The feminization of a fraternal institution: Swedish sickness funds
1890-1955
Liselotte Eriksson
Umeå Centre for Gender Studies
Umeå University
Lars Fredrik Andersson
Geography and Economic History
Umeå University
1
Abstract
Since the late 19th century, Western countries have implemented a wide range of public
insurance programs. In many countries, the evolution of public insurance has been modeled
on cooperative, mutual insurance funds. Especially sickness insurance funds have been
recognized for their importance, not only as forerunners to public insurance but also for risk
sharing, risk transferring and loss mitigation. By reducing risks related to sickness, illness and
accident, sickness funds improved social welfare.
In a society with a lack of sufficient medical care for the majority and where epidemics
flourished due to insanitary living conditions and illnesses like pneumonia and tuberculosis
caused thousands of lives annually, sickness- and burial funds performed an important task.
However, a state that could imply great danger and cause both death and misery in mid
nineteenth century was pregnancy. The risk to die while giving birth was 30 per cent in 1890
and an infant had a 60 per cent chance to survive its first birthday. To counteract infant
mortality, the government introduced a labour protection law in 1900 that prohibited women
in the industry to work until four weeks had passed after giving birth; the period was
increased to six weeks in 1912. In many families there were many women that were sole
providers for the family and in several working class households the wife’s salary was
essential to ensure the necessary minimum income. The lack of possibility to work and
provide for her family naturally affected unmarried women the most. A discourse, dominating
political decisions, where unmarried mothers had no place in the public sphere and the
ideology of the male breadwinner model, caused a discrepancy between reality where
unmarried mothers counted for a large share and where both unmarried and married women
had to work to secure a sufficient income.
Although researchers have investigated the evolution of sickness-, accident- and
pension insurance few have recognized the importance of the implementation of public
maternity allowance. It did e.g. not, in the case of America, see to the needs of women for
maternity allowance.
Keywords
Sickness insurance, feminization
2
Introduction
250 years ago the average Swede could look forward to less than half of the life expectancy
we enjoy today. The figures are primarily due to the extremely high death rate among small
children and new-born’s but also to the adult population to whom infections and epidemics
was a constant threat. 1 The industrialized society gave rise to increased urbanization and
reliance on salaried work. At the same time the lives of industrial workers became more
exposed to the risk of sickness and death than previous generations that had made their living
in the country side. Unsanitary conditions and crowded quarters gave rise to epidemics and a
wide spread of tuberculosis which could result in sickness and death. To meet these
challenges of the average nineteenth century wage earner, sickness and burial funds were
established rapidly all over Europe throughout the century.
Sickness funds have been recognized for its efficiency in controlling information
asymmetry controlling such as adverse selection and moral hazard (Emery, 1996). Indeed,
tests for asymmetric information in cooperative insurance societies examine how their pricing
policies affected the profile of members (Gottlieb, 2007). Gottlieb argues that cooperative
societies (unlike their contemporary substitutes) were able to overcome the asymmetry of
information and benefit from informational advantages. The small societies and the selection
mechanisms made it possible for funds to only engage in relatively known risks, reduce
adverse selection; and the social control reduced fraud and moral hazard. Emery (2010)
stresses that the reason for the American resistance to compulsory health insurance was that it
did not offer a better alternative than voluntary alternatives. Previous research on cooperative
insurance has hence focused on efficiency in sickness funds by measuring information
asymmetries, aspects of equity and equality has hence been neglected. We believe this is an
omission given the importance of access to insurance when discussing the social welfare
implications of sickness funds.
Previous research has focused on salaried male workers – the group most likely to
benefit from sickness insurance through membership in sickness funds. However, as many
sickness and burial funds were institutions explicitly organized around the principle of
masculine identity, the selection strategies employed by sickness- and burial funds did
involve an exclusion of women from access to sickness insurance coverage (Clawson, 1983).
Women were the ones most frequently excluded from sickness insurance and at the same time
also among the most exposed to the risk of the loss of income due to inability to work.
1
In the 1890s every tenth child died during its first year in Sweden (Ohlander 1993, p. 33).
