Legal Conditions for Refugees’ Mental Health: Implications of Legislative Changes in Programs for Newly Arrived Refugees in Sweden

Abstract

As the number of refugees in the world is increasing and it is known that social inequality negatively impacts mental health, it is important to study integration policies, such as labour market measures. In this article, the strategic interventions of the Swedish Public Employment Service are analysed to determine how the agency’s management handled and implemented the legal changes in the new support document for its case workers. The focus is on the effects of the changes in the legal text that transferred the responsibility for establishment initiatives for newly arrived migrants to the agency and, as a result, changed the conditions for newly arrived refugees’ mental health in the new establishment programme. Eight people representing different management functions at the agency were interviewed. The results show that the intention in the new programme to view newly arrived refugees in the same way as all other unemployed people, rather than as a special category, has meant that less attention is paid to the refugees’ mental health, and the opportunities for the agency’s street-level bureaucrats to help clients have decreased. In the face of predicted growing numbers of people having to abandon their homes due to conflicts and climate changes, governmental strategies such as these needs to be revisited in order for societies worldwide to be better prepared for that challenge.

1. Introduction

According to the World Health Organisation (WHO), risk factors for mental health problems largely stem from social inequality [1]. Refugees are a particularly vulnerable sub-group in this regard, and therefore it is pivotal to evaluate integration policies with regard to refugees’ mental health [2,3,4,5]. With 103 million people forcibly displaced, and 1.5 million children born to refugees between 2018 and 2021 alone, it is undoubtably one of the major challenges of our time [6]. Migration movements are driven by multiple factors and involve global political processes [7], although they also drive political changes and call for adaptations and the scrutiny of laws and regulations. It is therefore essential to study policies relating to migration and integration, such as labour market measures.

This article revolves around how the central management of the Swedish Public Employment Service dealt with the change when their mandate from the government was altered and their responsibilities were extended in 2018. The Act that was part of a governmental policy package announced in 2015 and valid up to 19 July 2021 and meant fewer grounds for protection, the granting of temporary residence permits as a general rule rather than permanent ones, limited opportunities for family reunification and stricter maintenance requirements for family reunification [8,9,10]. The temporary Act generally implies a sharpening of policies, especially those regarding border controls, legal entry and stay. Despite this, the ambitions of the integration policies are still high, even though they are strongly focused on the labour market and finding employment, as previously indicated.

When studying the mental health of refugees and asylum seekers, it is important to consider the legal texts and the support documents that interpret them to see how and whether they affect the ways in which bureaucrats can help to strengthen and support integration processes and if they make it difficult for refugees to access the benefits they are entitled to. This article discusses the relation between integration policies, social participation and mental health and explores how the relations between them are articulated by the people involved in the writing of the administrator support document that is used by case workers at the Swedish Public Employment Service. What this support document is and what it is supposed to do are discussed in full in the results section. To summarise, the document can be seen as a way of communicating between the different parts of the organisation, first and foremost between the management and the case officers to try to ensure the equal treatment of all job seekers at one of the largest government agencies in Sweden.

This article is the second of four interlinked studies. The first article—an analysis of the administrator support document—shows that changes in the legal text, and hence the support document, mean that less attention is given to the mental health and social participation of refugees in the new establishment programme [11]. The research project as a whole aims to understand how the amendment of the laws regulating residence permits and the conditions for social participation affect the mental health of newly arrived refugees (Act 2017: 584 replacing Act 2010: 197 and resulting in Ordinance 2017: 820) [12,13,14]. The new Act implied an extended mandate of the Swedish Public Employment Service motivated by a politically articulated need for accelerated efforts around labour market integration. Correspondingly, they have also changed the integrational efforts of the government to a more limited focus on integration as entry into the labour market, which is often alleged to be a sign of accomplished establishment in a new country [15]. Newly arrived refugees are usually covered by the Establishment Initiatives Act for a period of two years, which entitles them to professional support for learning Swedish, finding employment and managing their own livelihoods [8].

Newly arrived refugees, as well as other groups such as asylum seekers, have been pointed out as an especially vulnerable category, both in terms of health and social conditions [16,17]. Social capital and the requirement of a network (not least of potential employers) have always been regarded as factors related to finding employment, and there are indications this might be especially important in Sweden [18]. The understanding of social participation in this article derives from a model of different aspects of the concept resulting from a scoping review undertaken within the same research platform as the current study. This was an attempt to define “the concept of social participation as: access to, and active involvement in key social dimensions within the host societies, including not only the host society’s formal and established organizations and institutions, but also in social settings constructed on the basis of refugee communities’ own shared characteristics, preferences, and needs” [19].

