Balancing welfare and market logics: Procurement regulations for social and health services in four Nordic welfare states.

AIM: In increasingly market-oriented welfare regimes, public procurement is one of the most important instruments for influencing who produces which services. This article analyses recent procurement regulations in four Nordic countries from the point of view of addiction treatment. The implementation of public procurement in this field can be viewed as a domain struggle between the market logic and the welfare logic. By comparing the revision of the regulations after the 2014 EU directives in Denmark, Finland, Norway, and Sweden, we identify factors affecting the protection of a welfare logic in procurement. We discuss the possible effects of different procurement regulations for population welfare and health. DATA AND THEORETICAL PERSPECTIVE: The study is based on the recently revised procurement laws in the four countries, and adherent guidelines. The analysis is inspired by institutional logics, looking at patterns of practices, interests, actors, and procurement as rules for practices. RESULTS: Procurement regulations are today markedly different in the four countries. The protection of welfare and public health aspects in procurement - strongest in Norway - is not solely dependent on party political support. Existing service providers and established steering practices play a crucial role. CONCLUSION: In a situation where market steering has become an established practice and private providers are strongly present, it can be difficult to introduce strong requirements for protection of welfare and population health in procurement of social services.

The new suit of the Centre for Social Research on Alcohol and Drugs (SoRAD): A well-tailored costume for tackling research and challenges ahead.

This overview reviews the establishment and evolution of the Centre for Social Research on Alcohol and Drugs (SoRAD). It outlines its current organisation and updated research direction, and discusses SoRAD's future challenges and opportunities. SoRAD was established at Stockholm University to strengthen and support Swedish social science research on alcohol and drugs. It became active in 1999, and quickly grew in research efforts and reputation, while experiencing setbacks around 2006 and 2017. In 2018 SoRAD merged with the Centre for Health Equity Studies (CHESS), to form a new Department of Public Health Sciences. In its new suit, SoRAD acts as a research centre within the teaching department. The research activities on alcohol and other drugs and gambling behaviour and problems may be categorised into four main areas: social epidemiology; subcultures and social worlds of use and heavy use; policy formation, implementation and societal responses; and societal and other collective definitions of problems and solutions. The new arrangements, with an increased staff pool and close interplay with higher education, provide a more stable and long-term platform for achieving the main mission of promoting and developing social science research on addictive substances and behaviours and related problems.

Why Research Should Pay Attention to Effects of Marketization of Addiction Treatment Systems.

OBJECTIVE: Researchers generally assume that addiction treatment systems can be viewed as entities and planned with the citizens' best interests in mind. We argue that another steering principle, the market logic, has permeated many Western World treatment systems but is neglected in research. We demonstrate how it may affect system-level planning, service provision, and the service users. METHOD: We draw on an ongoing Swedish study, with some Nordic references, using several data sources: (1) public statistics on treatment expenditures and purchases; (2) interviews with service users (n = 36) and their service providers (n = 23) on different market features; (3) an observation of a large public procurement process concluding framework agreements based on competitive tendering; (4) interviews with officials involved with steering of the system and procurement (n = 16); (5) a workshop on procurement in the Nordic countries (n = 11 participants); and (6) 77 interviews with professionals, managers, and elected representatives. RESULTS: We outline seven propositions that call for further research attention: public procurement, as regulated in the European Union, is not suitable for addiction treatment; marketization challenges democracy, equity, needs assessment, and treatment planning; marketization causes new accountability problems and idle monitoring; marketization causes fragmentation and obstructs coordination and continuity of care; marketization causes unification of services and favors big bureaucratically sophisticated providers; treatment professionals' values are downplayed when a mistrust-based market logic replaces a trust- and needs-based logic; and marketization marginalizes treatment professionals and service users by limiting discretion. CONCLUSIONS: Findings point toward the importance of acknowledging and mitigating market principles in treatment systems to safeguard needs assessments and planning that serve the interests of the service users and the public.

Implications of Eligibility Criteria on the Generalizability of Alcohol and Drug Treatment Outcome Research: A Study of Real-World Treatment Seekers in Sweden and in Australia.