3
Women were exposed to a gender-specific health risks through delivery and childbearing.
This was combined with a law were female industrial workers at the end of 1870s, in many
western countries became, forbidden by law to work two or up to six weeks after giving birth,
without receiving any kind of compensation. In Sweden, female industrial workers did not
receive compensation until 1931 (SOU 1954:4, p. 14). If a woman was unmarried and the
only breadwinner, her and her child’s situation could result in starvation and severe poverty.2
In this paper, we address how the institutional structure impacted on female
membership in Swedish sickness funds during the period 1890-1955 – a period where the
female members went from marginalization to a substantial and integrated part of the sickness
insurance system. By addressing the issue of female membership, we believe that the paper
may help to provide a wider understanding of the equity and equality issues inherit in social
insurance. As the sickness insurance system developed from fairly small and independent and
privately funded units into a centralized and subsidized insurance system under public
control, the period of study offers a possibility to analyze how variation in institutional
structures affected the process of feminization.
The following of the paper is organized as follows. Section two outlines the historical
development of sickness funds; changes in regulatory environment and financing. Section
three provides a qualitative account of the mechanisms of exclusion of women of sickness
funds. Section four introduces our quantitative analysis of exclusion mechanism, while
section five provides the results. Section six concludes.
Historical overview of sickness funds
The first Swedish sick and funeral insurance funds were established in the early 1700s within
various trade guilds. These funds provided insurance for medical expenses and lost wages in
the occurrence of illness or accident as well as for funeral costs in the event of death. In this
respect, these funds are the equivalent of today’s sickness insurance providers. During the
period 1870-1885, there was an increase in establishment associated with this period’s rapid
industrialization and urbanization. A parliamentary committee set up in 1884 to study the
emerging insurance market observed that the health coverage offered by the existing
insurance funds was lacking in terms of that insurance societies frequently dissolved leaving
members without insurance.
2
From 1938 until 1955 women without membership in sickness funds could receive a means-tested subsidy.
4
In order to encourage the development of sickness and burial funds, the 1891 Law of
Registered Sick Insurance Societies implemented an administrative subsidy for those funds
that voluntarily registered with the government. Registration implied sending annual financial
statements as well as information concerning policy statutes to the Department of Public
Administration and after 1901, to the National Board of Trade. Registered funds received a
small subsidy which benefitted funds with a fewer number of members, while the subsidy per
member decreased with the number of members. Hence, the regulation stimulated the
development of especially small sickness funds and sickness funds showed continuous
problems with reaching a large part of the population and provide safe insurance alternatives.
Public financial support (subsidies) was provided not only for administrative costs, but
also for reducing membership fees and attracts new members; this in turn eventually
threatened the soundness of the business (Lindeberg, 1949, p. 250). Fierce competition for
members often led to detrimentally low premiums, a high rate of closures, and uncertain
coverage (Berge, 1995; Edebalk, 1996). The subsequent 1910 Law of Registered Sick
Insurance Societies increased regulation while maintaining the voluntary nature of the
Swedish health insurance system.
In 1910 the authorities demanded a more actuarially sound relation between fees and
benefits. Ex post assessments were forbidden except for temporary budget deficits and the
funds were to rely primarily on regular fees. Multiple memberships in funds were banned and
the burial benefit became much reduced by the law of 1910 and made many funds separate
their sickness- and burial business from each other. Exclusion of members was not accepted if
it was not regulated in the policy statues. The 1910’s act also demanded that a fund contended
at least 100 members to get registered. The pressure on organizational changes and
administrative requirements started a process of consolidation where funds merged. The
increased capital requirements further led problem with exit and recruitment of members in
small sickness funds. The public subsidy increased with the 1910’s act. However, the subsidy
was reduced with half if a member had multiple memberships in sickness funds – a common
feature in small local sickness funds (Nekby, 2004).