Research on refugee health mainly concerns mental health and is often focused on the effects of flight and forced migration [20,21,22,23]. In comparison, efforts to understand factors affecting mental health and the socioeconomic integration of refugees in the host country are less prominent in the research literature [19]. Regarding employment, research in Sweden has shown that when refugee trauma results in mental illness it affects cognitive functions, thereby making it harder to learn the language and retain employment [24]. Newly arrived refugees can experience social exclusion due to not being able to speak the host society’s language, not having a job, or by experiencing discrimination and a lack of access to important social resources, which in turn implies an increased risk of mental ill health and distress [24,25]. However, in the Swedish context, there are also studies, albeit on unaccompanied minors, showing how schools are important arenas for young refugees’ development of resilience [26].

Many refugees experience abuse and ill treatment during their journey to a safe haven [27]. Building trust between societal organisations and refugees is therefore important, especially for health institutions [28,29] and is something that becomes apparent in the health-seeking behaviour of the group [30]. Mistrust of the host society is a common feature amongst refugees, whereas trust in God and religious beliefs often help them to become active survivors rather than passive victims [31]. Apart from that, international research from diverging settings such as refugee camps in Jordan and general society in Canada has shown that participation in social networks and activities reduces mental illness among refugees [32,33]. Further, social participation in communities consisting of individuals with the same ethnic background (in the host society and/or in transnational networks) and intergroup activities with groups of migrants have been found to improve mental health, as well as integration into the society and labour market of the host country [34,35,36,37,38,39,40].

In this article, health is not only considered as the absence of disease, but also as a relationship between the individual and society. As the lack of social participation has been shown to contribute to ill health and psychosocial stress due to social isolation and exclusion [41], it is vital to look at the role of societal arenas where social participation is seen to enhance resilience, re-establish social lives and act as a protective factor against poor mental health outcomes [19]. One such dimension is government funded introduction programmes, which when aptly designed have proved crucial for refugees in their introduction to the labour market in Canada, Italy and the Netherlands [42,43]. Reception programmes are also gateways to societal systems, especially language courses [36], and create benefits for refugees in the labour market in the long term [44].

This study departs from the idea that the temporary law and the changes it brings will affect the social participation and mental health of refugees and asylum seekers. Here, we analyse the strategic interventions of a central actor in the Swedish labour market—the Swedish Public Employment Service—to determine how the agency’s management handled and implemented these legal changes. In conclusion, the implications of this study in a global context will be discussed.

2. Materials and Methods

In order to study the organisational aspects of the daily work of an authority such as the central management at the Swedish Public Employment Service, in this sub-project, interviews with those involved are conducted (a posteriori). The focus is on the deliberations and considerations regarding the social participation and mental health of the newly arrived refugees in the process of reforming the agency’s work. The project takes account of the insights gained from previous research that refugees and asylum seekers are vulnerable groups when it comes to social participation and mental health. For example, they have been shown to be more prone to depression, anxiety and/or post-traumatic stress disorders than age-matched general populations in those countries [16,17]. Further, the research group’s own previous studies of the support document show that the new support document pays less attention to mental health and social participation than the previous one, which indicates that a study of the work process is motivated [11].

2.1. Institutional Ethnography

Methodologically an approach called Institutional ethnography is applied. It departs from the ontological standpoint that people’s actions are coordinated in some way, even with those we have never met. This can be recognised as part of a symbolic interactionist universe and other similar theoretical approaches. Following Canadian sociologist Dorothy E. Smith, it is a design aimed at investigating ruling relations, i.e., understanding the varying relations within the institution and how they shape local experiences. Ruling relations are “translocal social relations that carry and accomplish coordination and control” [45]. From this point of view, bureaucracy and administration are sets of powerful relations in the practices of rule, or government/management.

Therefore, it is important to outline the process of creating a new support document at the agency, per se. In describing the process, we became aware of the deliberations and discussions within the agency and the extent to which the mental health and social participation of refugees and the newly arrived had been considered. The themes in the interviews were very open and related to their functions and roles in writing the support document. The descriptive answers that resulted gave us information about the organisation itself and the logic on which it was built (and is constantly being rebuilt).

