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The Liberalization Experiment: Understanding the political rationales leading to change in pharmacy policy
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Pharmacy, Department of Pharmacy. (Samhällsfarmaci)
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

In 2009, a pharmacy policy reform was introduced in Sweden whereby the state owned community pharmacy monopoly was abolished. As a result two thirds of the pharmacies were sold. As there were no longer restrictions on ownership and establishment, new pharmacies and new owners appeared. The overall aim of this thesis is to contribute to a more nuanced understanding of the stated and the underlying rationales for the reform, specifically, to understand how key stakeholders view the reform, and the future role of the community pharmacy. Document analysis was the method used to study the preparatory work, plenary debates, and interviews with stakeholders from political, professional and patient organizations.

The government directive stated that the reform would lead to improvement of availability and efficiency, a pressure on prices and a better use of medicines.  However, the results show that during the reforms’ preparatory phase, the rationales changed and only availability remained throughout the process. Diversity on the market was added later as a rationale. The effects of the reform were perceived in similar ways by the different stakeholder groups. The views on the reform was more negative after the reform.

Interviewees who were previously in favor of the reform were surprised that diversity had not been achieved; that the counseling in the pharmacies had deteriorated and that the availability of medicines decreased after the reform. Interviewees from political organizations had a more business-oriented view of pharmacies/ists, while participants from professional organizations had a more healthcare-oriented perspective.

Finally, this thesis studied the diversity rationale behind the pharmacy reform and compared it to the primary care reform. The results show that, in both cases, policy makers definitions of diversity were vague and unclear, which appear to have complicated their implementation.

Since the pharmacy reform neglected to investigate alternative means of achieving the goals/rationales, it can be argued that the reform was ideologically based and had a preconceived understanding as to how the community pharmacy sector should be regulated. There are several reasons for drawing this conclusion: the reform was launched despite the original rationales being considered as impossible to fulfill, and, except for abolishing the monopoly on state-owned pharmacies, the stakeholders did not seem to know what the reform would lead to, except increasing the number of pharmacies. The latter could have been achieved without the reform as the government had control over the state-owned pharmacy monopoly.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2019. , p. 55
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Pharmacy, ISSN 1651-6192 ; 268
Keywords [en]
pharmacy policy, reregulation, liberalization, Sweden, pharmacist, pharmacy
National Category
Medical and Health Sciences
Research subject
Social Pharmacy
Identifiers
URN: urn:nbn:se:uu:diva-380096ISBN: 978-91-513-0609-4 (print)OAI: oai:DiVA.org:uu-380096DiVA, id: diva2:1298579
Public defence
2019-05-17, Sal IX, Universitetshuset, Biskopsgatan 3, Uppsala, 13:15 (English)
Opponent
Supervisors
Available from: 2019-04-24 Created: 2019-03-24 Last updated: 2019-06-18
List of papers
1. Reregulation of the Swedish pharmacy sector: A qualitative content analysis of the political rationale
Open this publication in new window or tab >>Reregulation of the Swedish pharmacy sector: A qualitative content analysis of the political rationale
2015 (English)In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 119, no 5, p. 648-653Article in journal (Refereed) Published
Abstract [en]

In 2009, a reregulation of the Swedish pharmacy sector took place, and a fundamental change in ownership and structure followed. The reregulation provides an opportunity to reveal the politicians' views on pharmacies. The aim of thiS study was to explore and analyze the political arguments for the reregulation of the Swedish pharmacy sector in 2009. The method used was a qualitative content analysis of written political documents regarding the reregulation. The primary rationales for the reregulation were better availability, efficiency, price pressure, and safe usage of medicines. During the preparatory work, the rationales of diversity on the market and entrepreneurship were added, while the original rationales of efficiency, price pressure, and better usage of medicines were abandoned. The reform can be seen as a typical New Public Management reform influenced by the notion that private actors are better equipped to perform public activities. The results point to that the reform was done almost solely in order to introduce private ownership in the pharmacy sector, and was not initiated in order to solve any general problems, or to enhance patient outcomes of medicine use.