From 1910, sickness funds that offered maternity allowance were given subsidies. The
rationale behind subsidizing funds with maternity allowance was the labor protection law of
1900 that prohibited women in industrial occupations to work six weeks after receiving a
child. The labor protection law restricting the industrial work of mothers was an international
convention which was put forward at the first International Labor Protection Congress in
Berlin 1890 and was passed as an international convention in Washington 1919. Against the
5
recommendations of the convention and in contrast to several other countries, Swedish
women did not receive any compensation for this compulsory leave from work (Nordgren,
1933, p. 4-5). Several other countries with labor protection laws regulating the work of
women, recognized the importance to compensate women in industrial work for their loss of
income and introduced state funded compensations (SOU 1929:59). In Sweden however,
instead of granting women compensation for their loss of income, Swedish politicians choose
to give subsidies to sickness funds that offered maternity allowance as a way to encourage
sickness funds to take on maternity allowance as business and stimulate the possibility for
women/families affected by the labor protection law to make the necessary precautions in the
event they planned to have children. A state funded compensation to women affected by the
labor protection law was not realized until 1931 (SOU 1954:4, p. 14). The budget for
subsidies to sickness funds constantly had to be raised due to increased demand for maternity
allowance and the many sickness funds that came to offer maternity allowance.
A second major institutional change was introduced in the 1930s. In 1931, after six
years of enquiry, it was settled that all sickness funds should be divided into local- and central
sickness funds. Only one central sickness fund should exist in each municipality, the local
funds had responsibility to collect fees from members and controlled the reported sick
members. The local sickness funds had responsibility for the sickness benefits the first 21
days, after that the central sickness funds took over. A major improvement for women
regarding the regulation of 1931 was that all registered sickness funds now became obliged to
offer maternity allowance.
In Britain, the National Insurance Act of 1911, granted women affected by the labor
protection legislation compensation, this is probably the reason to why maternity allowance in
friendly societies was very rare in Britain (Brown and Taylor, 1933, p. 7). In Sweden
however, where no state compensation was granted women affected by the labor protection
legislation and where maternity allowance in sickness funds became state subsidized,
women’s membership in sickness funds rose rapidly during the period 1900-1954, see figure
1.
The subsidies for sickness funds providing maternity allowance and later regulatory
changes towards centralization and subsidizing may have contributed to the feminization of
sickness funds. To examine the decline in female exclusion and rise in women’s membership
in sickness funds the following section outline the data and the methods for examine how
changes institutional structure impacted on the female membership in Swedish sickness funds
during the period 1890-1955.
6
20
30
40
Per cent
50
60
Figur 1. Female participation rate (per cent) in Swedish sickness funds 1900-1954.
1900
1920
1940
1960
Year
Source: Registrerade sjukkassors verksamhet 1901-1910, Registrerade sjukkassor 1910-1930;
Erkända Sjukkassor 1938-1954.
Examining women’s membership in sickness funds
To trace the mechanism of female exclusion and the impact of institutional changes on female
participation in sickens funds we have utilized archival and official statistical data. The
qualitative data comprises of archival material derived from Stockholms stadsarkiv
(Stockholm City archive), Riksarkivet (Swedish National archive) and Göteborgs Landsarkiv
(Goteborg Regional archive). The focus on the two first archives situated in Stockholm is
partly due to that the data set used is on sickness funds in Stockholm and the archives together
with the one in Goteborg hold a large share of the material available through the National
Archival Database (NAD) on female sickness funds. Women’s sickness funds available and
possible to identify as female sickness funds through NAD are only 23. This is a very small
share of the female sickness funds evolving in the late 19th and early 20th centuries. Besides
the archives searchable through NAD, there are several non-searchable, local archives holding
an unknown amount of material of female sickness funds.
The official statistical data include information on each fund with respect to income,
loss and balance accounts. The data give a detail account on source of income
(premiums/fees, public aid and employers aid) and on expenditures (claims experiences,
administrative costs, capital costs etc.). The data include information on geographical
location, occupation, number of sickness days etc. From the census of sickens fund, we have
employed a sample of sickness funds registered in Stockholm in our econometric analysis.