2.2. Participants and the Selection Process

The interviewees were chosen with the aid of a head of section at the Swedish Public Employment Service who was currently in charge of a division with responsibility for upgrading the support document. As reorganisation and staff turnover are parts of the regular life of an organisation, we experienced difficulties in finding people who had worked closely with the support document. It was also hard to determine which people should be interviewed, in that some of the referral bodies seemed to have done very little, while others appeared to have had more important roles. Therefore, the help and input of the division manager and the other people who were interviewed were critical for identifying who to interview and finding those who were in post now or earlier. A snowball sample technique was therefore used. The interviewees were contacted by the researchers as this study progressed and until it was felt that saturation in the data had been reached. This should not be understood as an ad hoc process but as the result of a sensitivity to the studied field and a growing understanding of which functions and people needed to be interviewed to get the most adequate and rich material with regard to the research object.

Eight people representing the different functions in the Swedish Public Employment Service were interviewed: a division manager, four qualified desk officers working with the establishment assignment, rehabilitation and operational development, a coordinator for occupationally disabled persons, a project and sub-project manager and an analytic inquiry officer. They were chosen due to their involvement in writing the support document. Further details have been withheld for ethical reasons, although this information at least gives the reader an understanding of the chosen functions and positions.

Due to the COVID-19 pandemic, the interviews took place online via Zoom in groups. Focus group interviews turned out to be a good choice, given that some time had elapsed since the project was carried out. This meant that the interviewees were able to remind each other about the discussions that had taken place and which units had been involved [46,47]. Some of the participants were interviewed more than once. As they had provided us with new names of interviewees, which widened the scope of knowledge, they therefore saw the need to participate again in the interviews. The five different focus group interviews with people at management level turned out to have slightly differing content, although the same open interview guide was used. For example, asking about the process in general generated different views depending on the interviewees’ roles and areas of responsibility. The analysis actually started during the interviews, since a common categorisation and understanding was forged in the conversations [48].

From the beginning the intention was to also interview politicians and managers at both the Ministry of Employment and the Swedish Public Employment Service. However, as it was difficult to track the people who had worked on the legal text at the ministry, the decision was taken to focus solely on the project group at the Swedish Public Employment Service, which we assessed as being able to give a comprehensive and detailed enough account of the project.

The project was reviewed and approved by the Swedish Ethical Review Authority and informed written consent was obtained from all the participants involved in this study.

2.3. Analysis of the Interviews

The analysis of the transcribed interviews was carried out by finding recurring patterns in the way the participants talked about the project [48]. Themes emerged, which in turn were linked to the objects of study. Connections were established in the group interviews and were carefully considered when reading through the transcripts. The themes that emerged are presented below, in the results section. By mapping the ruling relations and asking the participants to expand on certain aspects that emerged during the interviews, the research team gained knowledge about the considerations of mental health and social participation that were taken.

Choosing the support document and its implementation for analysis is motivated by the aim to see the end effects of the changes in the legislation for the street-level bureaucrats and, by extension, the refugees. An interlinked and simultaneous process of introducing a new working method also became central in the interviews and therefore also in the thematic results presented here. Although not a direct effect of the changed legislation, the simultaneity makes it difficult to discuss the one without mentioning the other. This article, which is based on the second study, is at an intermediate level before reaching the case managers in study three. At this intermediate level, we can discern the intentions of the management and analyse their views of the process and how they identified the needs of the street-level bureaucrats and their clients. To study the relations between integration policies, social participation and mental health that were articulated by the people involved in the writing of the administrator support document used by case workers at the Swedish Public Employment Service, we used institutional ethnography as a method.

The data are organised and analysed in three thematic sections, following the methodological implications of institutional ethnography, which connotes a mapping of the ruling relations at the agency. Already in the early interviews with the management it became clear that the process was somewhat complex. Hence, the first theme deals with the process itself and outlines the work from the perspective of the interviewees and how they understood the nature of the document. It also addresses the difficulties in understanding the process. In the second theme, the work at the agency is analysed with regard to everyday situations, such as staff changes and staffing issues. In this section, the work procedure and the organisation are outlined, since a new working method was introduced shortly before the different and simultaneous processes were talked about by the participants as being interlinked. Lastly, in the third theme, the focus is on how the interviewees thought that mental health and social participation were considered in the process. Our first study—the document analysis of the support document—showed that the new support document offered fewer opportunities for the street-level bureaucrats (i.e., the case workers) to provide for the clients in these aspects. This new study therefore addresses and comments on those findings by giving the management an opportunity to explain their intentions.

