institutions belonging to different institutional sectors . For schools, on the other hand, there are important differences. Nonprofit schools seem to consistently offer more room for empowerment and a broader range of services for users. One central explanation for this is the administrative freedom these schools enjoy. Nonprofit schools are located outside of larger structures of hierarchical governance, such as municipalities and for-profit firms. This gives nonprofit schools fewer sources for steering, and thus more decision-making power rests locally at these schools. Fewer stakeholders mean a greater share of power for existing stakeholders, and parents are the principal stakeholders. Ben-Ner (1986) has shown how nonprofits are often founded by entrepreneurs who have strong convictions in terms of their missions and methods. They, therefore, construct mechanisms that protect what is distinctive about their services, their steering capacity, and the room they allocate for user empowerment. As we have seen in this study, parental influence is also part of the reason why nonprofit schools have been established. There may also be an aspect of self-selection involved, since families who seek nonprofit schools often wish to actively influence how the schools are run. However, for the potential agency of these families to blossom, it is necessary to allow it to develop, which nonprofit schools do.

Two further arguments underline the importance of administrative freedom. First, the Swedish example of a public school governed by parents displays as much empowerment as nonprofit schools. Accordingly, when public schools have the same administrative room for manoeuvring, they can empower their users in the same fashion as nonprofits. However, this potential is seldom used as this school model is uncommon. A likely interpretation of this is that granting public schools a significant degree of freedom from public hierarchy undermines the input channel of the local democracy—the votes cast in elections. Local politicians are evaluated by how they run schools; thus, appearing to lean back and leave school operations to parents may be seen as a failure to assume a central part of their responsibility. This represents a dilemma between different forms of democratic legitimacy. The dilemma is, however, not present when nonprofits run schools, since in these cases local politicians are not held responsible. It is also an indication that even though earlier reported studies suggested that a growing number of decisions are being made at the output side of the democratic process (Andersen 2006), there is a limit to this development when politicians seek to remain in charge of services. Aside from the issue of democratic legitimacy, politicians also seek to safeguard the model of a unitary school system that all children attend. The idea is that this model promotes social integration across economic, cultural and religious cleavages in society. The willingness to give freedom to nonpublic schools may depend on the willingness to give up or downsize ambitions for a unitary school system as an arena for social integration.

Second, nonprofit nursing homes do not offer the same level of diversity and empowerment as schools. This demonstrates how nonprofit institutions are dependent on the public sector ’s approach to service areas when they are part of the public service system. In all municipalities, nonprofit and for-profit nursing homes have about the same room for collective user empowerment as their public counterparts, while variation does exist between municipalities. This implies that municipal-level regulations are important for influencing levels of empowerment, which suppresses any potential nonprofit or for-profit providers may have to deviate from the public approach to empowerment. Illustrative of this is a statement from an administrative leader in a Swedish municipality who pointed out that the number of compulsory demands made of nursing homes tends to lead them to become ‘all the same’ (Interview, administrative leader, municipality, Sweden).

What is shared between service areas is the agreement that individual empowerment is experienced by users as being more important than collective forms of empowerment. Most users are satisfied with their level of individual empowerment, both in nursing homes and schools. There is somewhat more discontent among users at nursing homes , but such users tend to add that it is not based on lack of will from the staff, but instead on the shortage of staff and resources. There are few important differences in this respect across institutional sectors, municipalities and countries. These differences seem more dependent on the individual attributes of staff members. In addition, municipal-level regulations and institutional arrangements in companies or institutions influence individual empowerment . A telling example is the for-profit school in Sweden that has its own ombudsman. Students at this school have additional opportunities to voice complaints. The commercial interests of for-profit schools may also compel them to be more diligent in following-up on complaints. Whether these incentives work in this way is an empirical question we do not have the data to answer at this time. Either way, they demonstrate the potential for increased individual empowerment in different steering structures.

Participation—Administrative Integration Gives Arenas for Participation

The main findings regarding participation mirror the findings about empowerment. When institutions become detached from the public hierarchy, their users participate less in local policy processes. This means that, unlike for empowerment, the lowest levels of participation in local policy processes are found among users of nonprofit schools. Formal arrangements for user involvement are important as they can explain variations in user participation between service areas and municipalities.