7
The econometric analysis is sought to empirically examine the impact of institutional
structure on female participation. The basic proposition to examine is how key components of
the instructional structure that change due of legislative initiative, regulatory changes and
subsidies impact on female participation. Table 1 outlines the key components in the
institutional structure during the period of study.
Table 1. Key components of sickness fund’s instructional structure 1900-1955
Period 1.
Period 2.
1892-1909
1910-1930 1931-1954
Public subsidies
X
X
X
Size of fund
X
X
X
Occupation based
X
X
X
X
X
Maternity allowance
Period 3.
Period 1 is governed by the 1891 act of sickness funds; Period 2 is governed by the 1910 act
and period 3 the 1931 act. The first period was characterized by limited public subsidies and
small sickness funds. The occupational based funds were common and frequently based on a
close mutual identity of fraternalism which is expected to have excluded women. After the
1910’s act subsides and size of funds increased and also maternity allowance was provided
from the mid-1910s. A more centralized structure of highly subsidised sickness funds were
attained after the 1931 act.
To account for how the key components of the institutional structure impact on the
female participation rate, we have measured the components as follows. Public subsidies are
measured as the share of public financial support of all incomes. The size of insurance funds
is measured as number of members. In addition to the size, the structure of insurance is
considered during period 3 when funds was divided into centralized (national) and local
insurance funds. The extent of centralization is measured as number of local funds divided by
number of members. To examine if occupation-based funds excluded women, we have
constructed a dummy-variable for occupation-based funds. To account for the impact of
8
maternity allowance, we have constructed a maternity allowance variable that measures the
share of maternity as share of total expenses.
Table 2. Variables and definition
Variable
Definition
Female participation measured as the share of women of all
Female
members
Public subsidies measured as public financial support as
Subsidies
share of total income
Size
Size of fund measured as the number of members
Decentralization
Centralized structure measured as number of local sickness
funds divided by number of members
Occupational based, indicated by a dummy=1 if
Organization
occupational based, 0 otherwise
Maternity allowance measured as share of expenses on
Maternity
maternity as share of total expenditures
To empirically examine how the institutional components impact on the female
participation rate we have employed a panel-data design as our primary strategy. As the panel
and variable structure only is coherent for sub-periods, the analysis is divided for the periods
given in table 1. For period 2 a further division is needed as the data on size of maternity
allowance is only given for the period 1921-1931. The period 1912-1920 also suffer from
omitted values on female participation and on maternity allowance. To control for the
potential sample bias, a sample selection model is employed (period 2:b).
The impact of institutional structures on female participation
Table 3 report the impact of institutional components on female participation in sickness
funds. During period 1 both the fixed and random effect gives the same outcome and a
reasonable fit respectively. Public subsidies give a positive and significant effect on the
female participation rate. We find also an expected positive impact of size and a negative
impact on organization, suggesting that small and occupation oriented sickness funds exclude
women to a greater extent.
9
After issuing the 1910’s act on sickness funds and the consolidation of smaller funds the
impact of size reverse. The impact of subsidies is still significant and positive, although the
coefficient is smaller. In turn, the negative impact of organization grew stronger. Both the
random and fixed effect model gives fairly the same outcome and a reasonable fit. For period
2:b a Heckman sample selection model was employed due to omitted values on female
participation and maternity allowance. The selection model gives a positive but only weakly
significant impact of size on female participation. Organization gives a negative and
significant impact both in the selection and outcome model. Maternity allowance gives a
positive and highly significant impact in the selection model (dummy variable), but a nonsignificant impact in the outcome model (continuous variable). The result suggests that funds
that provide maternity allowance have a higher female participation rate, while the size of
maternity allowance is not significant.
Table 3. Impact of institutional components on female participation in
sickness funds, multivariate analysis by periods 1, 2 and 3.
Variable
Period 1.
Period 2:a
RandomFixed-effect effect
Subsidies
Size
1.27
***
1.82
***
Period 2:b
Period 3.