3. Results

If we go back some 20 years to the early 2000s, approximately 30,000 people applied for asylum in Sweden each year. These figures started to increase in the early 2010s. By 2015, the number of asylum seekers had risen to over 160,000, the highest ever, mainly as a result of people fleeing from the war in Syria. As indicated above, since 2015, the possibility of entering Sweden has been reduced due to political decisions, which is one of the factors that has led to a reduction in the number of asylum seekers. In 2019, some 22,000 people sought asylum in Sweden. However, due to restrictions following the COVID-19 pandemic, the number dropped to 11,000 in 2021 [49]. At the time of writing, some 55,000 people escaping from the war in Ukraine have applied for temporary protection according to the Mass Refugee Directive, which was activated by the EU on 4 March 2022 and means that all refugees from Ukraine are entitled to immediate temporary residence and work permits in the member states [50]. This means that the authorities have had a lot of cases to deal with during the last years and that the new legal text was implemented at a time when the case officers were working hard to keep pace.

3.1. Implementing a New Law—The Process Outlined

The project at the Swedish Public Employment Service of formulating a new support document to match the changes in the legal text meant doing in six months what the agency normally handled over a period of two years. In other words, it was done under severe time pressure. A clear sign of that was that the document was produced simultaneously with the actual legal text, which is normally formulated beforehand. Further, according to one of the interviewees, it also meant that at the end of the process more than 80,000 individuals had to understand that they were now part of a new legislation involving almost every registered job seeker and employment officer.

What is a support document? In one sense, it is a communication within the organisation to secure certain ways of understanding and interpreting legislation and regulations in order to work as consistently as possible with cases in a nationwide context. This is a way of ensuring that every unemployed job seeker is treated equally. One of the interviewees described the intention as follows.

Actually, the support document is the agency’s way of getting laws, ordinances, regulations, systems and everything that the case workers have to take into account … I mean, help them to carry out their tasks properly.

(Interview, 24 March 2021)

In other words, the support document simplified the case workers’ everyday work. The interviewees continued by explaining that case officers cannot be expected to know every detail of the law and the possible changes in it. This meant that in the life span of a support document several new versions were published as and when necessary. Several versions were often published in the same year and minor changes seemed to occur more often.

Organisations could be seen as consisting of social contacts, where communication in different forms is an important factor [51]. In the interviews, we tried to map what the process of writing a support document included and which functions were involved at the management level and how it was communicated within the management. However, as mentioned in the method section, it was difficult to reconstruct the process in a concrete way three-four years after the support document had been written and processed, although at a very general level it was easy. When the agency received the assignment from the department a project group was created involving different divisions, each with their distinct liability and advisory functions. Nevertheless, as the agency was frequently rearranged (the most recent reorganisation was being completed at the time of our interviews at the main office) and officials came and went, many of the people in those posts were no longer employed at the agency when we started our research.

The organisation around the different projects also made it difficult to understand how they had been executed. One interviewee explained it as follows:

So that’s why we had four sub-projects because … We were working on the establishment, the compensations, implementation [of the support document] and IT. I was in charge of the establishment sub-project and managed around 20 employees and we had sub-groups beneath us. My colleague was responsible for the support document and those who went in and out of that. But, based on what we and the legal department deemed necessary competences, we picked a group of people to work on the different paragraphs and so on.

(Interview, 8 June 2021)

The project at the Swedish Public Employment Service was instigated in 2017 when the former establishment plan—a legislation of rights—was to be superseded by the new establishment programme cf. [11]. Besides that, a new regulation for economic compensation for newly arrived refugees took effect. Therefore, the focus was mainly on changing how the introduction benefits were handled; something that according to the case workers involved too much effort and left little time for their core areas of work [52]. In the establishment programme, the pecuniary benefits were instead to be handled by the Swedish Social Insurance Agency. Hence, among other things, the new establishment programme meant that the case workers were no longer responsible for assessing the applicants’ capacity for work as they had done earlier under the establishment plan. This meant that it was no longer mandatory for the case managers to ask questions about a job seeker’s health.

Another aspect of this process was that the decree was delayed, which meant that the formulation of the support document had to start before the wording of the Acts that were to be used existed. Thus, contacts with the Ministry of Employment were especially important for those responsible. Weekly reconciliations with the ministry were required in order to understand the intentions of “the politics” in this project, which at the time had the highest priority at the Swedish Public Employment Service.

In other words, the process involved continuous dialogue with the ministry and the government regarding the intentions of the new legislation. This precarious situation shed light on the division of labour between the ministry and the agency. As one of the interviewees stated:

We have the preferential right of interpretation. I mean, the government or ministries should not intervene and are quite careful about that. But of course, we have dialogues about the aim, the intention and what is possible.