BACKGROUND: Clinical studies of alcohol and drug treatment outcomes frequently apply participant eligibility criteria (EC), which may exclude real-world treatment seekers, impairing the representativeness of studied samples. Some research exists on the impact of EC on alcohol treatment seekers. Little is known about drug treatment and country differences. OBJECTIVES: We tested and compared the degree to which commonly used EC exclude real-world treatment seekers with problem alcohol and drug use in Sweden and Australia, and compared the impact of EC on outcomes. METHODS: Two large naturalistic and comparative service user samples were used. Respondents were recruited in Stockholm County (n = 1,865; data collection 2000-2002), and Victoria and Western Australia (n = 796; in 2012-2013). Follow-up interviews were conducted after 1 year. Cross-tabulations, Chi-square (χ2) tests and logistic regressions were used. RESULTS: Percentages of the samples excluded by individual EC ranged from 5% (lack of education/literacy) to 70% (social instability) among Swedish alcohol cases and from 2% (low alcohol problem severity) to 69% (psychiatric medication) among Australian counterparts; and from 2% (age 60+ years) to 82% (social instability) among Swedish drug cases and from 1% (age 60+ years) to 67% (psychiatric medication) among Australian counterparts. Country differences and differences across substances appeared independent of country effect. Co-morbid psychiatric medication, noncompliance, poly drug use, and low education EC caused positive 1-year outcome bias; whereas female sex and old age introduced negative outcome bias. Conclusions/Importance: Commonly used EC exclude large proportions of treatment seekers. This may impair generalizability of clinical research, and the effects of many EC differ by country and drug type.

Implications of enrolment eligibility criteria in alcohol treatment outcome research: generalisability and potential bias in 1- and 6-year outcomes.

INTRODUCTION AND AIMS: It has been acknowledged that participants in clinical trials differ from real-world service users, primarily due to the extensive use of research eligibility criteria (EC). Generalisability and outcome bias become pressing issues when evidence-based treatment guidelines, crystallised from outcome research, influence treatment provision. This study reports on the effects of EC on generalisability and short- and long-term outcomes among real-world treatment-seekers. DESIGN AND METHODS: Ten of the most commonly used EC were operationalised and applied to a large representative service user sample (n = 1125) from Stockholm County, Sweden, to determine the percentage of real-world problem alcohol users that would have been excluded by each EC and the extent to which EC bias the 1 and 6-year alcohol outcomes. RESULTS: Individual EC excluded between 5% and 80% of real-world service users and 96% would have been excluded by at least one EC. Most of the EC introduced a positive/upwards bias in 1- and 6-year outcomes. Most notably, the removal of the unmotivated/non-compliant service users caused an upwards bias that would considerably boost estimates of treatment effectiveness. Other bias effects were smaller. Six-year effects were generally higher than for 1 year. DISCUSSION AND CONCLUSIONS: Outcome studies that exclude complex and non-compliant cases are not representative of real-world service users, and thus effectiveness estimates from clinical trials are biased by several commonly used EC. EC should be used judiciously and be taken into account in practice guidelines. This burgeoning research area should be further developed. [Storbjörk J. Implications of enrolment eligibility criteria in alcohol treatment outcome research: Generalisability and potential bias in 1- and 6-year outcomes. Drug Alcohol Rev 2014;33:604-11].

The association between self-reported mental health status and alcohol and drug abstinence 5 years post-assessment for an addiction disorder in U.S. and Swedish samples.

This study compared whether self-reported mental health status was associated with likelihood of being abstinent from alcohol and drugs five years after baseline assessment for an addiction disorder in two representative samples; one from Sweden (n = 469) and one from the US (n = 667). Self-reported mental health status was measured through the ASI score of mental health symptoms and history of inpatient and/or outpatient treatment. Through logistic regression modeling the study controlled for demographic characteristics including age, gender, employment status and social network connection with individuals who do not use alcohol/drugs. For both the US and Swedish samples employment status and having a social network that does not use alcohol and drugs were associated with being likely to be abstinent from alcohol and drugs five years after initial assessment. For the US sample only, individuals who reported symptoms of anxiety were 50% more likely not to be abstinent from alcohol and drugs at follow-up. For the Swedish sample, current mental health status was not significantly associated with abstinence. However, reporting a lifetime history of inpatient psychiatric treatment at the baseline assessment was significantly associated with not being abstinent at 5 years post assessment; those with a lifetime history of inpatient mental health treatment were 47% less likely to report abstinence. While specific variables differ across Sweden and the US, psychiatric comorbid status, employment and social network are each associated with drug and alcohol abstinence cross-nationally.