Fixed-
Random-
Heckman
Heckman
Fixed-
Random-
effect
effect
outcome
selection
effect
effect
1.26
***
0.28**
1.8
***
-2.73**
0.56
***
0.004
-3.2
***
-0.001
0.002
*
Decentralization
Organization
-18.69
Maternity
-
Constant
30.13
***
-18.7
***
-24.4**
-23.8
***
-25,2
***
-1.27
***
30.33
***
66.72**
65.48
***
29.8
***
-0.73
-0.72
-101.1
***
-102.1
***
-0.64
*
0.89
***
0.22
***
0.23
***
*
62.4
***
67.4
***
-0.25
R-sq
Within
0.15
0.15
0.23
0.23
0.38
0.38
Between
0.54
0.54
0.61
0.96
0.53
0.53
Overall
0.15
0.15
0.23
0.23
0.34
0.34
The positive impact of maternity allowance is highly significant during the third period (when
all sickness funds provide maternity allowance). The results show that maternity allowance
played an important role for the demand of sickness insurance, see figure 2.
10
Figure 2. Income share of public subsidies in per cent (subsidies/total income) and
expenditure share of maternity allowance in per cent (maternity allowance/total
0
10
20
30
Per cent
40
50
expenditure) in Swedish sickness funds 1900-1954.
1900
1920
1940
1960
Year
Maternity allowance
Public subsidies
Source: Registrerade sjukkassors verksamhet 1901-1910, Registrerade sjukkassor 1910-1930;
Erkända Sjukkassor 1938-1954.
Mechanisms of exclusion of women from sickness insurance
Despite the growing number of female members in sickness funds, membership in especially
the early local sickness funds was based on trust, kinship, fellowship and community.
Prospecting members often had to be recommended by several other members who in turn
risked their position if the new member did not behave in accordance with the regulations and
norms of the fund. Many sickness funds also demanded of their members to show a priests
certificate, for guaranteeing their honesty and good morals. Besides formal demands on
membership as age, residence, occupation and work place, membership could be based on a
certain position, class, religion, temperance and acquaintanceship; but the most common base
of exclusion was gender. Women were often excluded from becoming members in sickness
funds and in funds where they were allowed to enter they were considered “half” members or
received their “membership” as wives of members and received less benefit (Lindeberg,
11
1949). Some funds accepted female members, but only for burial benefit (e.g. Motala sockens
erkända sjukkassa 1846-1946, 1946, p. 30).
Sickness funds that usually excluded women in the first paragraph were small and local
funds examples of this were assessment societies which only comprised of a fixed number of
members, e.g. 100 or 150. The popularity of these funds peaked between 1870’s and 1880’s
and the forthcoming state regulations further restricted their business. The other category of
sickness funds that explicitly excluded women were fraternities like the Brotherhood’s
sickness- and burial fund established 1883, (Brödraföreningens sjuk- och begravningskassa).
Fraternities arranged parties and picnics and in the monograph of the Brotherhood’s sicknessand burial fund. In these types of funds women could be included to the extent that a burial
benefit was granted the wives of members; this benefit was always lower than for the male
members. In the case of the Brotherhood’s sickness- and burial fund, women were allowed to
enter the fraternity in 1914, when also maternity allowance was introduced in the fund
(Brödraföreningens sjuk- och begravningskassa: kort historik vid femtioårsjubileet, 1932).
Fraternities as well as assessment societies with a fixed number of members, were usually
established in the late 19th or early 20th century and it was quite common that these funds with
their old policy statues merged or dissolved as a consequence of the regulation of 1910
(Lindeberg, 1949).
The largest and more expansive category of funds was funds connected to occupation in
some way. This type of fund had a long heritage, starting with the guilds in 1700s.
A nationwide investigation of 1915, where 250 occupational funds were included, the
policy statues show that women’s membership in occupational funds was conditioned
(Socialförsäkringskommittén 1915, sjukkassestadgar 28:RA). They were allowed only as
wives of members and granted a much smaller benefit then their husbands, many of these
funds came to offer maternity allowance for members’ wives after 1910. Women were only
accepted on the same conditions as men in occupational funds funded by employers that
demanded compulsory membership among their employees. Even if women officially could
be full members in these sickness funds, women became marginalized in other ways. In a
protocol of the sickness fund of a sugar refinery, it was heavily discussed whether female
members should be allowed to bring a male companion to a party or not (Sockerraffinanderiet
Öresunds Sjukhjelpsförening, in En återblick over sjukkassorna i Lund under ett halvsekel,
1961, p. 9).