(Interview, 8 June 2021)

In this description, the agency is portrayed as having a considerable degree of freedom to interpret what the legal text meant for its activities. The ministry is careful not to interfere, because that would amount to unconstitutional ministerial rule. However, as the legal text was not yet in place, the process was more dialogical and involved closer interactions than would normally be the case. The interviewees described the process as fairly smooth. The largest stumbling block between the Ministry of Employment and the agency seemed to be the introduction of training/education and how realistic it would be to find training positions for all the unemployed registered in the programme. As far as can be ascertained, the critique did not concern the intention itself. Rather, the agency questioned the viability and practicability of the suggested method.

In sum, the interviewees meant that the establishment programme was significant, in that it not only signalled that the category of newly arrived required special attention, but also that certain actions were possible. Only two other programmes were available besides the establishment programme: the Job and Development Programme for long-term registered unemployed and the Youth Job Guarantee for those aged 20–24. This stands in contrast to viewing refugees and asylum seekers as any other category of job seekers. The division with the main responsibility for producing the support document was the Department of Integration and Establishment. Other divisions were used for referral purposes. The Department of Integration and Establishment no longer exists at the Swedish Public Employment Service, which could be a consequence of the programme’s intention to view the newly arrived in the same way as all the other unemployed, rather than as a special category.

3.2. Equal Treatment and Working Methods

Interpretations underpinning the articulations and formulations in the support document are made by different divisions at the management level. As each division provides its own specific expertise, it can be viewed as the agency taking an official stand in given matters. Therefore, a support document aims to ensure that the laws and regulations are interpreted equally throughout the agency, which of course is a matter of managing cases in a just and impartial way. As an expression of that, the Swedish Public Employment Service also started to work with what it termed “systematised working methods”, with the intention of ensuring that every job seeker who wanted to participate in a certain activity would have the opportunity to do so. Another part of the systematised work procedure is the questionnaire on health issues, which we will return to later in this article.

In a report produced in cooperation with the Social Insurance Agency in 2016, the Swedish Public Employment Service identified and pointed to the need to develop strategies, competences and methods for working with health issues in a better and more systematic way with the newly arrived as a specific category [53]. Those insights and intentions preceded the work with the new legislation and formulation of the new support document and were therefore important for how the support document was formulated. This was described by one of the interviewees in the following way:

During, well, I don’t remember exactly when, but a new working method was introduced called a sytematised working method within the establishment [project] but … It was introduced in 2016 already or something like that. […] Right, to ensure that people get the opportunity to parttake in adequate activities, and that it is something like on-the-job training which is offered but also the need for supplement with other activities. So, this working method was also brought into the establishment programme.

(Interview, 24 March 2021)

The systematic working method was important with regard to health issues, because it was in that context that a specific set of questions was introduced and used. This is discussed further in the next section.

As indicated earlier, the rhythm of change in terms of organisation and staffing appeared to be rapid at the agency. This resulted in comments from the interviewees that someone else may be better acquainted with the project and be able to give more adequate answers to our questions, even though the questions were open. Either they claimed not to have been involved in the detail or they had entered the project later on. In other words, the level of compartmentalisation was significant in the sense that each division brought its special expertise to the table yet viewed the project in different timelines. It could be said that the agency suffered from a partial loss of memory, since the everyday life in the main office was described as reacting to changes in the organisation.

A common way of organising public authorities and municipalities in Sweden is to create functional line organisations and sub-organisations with specific tasks as part of the modernisation (New Public Management) that has been ongoing since the beginning of the 1980s and has reduced the organisational differences between the public and private sectors [54]. This kind of organisation is commonly referred to as a drainpipe organisation, because each branch has separate (waterproof) conductors which could pose a challenge to communication and interaction between the different parts of the agency [55]. Additionally, the decentralisation of accountabilities increases the demand for a well-functioning communication between the different parts.

In sum, from an organisational perspective, it became apparent that departments changed and disappeared over relatively short time spans, as did some of the staff, and that new departments and organisations were formed. A systematised working method and the support document therefore provided some kind of stability in such an environment, and continuous revisions kept them up to date. However, it was quite difficult to reconstruct the process in retrospect four years after it had begun, and meant that the support document took on a life of its own at the same time as the department responsible for producing it was dissolved. In the next section, we look at what happened to the support document when it was used and interpreted by the case officers.