The countries were uniform in their stated aims regarding user participation in policymaking. Open meetings among policymakers, and regular meeting points between users and policymakers, occur in many places. The users most capable of taking advantage of these spaces are at institutions integrated with the public administration. These include nursing homes, public schools and, interestingly, for-profit schools. When municipalities outsource services, they do so without reducing their perceived responsibility for the services. Nursing home users have no option to opt out of services from for-profit providers, and local policymakers, therefore, retain their ability to involve themselves in them. Users of nonprofit schools have consciously opted out of the realm of local policymakers, and are thus less of a concern for the municipality. Since decisions regarding opportunities to open up these schools rest at the national level, there is no process whereby the electorate can hold local policymakers responsible for the service content of these schools. Swedish for-profit schools are approved nationally, but are somewhat more attached to the municipal structure and are thus in a middle position.

This dimension exhibits fewer differences between service areas. All municipalities conduct user surveys, and these are administered in all institutions except nonprofit schools. User surveys are the only opportunity for direct communication between users and local policymakers. In addition, municipalities have arenas for representatives of institutions to participate. For nursing homes , there is no difference between public, for-profit and nonprofit institutions when it comes to their participation in these arenas. For schools, the more detached nonprofit schools are more isolated when it comes to participation. This is partly because local policymakers have less influence over what happens at nonprofit schools. It is a curious situation, since issues discussed in these arenas often include more than municipal school policies and are thus of interest also to the parents of children in nonprofit schools.

The implication here is that a trade-off exists between empowerment at institutions and participation and influence in local policy process. The institutions where users have more local influence get less attention and less room for influence from the municipal level. This gives them more room to manoeuvre locally but also gives them less administrative support. Albeit to varying degrees, municipalities are important for all these institutions, and so to be excluded from the municipal decision-making structure undermines the opportunities citizens have to influence decision making in their communities. For policymakers, the exclusion of citizens from platforms for communication with them can present a skewed view of the opinions of citizens, especially those who by definition have taken an active stance on particular welfare issues.

There is some variance between countries. In Denmark, user boards at nursing homes can report about successes in changing municipal policy, and interactions with local policymakers are a natural part of their tasks. This also happens in Norway, but to a lesser extent, while in Sweden it is all but absent. For schools, divisions between the strong influence of public schools and the lack of influence of nonpublic schools are evident across countries. The greater presence of participation in Denmark can be seen in the light of Scandinavian countries’ respective ‘power studies’, where the Danish research team drew more optimistic conclusions about the state of democracy on the basis of investigations into the implementation of policies (Andersen 2006).

Conclusions

Effect of Institutional Sector Depends on User Choice and Administrative Freedom

This chapter used experiences from 27 institutions in seven municipalities in three Scandinavian countries to explore whether it matters who provides publicly funded and regulated services. There is accordingly a wealth of data underlying the inferences made in this study, but they are not representative in any statistical meaning of the word. The results in this chapter must, therefore, be regarded as exploratory. There are many potential approaches to a comparison of service providers from different institutional sectors. Here I have chosen active citizenship : the ability for users to take control over their own lives when they are dependent on services.

There are differences between public, for-profit and nonprofit providers when it comes to active citizenship. However, these differences vary between the dimensions of active citizenship and service areas . Generally, nonprofits deviate more than for-profits in terms of public options. These deviations include providing more room for active citizenship along the dimensions of choice and empowerment , and less so for participation . What is needed is an understanding of these variations.

The first step is to look at the interaction of administrative freedom and user choice . Illustrative in this respect are the differences between Norwegian and Danish nonprofit schools and the elderly care sector in all three countries. In all three countries, this study shows nursing homes are closely integrated with the municipal hierarchy. Municipalities have ample room to intervene in nonprofit nursing homes , a power that undermines their autonomy and ability to be different from municipal nursing homes. For for-profit nursing homes , tender documents are very detailed and thus leave little room to develop distinctive characters. Furthermore, they are measured by the same parameters as municipal nursing homes and provide incentives to strive for the same goals. Overall, this means that nonpublic nursing homes have little administrative freedom and limited opportunity to develop distinctiveness.