It is clear that the inclusion of women in occupational sickness funds were based on
their civil statues. Women got access to sickness insurance primarily as wives to members.
12
Unmarried, self-sufficient women were not welcome in these funds. One example is that the
entering of women in new occupations could imply that they got access to sickness insurance
in funds that targeted members in certain occupations and where the exclusion of women was
not mentioned in the policy statues. This was the case with Gothenburg’s grammar schools
teachers’ sickness fund, established 1898 (Göteborgs läroverkslärares sjukksassa). In early
20th century a very limited number of women got access to the fund in their roles as art
teachers, but with an increase in female grammar school teachers the fund also experienced an
increase in the number of female members. According to the fund, the large number of
women led to “alarming” experiences, which made it change its policy statues and stopped
women from entering the fund. Implicitly the fund accused female members to overuse the
system by adding that many male members, although sick, never had troubled the fund with
demands of sickness benefit and that many men had died without receiving any benefit at all
(Göteborgs läroverkslärares sjukkassa 1923-1947, 1948, p. 7-8).
According to Clawson (1986), fraternalism created solidarity and connected the interest
of members together. Married women, viewed as wives to members, not receiving full
membership in sickness funds opposed no threat to funds that were based on fraternity.
Unmarried women on the other hand, trying to receive membership in their capacity as
workers became viewed as a threat to fraternalism and solidarity of the sickness fund.
The exclusion of unmarried women from receiving sickness insurance made them
establish their own funds. The number of female funds never became large; in 1918 there
were only 35 female sickness funds. The need for funds for women only seem to have been
most important in late 19th and early 20th centuries when the most female sickness funds were
established.
As the quantitative analysis gives at hand, women were most frequently members in
public sickness funds. The characteristics of these funds were that they were relatively new,
established during the first half of the 20th century, that they were national funds, often were
results of several merged sickness funds and eventually in 1931 became central sickness
funds in their respective municipality (Lindeberg, 1949).
Discussion
13
This paper has shown that changes in the institutional structure played an important role for
the process of feminization in Swedish sickness funds during the period 1890 to 1955. In the
early part of the period, excluding mechanism attributed to the small mutual pools based on
occupation, had a significant and negative impact on female participation. The relaxation of
such mechanism following the 1910s act of sickens funds, was important for increasing
female participation rate. Consolidation of the smaller mutual pools and prohibition of pure
mutual (ex ante premium payment) are identified as important steps for reducing the impact
of size on female participation.
Public financial assistance in general and the support for maternity allowance in
particular played a decisive role for the feminization of sickness funds. Already in the early
part of the period, a significant and positive impact of public subsidies on female participation
is identified. Introduction of maternity allowance in the mid 1910’s had an additional positive
impact. Also at the end of the period, when all funds provided maternity allowance, we find a
positive association with female participation. Growing public control and centralization of
sickness funds provided in addition an important support for the rise in female participation in
Swedish sickness funds.
Clawson (1986) argues fraternalism and the exclusion of women from benefit societies
had an important function in creating a mutual identity and to bind the interest of members
together. Therefore, the measures to exclude women seem to have weakened with the
regulatory changes following the 1910’s act of sickens insurance. An indication of this is that
older and more traditional sickness funds, like occupational sickness funds and fraternities,
seem to have excluded women to a higher degree than newer, national, public sickness funds.
This also explains why the establishment of female sickness funds primarily occurred
relatively early, before that state regulations had forced the sickness funds to merge and grow
larger.
The exclusion of women from occupational sickness funds turned, for married women,
into discrimination where they got access to sickness insurance and maternity allowance in
their capacity of wives of members of sickness funds. They paid half the premium and
received half the benefit.
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15