3.3. The Handling of Health Issues

One of the divisions involved in producing the new support document for case officers was the Department of Rehabilitation, which was the most central to this study in that it had expertise on health issues, although in this project it only had an advisory function. Its task was to identify and transform the necessary precepts from the old plan to the new programme, such as adapting activities for the traumatised so that they could participate in activities like everyone else, or assessing their capacity for work. A team from the Department of Rehabilitation consisting of public health scientists, occupational therapists and psychologists was formed, which in reality functioned more as a sounding board than anything else.

In the participants’ discussions with each other during the interviews, it became apparent that one central way in which the agency operated was in creating adequate concepts. The concepts were sometimes tied to the legislation, which determined which categorisations the agency should use. However, some of the concepts were subject to debate and interpretation. When the support document for the new programme was being written, efforts were made to harmonise it with similar documents for the other programmes. This was also an opportunity to review what had been decided before. One concept that came under review was that of “performance capacity”. One of the interviewees explained:

Yes, it was a completely new concept that had somehow been made up in the old rules that everyone found very difficult to understand and interpret, both at the Swedish Public Employment Service and in the health care services. It was abandoned because it caused some trouble.

(Interview, 22 June 2021)

The problem that the concept had once solved was that the organisation needed to be able to assess people’s capacities to take part in the different activities that were offered, which was not the same as the working capacity that was assessed by medical doctors. For example, it might be possible to go to a language class one night a week but not be able to work.

In order to assess performance capacity in the now abandoned establishment plan, the case officers had been equipped with a battery of queries about health. The aim of these queries was to establish whether or not the applicants had any health issues that would affect their potential participation, such as being hard of hearing. As the concept performance capacity was deemed inadequate, it was not included in the new support document and the new practice of the case managers. However, the battery of queries remained as a supplement to the new support document as optional inquiries that the case managers could ask as and when appropriate.

The group was also tasked with reviewing “other activities”, since there is a sense that the agency needed to tighten its directives. This was a category of activities that had been used for those who had been assessed as having a reduced working and/or performance capacity. One of the interviewees called these other activities “social activities”, in that one of the aims was establishment in society, and there was also a hope that connections would be made between the civil society and the newly arrived. According to the interviewees, the hope was that the newly arrived would discover how Swedish society worked; something that would be particularly important for someone with health issues or disabilities.

Other activities were used for those who were unable to take part in the regular activities and were typically something that the job seeker would do by themselves. A suggested change was to offer other activities as a complement to the regular activities, and not on their own as stated in the establishment plan so as to tighten the grip on them somewhat. As one of the interviewees stated, while the intention had been good, there was a feeling that it had occasionally been misused. In line with that, an added requirement was that there needed to be a provider for the activity, meaning that it could no longer be something that the job seekers did by themselves.

Although the query battery on health was removed from the support document and instead became a non-compulsory auxiliary, it was stated that the task of a case manager was to detect whether job seekers had (mental) health issues that affected their ability to work, regardless of whether they were newly arrived or not. The results of the study of the case managers, presented in the 3rd article [56], problematise this and show that for some of the case managers health issues were downplayed in the new establishment programme. However, what was preserved from the previous plan was ensuring that the possibilities for health-promoting activities or being able to take part in an activity despite not having 100% capacity for work were retained.

Some members of the group had also educated the case workers in how to use and administer the other activities. One of the interviewees stated that mental health was a significant part of that material. When we asked the former educators about what they would want a case worker to do when meeting clients, their answers displayed the complexity of the issue.

Well, it’s a difficult question when you put it like that, because it depends a bit on what the case workers themselves feel that they are competent in. Do they have the competence to reconnect with the job seeker themselves to get in touch with the medical services for their ailments, or do they need the assistance of a professional, such as an occupational therapist? These are the two options.

(Interview, 22 June 2021)

It is clear from the above that individual differences between case workers can lead to different outcomes for the job seeker depending on who they meet, whether they have to deal with things themselves or are expected to contact an occupational therapist. The ideal of a systematic way of working with health aspects could thus be hampered by the differences in the case workers’ competences.

In sum, the people in the advisory group on health issues felt that their work was successful in the sense that health aspects became part of the Act. One of the interviewees thought that it was the wording about coordination responsibilities that enabled the Swedish Public Employment Service to include health aspects, i.e., the phrase in the legal text alluding to the agency’s responsibility for “social life” and not just the labour market. As one of the interviewees put it (interview 8 June 2021), writing a support document was a balancing act between managing the detail, individual responsibilities and “demanding, pushing, supporting and caring for”. According to an interviewee, the lack of specific requirements and checklists in the support document was a result of trusting the case managers to be professional in their practices. Support documents do not have that degree of detail, in general, it was stated.