This is in contrast with what we find for nonprofit schools in Norway and Denmark. These schools are outside municipal control since they are approved at the state level. The directorate for education collects the opinions of a municipality about establishing a nonprofit school, but the municipality will not be able to prevent its establishment. Moreover, municipalities do not supervise or inspect nonprofit schools. In addition, nonprofit schools are governed by different laws than public schools and thus have different legal elbow rooms than nonpublic nursing homes. In comparison, Swedish nonprofit schools can be established without municipal approval, but municipalities monitor them more extensively than they do in Norway and Denmark . For example, nonprofit schools are included in some municipal quality surveys. Moreover, nonpublic schools in Sweden are governed by the same laws as public schools, which provide less space and incentives to develop distinctive characteristics. The result is that there is less variation between schools in Sweden than in either Denmark or Norway . The other side of this point is that we find competition between schools to be stronger in Sweden than it is in Norway, with Denmark occupying an intermediate position. When distinctive characteristics of a school are not used as selection criteria, general perceptions of school quality determine which school families ultimately choose. The struggle to create quality perceptions invites competition and pits schools against each other. Therefore, Swedish interviewees reported that unhappy families often used competition between schools as a means of changing schools.

This study suggests that user choice is decisive for establishing distinctiveness in public, for-profit and nonprofit institutions . User choice is what enables the state and municipalities to let providers develop distinctive profiles from public options, since this implies that distinctiveness is not forced upon any user. This distinctiveness is an important factor in its own right, but allowing for institutional distinctiveness has two further implications for empowerment and participation . First, institutional arrangements that allow for diversity are also more flexible in how they are run. Institutions can use this flexibility to make changes based on input from users. The potential for obtaining real changes through arenas for empowerment at institutions is, therefore, greater since the room for change is larger. We see this effect in nonprofit schools, where their detachment from public hierarchy creates possibilities for the democratic involvement of parents to a larger degree than in the other institutions.

Second, users involved in nonpublic, and especially nonprofit, institutions have often obtained the service they preferred by selecting a provider that was distinct from the public provider. If they had been forced to remain with a provider within the public hierarchy, they would be more likely to use voice to seek changes from policymakers. The existence of a broad range of service providers therefore weakens the motive for using political channels to influence the content of services. Moreover, many of the arenas currently in place to inform local policymakers about the views and opinions of users exclude users of nonprofit schools. Local politicians are more concerned with nonpublic nursing homes , since the lack of user choice there makes it a political–administrative decision which citizens use against them.

Emphasis on governance tools must be balanced with an examination of the characteristics of the users. Of the three analytic dimensions, I found the greatest variation in active citizenship between the different service areas. Users of schools have more capacity for active citizenship than users of nursing home services. They are also more willing and able to exploit the existing capacity. Part of the explanation for this can be found in the nature of services and users. Parents are more inclined to involve themselves in school services than elderly users at nursing homes who typically are in poor health and do not always have relatives available to speak on their behalf.

Implications for the Scandinavian Model

A part of the Scandinavian welfare model is that municipalities have broad and comprehensive responsibilities for providing services to citizens. A reason for this is that assigning decision-making power to the municipal level is expected to yield services better tailored to the needs of citizens. When decisions are made at the local level, they are more compatible with the local context and local priorities (Kjølsrød 2005). Moreover, Norwegians find local democracy to be an important part of the democratic system, but they mainly regard municipalities as service providers, a belief that underscores the importance of this aspect of their functioning (Rose 2011). However, this study shows that nonpublic schools which are removed from the municipal decision-making sphere can better tailor their services to the interests of users. This demonstrates how detaching service providers from the municipal level gives them more room to manoeuvre and enables them to develop distinctive services and increased flexibility in order to heed signals from users. The challenge for the Scandinavian welfare model is whether this development challenges the demand for equality in services.

The term ‘welfare municipalities’ describes the trade-off between universalism and local decision-making capacities (Kröger 1997; Burau and Kröger 2004; Grønlie 2004). State oversight is normally seen as a limiting room for both local policymakers and street-level bureaucrats and thus creates uniform services across municipalities (Henriksen et al. 2012, 471, Tranvik and Selle 2005). Strong, autonomous municipalities supposedly undermine the universality of services as they create variations between municipalities. This study gives nuance to this finding since it demonstrates how the state can also obtain service differentiation by weakening municipal control—when nonpublic school approval takes place at the national level. When the state grants freedom to a nonpublic provider to develop the content of their services, it diminishes municipal power and increases diversity. In turn, universalism in the context of the content of services is also reduced.

At the same time, the nursing home case studies also show that there are no necessary advantages for active citizenship that automatically come from provider plurality. Rather, the potential for active citizenship is demonstrated under certain conditions. In the school sector, nonprofit providers stand out by giving increased autonomy to users both in the form of catering to niche preferences and enabling user influence in the operation of schools. In this way, nonprofit providers can be understood as the prime exponents of a core feature of what has been labelled the Scandinavian form of citizenship, which democratize[s] all aspects of society (Hernes 1988; Janoski 1998, 20). It might be a paradox that in a welfare model dominated by public providers, nonprofit providers arguably represent the most advanced example of one of its most successful tenets. This implies that a natural next step in developing Scandinavian welfare societies based on core citizenship values is to actively use the welfare mix to give influence to citizens and curb the power of public bureaucrats.

