ORIGINAL ARTICLESanctioning the sick: Do perceptions of activatingthe sick and diagnosis matter?Silje Bringsrud Fekjær1| Erik Børve Rasmussen2| Lars Inge Terum11Centre for the Study of Professions, OsloMetropolitan University, Oslo, Norway2Department of Social Work, Child Welfareand Social Policy, Oslo MetropolitanUniversity, Oslo, NorwayCorrespondenceSilje Bringsrud Fekjær, Centre for the Study ofProfessions, Oslo Metropolitan University.P.B. 4 St. Olavs plass, 0130 Oslo, Norway.Email:silje@oslomet.noFunding informationThis work was supported by the ResearchCouncil of Norway's Welfare, Working Lifeand Migration (VAM) program (257603/H20).AbstractThe recent inclusion of behavioural conditionality in health-related benefit programmes raises questions about frontlineworkers' (FWs') discretionary use of sanctioning. Using anexperimental vignette design in a survey of 824 FWs in theNorwegian Labour and Welfare Administration (NAV), weinvestigated whether FWs' perceptions of diagnosis andsick recipients' obligations affect their propensity to sanc-tion for non-compliance. We find that the recipients' diag-noses did not influence FWs' propensity to sanction fornon-compliance. Recipients with a symptom diagnosis(ME/CFS) were sanctioned to the same degree as thosewith a diagnosis based on objective medical evidence(Bekhterev's disease). However, FWs who generally foundit difficult to impose activity requirements on recipientswith health-related problems were also less prone to enactsanctions. Our results support the notion of competingapproaches to activating and sanctioning the sick. FWs whoagree that it is difficult to activate the sick also tend toavoid sanctioning, whereas the propensity to sanction ismore widespread among those who disagree that activatingthe sick is difficult.KEYWORDSactivation, behavioural conditionality, disability, health problems,sanctions, sick role, subjective symptoms, vignette experiment[The copyright line for this article was changed on 30 March 2022 after original online publication]Received: 26 April 2021 Revised: 3 January 2022 Accepted: 6 January 2022DOI: 10.1111/spol.12790This is an open access article under the terms of theCreative Commons Attribution-NonCommercialLicense, which permits use,distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.© 2022 The Authors.Social Policy & Administrationpublished by John Wiley & Sons Ltd.726Soc Policy Adm.2022;56:726–741.wileyonlinelibrary.com/journal/spol
1|INTRODUCTIONA trend in European welfare policies is the turn towards activation and behavioural conditionality (van Berkel et al.,2017). The policy aim is to steer the client's conduct towards activity and return to work. Hence, recipients of bene-fits are increasingly obliged to behave in prescribed ways in accordance with activity requirements. The recipientmust actively contribute to the process of returning to work, including work training and other activities. Failure tocomply may result in reduction or termination of the recipient's benefits. Although initially restricted to recipients ofunemployment benefits, the target group for behavioural conditionality has been expanded to include recipients ofhealth benefits, that is, those not working because of sickness or disability. This expansion creates new challengesfor frontline workers (FWs) that have scarcely been examined (Geiger,2017).A central challenge in this regard, is FWs' assessment of the recipients' health issues and their ability to meet theexpectation of participating in activity requirements and work. However, few studies have examined how FWs' concep-tion of what Talcott Parsons (1951) called the clients'sick roleaffects their propensity to impose sanctions. The sick rolerefers to when a person is declared sick and is thereby exempt from normal obligations and from blame for their presentstate (Parsons,1951). However, the sick person is also expected to seek qualified help and to cooperate with physiciansor other qualified therapists“in the process of trying to get well”(Parsons,1951, p. 456). What, then, are FWs' percep-tions of whether sick recipients can legitimately be required to participate in activity and work? And does their propen-sity to sanction vary with the recipient's diagnosis? Different diagnoses are valued differently, affecting how patients areunderstood by doctors (Album et al.,2017) as well as lay persons (Geiger,2021; Grue et al.,2015). There has, however,been scant investigation of whether diagnoses are also important at the welfare administration's frontline.This article examines FWs' discretionary administration of welfare conditionality for recipients of health benefits.Previous studies indicate that FWs' perceptions of welfare reforms, as well as recipients' attributes, affect theirassessments and decisions (Schram et al.,2009; Torsvik et al.,2021). Our study explores the importance of workers'perceptions of both the sick recipients' attributes and obligations within the context of an activation scheme.To that end, we conducted an experimental study with a vignette design in a survey of 824 FWs in the Norwe-gian Labour and Welfare Administration (NAV). FWs in NAV are the day-to-day implementers of a scheme calledWork Assessment Allowance (WAA)—a time-limited maintenance scheme for clients with reduced work capability.The eligibility criterion for WAA is that impaired work capability must be primarily due to illness, injury or defect.However, the receipt of benefits is conditional on the recipient's active contribution to the process of returning towork. The importance of FWs' perceptions of sick recipients' attributes and obligations for their sanctioning practicesis therefore of great interest.2|DISCRETION, SICKNESS, AND WORKIn this study, we examine how FWs respond to recipients' health issues when they assess non-compliance withactivity requirements. As street-level bureaucrats (Lipsky,2010), FWs interact directly with citizens and have discre-tion in the execution of their work. To have discretion means to have some freedom of choice delegated by a higherauthority. FWs'“space for discretion”(Molander,2016) is restricted by political aims, legal rules and professionalstandards. Within this space, however, there is an expectation that FWs act in accordance with their best judgement,which also includes their preferences, attitudes and interpretations of clients' attributes (Baviskar & Winter,2017;Jilke & Tummers,2018).The role of street-level bureaucrats in implementing behavioural conditionality differs somewhat from that ofassessing eligibility and administering social protection. The aim of behavioural conditionality is to steer the recipi-ent's conduct towards activities with the aim of returning to work. Three key characteristics are:behavioural require-ments(skill-enhancement courses, trainee work, etc.) are a condition for continued receipt of benefits; compliancewith the requirements is assessed throughmonitoring and verification processes; andsanctionsare indicated forBRINGSRUD FEKJÆRET AL.727