4. Discussion

To investigate the effects of the changes in legislation, the choice was made to study how they affected the work of the case managers and how the management and case officers saw their effect on the situation of the newly arrived refugees. This study therefore departs from a street-level bureaucrat perspective, as introduced by Michael Lipsky [57]. A street-level bureaucrat is someone who interacts directly with citizens in their everyday practices and has the power to make assessments and decisions that structure and delimit citizens’ lives. Case managers at the Swedish Public Employment Service have been taken as examples of street-level bureaucrats because they have the authority to open and close doors to the labour market when making decisions about what appears to be fitting work for a job seeker [58].

The articulations and interpretations of the laws by street-level bureaucrats in an everyday document that guides the work of the employment officers offer an opportunity to study how aspects of social participation and mental health are present in the discussions at management level. When formulating the support document, the deliberations and decisions that are made display how the law is interpreted and indicate which considerations are viewed as important by the management. Interviewing the responsible managers thus facilitates an analysis of the arguments that supported these specific articulations and how less attention is given to the mental health and social participation of refugees in the new establishment programme, which was also a result presented in the first article [11]. In other words, although refugees’ mental health and the interrelation with social participation is the motivation for this study, in this article, the focus is on the logics, as presented by functions at the management, of the legal framework and official documents that can foster or hinder social participation and affect the everyday life and possibilities of refugees.

The task of a street-level bureaucrat is to implement the policies of the organisation, which means that they have to resolve contradictions in laws, policies and rules [59], a process in which they can have more or less freedom for decision making [60]. The purpose of policies in bureaucracy is generally to ensure equal treatment and that every case manager follows the same protocol for different cases, hence the need for a support document. However, following strict policies and regulations to the letter is not always considered as the most equitable way of treating clients. From the point of view of the street-level bureaucrat, a fair and equal treatment might instead be dependent on flexibility and finding special solutions for special circumstances [61]. In other words, the everyday task of the case managers is to find a balance between (a) implementing policies and (b) pragmatically solving the cases in the best possible way for those citizens in most need of society’s support [62]. For this reason, the role of the street-level bureaucrat is often politically controversial [57]. The support document is produced to help the case managers resolve these kinds of conflicts between laws and policies and enable them to interpret legal texts and current regulations in a legally secure way.

The new law can be understood in relation to what de Haas, Castles and Miller have discussed concerning restrictive migration policies, namely that they seldom present a complete shutdown, but rather a selection of who can enter the country [7]. This selection implies that particular groups are welcomed and considered valuable. A similar question concerning universalism or particularism emerges in this study, which is difficult for agencies and researchers alike to address. One of the overarching results of this study is the intention in the new programme to view newly arrived refugees in the same way as all other unemployed people, rather than as a special category. The question is theoretical and general, what the effects of viewing refugees like any other person seeking a job and what the effects of seeing refugees as a sub-group with particular needs are, but it needs to be asked. Further, the restrictive policy and reduced number of grounds for protection may well go hand in hand with the continued ambitions for integration, which in regard to this legal text was interpreted by the department as quite synonymous with finding a job. The logic stating that if the applicants are not viewed as refugees but are classed as any job seeker, they may have a better chance of finding employment in Sweden. As it turns out then, certain groups of migrants (refugees and asylum seekers for example) are singled out to be restricted, but those who have entered the country and received a temporary residence permit are to be treated as anyone else with no special needs (in regard to the labour market and finding a job). It would be interesting to follow up how this plays out in the wake of the new, large influx of refugees from Ukraine and see differences in the conditions in regard to the Syrian refugees, for example.

Another central result concerns the decentralisation of accountability that was observed, which increases the demand for well-functioning communications between different parts of the organisation. As for many government agencies in Sweden, an ever-changing organisation poses a special challenge. The introduction of a systematised working method that includes health issues is a way of meeting those challenges. Following up on the important task of reviewing the design and implementation of government funded introduction programmes will be further addressed in a forthcoming article [56].

Regarding mental health, it is fair to say that this aspect permeates all the documents relating to health but is seldom specified when it comes to what is implied. The specialists that we interviewed seemed to have been very involved in health issues and discussions that appeared to be ongoing at the management level. Despite this, and as shown in a previous article [11], traces of these discussions and concerns in the document itself are few and far between. What we have rather seen is that individual discrepancies have been created, in that it now depends on which competences the case workers themselves feel that they have, access to specialists that they can refer applicants to and their own time and engagement in health aspects.