On the other hand, the democratising effect of nonprofit providers is dependent on the state yielding its responsibility and influence to smaller groups of citizens. It is an individual choice to opt for a nonpublic school, but collective efforts are necessary in order to obtain such alternatives. Fundamental to Scandinavian state individualism is that the state guarantees services to citizens and thus liberates them from smaller collectives in society (Trägårdh 1997). A future welfare society where providers are granted more liberty in the welfare mix may make services more dependent on initiatives of smaller collectives, and the individual’s integration into alternative structures such as families and religious groups may become more important, a possibility which could weaken a central and distinctive value of the Scandinavian welfare model .

Diversity in terms of providers and service content is beneficial for active citizenship , but it is important not to lose sight of those citizens who do not want or are unable to exercise active citizenship. Their interests are as important as the interests of the ones who continuously and actively seek to influence services for their own benefit. Some studies from Sweden have shown that user choice schemes in schools have led to increased differences between schools (Böhlmark and Holmlund 2012; Lindbom 2010). The goal of for-profits and their incentives—to prioritise profit over quality—has been identified as a threat to the equal and high quality of the welfare provision (Steinberg 2006). In earlier studies, Meagher and Szebehely (2013) found that due to tight regulation of services, Scandinavian elderly care has avoided many of the negative effects of marketisation that have occurred in the US. Tuning down the level of public regulation in order to enhance diversity between providers may accordingly have unwanted consequences for service quality involving aspects not included in this study.

In a study of Danish home care, Rostgaard (2006) found that the new ‘consumer citizens’ can have more influence over services, but that there are differences in the ability of users to exploit this opportunity. This is an issue we are not able to answer satisfactorilyin this study, and further research on this issue in Scandinavia is needed. Likewise, it is an independent value in the school system that children from different backgrounds with different values and interests meet in a public arena, which increases integration between different groups in society. This type of value must always be assessed against different dimensions of active citizenship .

One can envisage that the more individual constituents of active citizenship, such as user choice and individual empowerment, may sometimes conflict with equality values in Scandinavian welfare. The collective aspects of active citizenship , such as a user council and close contact between users and decision makers, are more easily compatible with an equity ideal. Moreover, the mentioned violations of human rights in Norwegian nursing homes affect some of the weakest users. This underlines that it is not sufficient with mechanisms for the individual advancement of one’s own interests. Collective arrangements are necessary for the whole range of users’ interests to receive attention. The private resources of individuals cannot decide the level of service for citizens.

In the nursing home sector, differences between public, for-profit and nonprofit providers are not large in terms of active citizenship. Here the differences are rather between municipalities and countries. This shows how important legislations, regulations and choices made by local policymakers can affect the capacity for active citizenship . The legal position of user boards at public schools gives influence to the users. Similarly, municipal guidelines concerning the role of user boards can secure user influence in relevant nursing homes . Active citizenship can be promoted by providing nonpublic, particularly nonprofit, providers a framework that will promote their user influence models; it can also be extended through government legislation and directives for the advancement of user influence at all institutions.

Finally, does it actually matter who performs services? Yes, but not if there are capacity problems, little real user choice and tight municipal governance . The state and municipalities decide who will perform public welfare tasks. If the public sector chooses, it can use nonpublic actors strategically to promote more and different values than what public institutions deliver. To get maximum benefit from the diversity that nonpublic institutions offer, one must ensure adequate capacity and it is thus beneficial to have a user choice system. Further, it is necessary to be conscious of the autonomy institutions should have. They should be given the opportunity to develop distinctiveness , but at the same time they should be required to establish venues for user influence. By using these tools, the public sector can use the welfare mix to promote active citizenship . However, it is necessary to balance measures to promote active citizenship against the effects they have for equality values in Scandinavian welfare. What this study demonstrates is the broad range of options that exist when designing welfare services and some of the mechanisms involved in determining the outcome of active citizenship . Governments can regulate shares of providers in the welfare mix and the activities of the providers in the welfare mix. The division of strictness and lenience on those two dimensions is decisive for active citizenship.