The results in this study can be related to discussions about introduction programmes for refugees and asylum seekers in a wider European context. The stricter focus on the labour market, employability, outsourcing to organisations within the civil society and information about Swedish society in the establishment programme is potentially problematic. In the 4th article of this project, the effects of that change are noted and the relations between the Swedish Public Employment Service and the civil society discussed [63].

In a study of emergency departments in Europe, it has been shown that the use of primary health care (PHC) among migrants and refugees is lower than amongst the majority population. They also have a higher use of emergency departments than primary health care services, which can be a sign of an unawareness of which services are provided within PHC and their entitlement to use them [64]. As refugees and asylum seekers are particularly vulnerable groups, it would be worth viewing them as having specific needs. There also seems to be a narrow focus on certain diagnoses, and studies on subjects such as depression and migration status among the elderly are scarce [65]. It has been stated that most EU member states have very little knowledge about migrants’ health and few possibilities to monitor or develop the systems for handling it [66,67]. The agency’s aim to find a more systematic way of working can thus be applauded, but when it comes to the mental health of refugees, this intention is hampered by the choice to not make questions of health mandatory in the introductory interviews with job seekers.

5. Conclusions

One of the factors that affect the health of refugees is migrant integration policies [3]. The new legislation, the new programme and the support document all aim to create opportunities that make refugees employable cf. [43]. This is the main goal of the new legislation and is reinforced by giving the responsibility for integration to the Swedish Public Employment Service. To understand the changes and their possible effects for case workers, and ultimately the newly arrived, we interviewed people holding central posts at management level in an attempt to map the ruling relations involved in the process. In this respect, we found a set of loosely connected relations. At the agency itself, there are competences and expertise in the management body that can be utilised as and when necessary. The same can be said for the health experts in the studied project. The most central actors are those responsible at the Swedish Public Employment Service and their counterparts at the Ministry of Employment. A decentralised organisation like this is dependent on communication, which is sometimes hampered by the constant change in regulations and personnel at the management level.

The management’s intention has been to ensure a systematic and equal way of dealing with job seekers, regardless of whether they are newly arrived refugees or born and bred in Sweden (this can be seen as somewhat synonymous to the abolishment of specific ombudsmen and instead creating a general ombudsman against discrimination in 2009). The degree of freedom for exercising authority is greater now that the role of the Swedish Public Employment Service has been enhanced. However, when it comes to mental health, the opportunities for street-level bureaucrats at the agency to help clients have decreased. For the refugees, there should be concern about the arbitrary chances of obtaining help, since the individualisation of the case workers’ responsibilities and the jobseekers’ responsibilities now makes it harder to deal with health aspects in a systematic way.

It is somewhat contradictory that the choice was made to view newly arrived refugees as any other job seeking citizens at a time when the new law clearly suggests that there will be significantly fewer permanent residence permits granted and the vast majority of refugees will be regarded as temporary residents for a foreseeable future. How can such a change in policy be motivated when research on high-income countries has shown that long-term adjustment hindrances and social exclusion are factors that affect refugees’ mental health negatively [68]. Further, already at UNESCO’s conference in Durban in 2001, it was established that racism and discrimination need to be addressed in relation to mental health [69]. In the early 2020s, we see that this still poses a challenge in Sweden and elsewhere. For example, the devastating effects of the temporary law on the situation for unaccompanied minors in Sweden has already been shown, where suicide attempts have increased largely [70]. A longitudinal study in Sweden has also shown a difference between Western and non-Western migrants, where there is less proof of a ‘healthy migrant effect’ in the latter category [71]. In this case, we can see potential negative effects of disregarding the vulnerability of the group concerning mental health, in that the new law would encourage the newly arrived to appear healthy, and thus employable, rather than seeking care for illnesses and conveying their concerns for their mental health.

The inequalities in health care globally were exposed once again during the COVID crisis. For example, in 43 African countries, they had intensive care unit beds at a a rate of 5 per million, a number to be compared with Europe where the average was 4000 beds per million [72]. Knowing that risk factors for mental health problems largely stem from social inequality, as stated earlier in this article, it is important to see the specific risks for refugees and newly arrived refugees in particular, and design systems apt to cater to their situation. In the face of predicted growing numbers of people having to abandon their homes due to conflicts and climate changes, governmental strategies such as these need to be revisited in order for societies worldwide to be better prepared for that challenge.