Keywords
Pharmacy policy, Regulation, Community pharmacy, Sweden
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:uu:diva-256851 (URN)10.1016/j.healthpol.2015.03.009 (DOI)000355031900011 ()25841749 (PubMedID)
Available from: 2015-06-26 Created: 2015-06-26 Last updated: 2019-03-24Bibliographically approved
2. The Raison D’être for the Community Pharmacy and the Community Pharmacist in Sweden:: A Qualitative Interview Study
Open this publication in new window or tab >>The Raison D’être for the Community Pharmacy and the Community Pharmacist in Sweden:: A Qualitative Interview Study
2016 (English)In: Pharmacy, ISSN 2226-4787, Vol. 4, no 1Article in journal (Refereed) Published
Abstract [en]

Community pharmacies are balancing between business (selling medicines and other products) and healthcare (using the pharmacists’ knowledge in order to improve drug utilization). This balance could be affected by regulations decided upon by politicians, but also influenced by others. The aim of this study was to explore important stakeholders’ views on community pharmacy and community pharmacists in Sweden. The method used was that of semi-structured qualitative interviews. Political, professional, and patient organization representatives were interviewed.

The results show that informants who are pharmacists or representatives of a professional pharmacist organization generally have a healthcare-centered view on community pharmacy/pharmacists. However, different views on how this orientation should be performed were revealed, ranging from being specialists to dealing with uncomplicated tasks. Political organization representatives generally had a more business-oriented view, where competition in the market was believed to be the main driving force for development. A third dimension in which competition was not stressed also emerged; that community pharmacies should primarily distribute medicines. This dimension was most prevalent among the political and patient organization representatives. One conclusion to be drawn is that no stakeholder seemed to have a clear vision or was willing to take the lead for the development of the community pharmacy sector.

Keywords
community pharmacy; regulation; pharmacy policy; pharmacy reform; legislation; Sweden
National Category
Social and Clinical Pharmacy Pharmaceutical Sciences
Research subject
Social Pharmacy
Identifiers
urn:nbn:se:uu:diva-380060 (URN)10.3390/pharmacy4010003 (DOI)
Available from: 2019-03-23 Created: 2019-03-23 Last updated: 2019-09-05Bibliographically approved
3. Stakeholders’ expectations and perceived effects of the pharmacy ownership liberalization reform in Sweden: a qualitative interview study
Open this publication in new window or tab >>Stakeholders’ expectations and perceived effects of the pharmacy ownership liberalization reform in Sweden: a qualitative interview study
2016 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 16, article id 379Article in journal (Refereed) Published
Abstract [en]

Background: Reforms in the health-care sector, including the pharmacy sector, can have different rationales. The Swedish pharmacies were prior to 2009 organized in a state-owned monopoly. In 2009, a liberalization of the ownership took place, in which a majority of the pharmacies were sold to private owners. The rationales for this liberalization changed profoundly during the preparatory work, making it probable that other rationales than the ones first expressed existed. The aim of this study was to explore the underlying rationales (not stated in official documents) for the liberalization in the Swedish pharmacy sector, and also to compare the expectations with the perceived outcomes.

Methods: Semi-structured interviews were conducted with representatives from key stakeholder organizations; i.e., political, patient, and professional organizations. The analysis was performed in steps, and themes were developed in an inductive manner.

Results: One expectation among the political organization participants was that the ownership liberalization would create opportunities for ideas. The competition introduced in the market was supposed to lead to a more diversified pharmacy sector. After the liberalization, the participants in favor of the liberalization were surprised that the pharmacies were so similar.

Among the professional organization participants, one important rationale for the liberalization was to get better use of the pharmacists’ knowledge. However, all the professional, and some of the patient organization participants, thought that the counseling in the pharmacies had deteriorated after the liberalization.

As expected in the interviews, the post-liberalization pharmacy sector consists of more pharmacies. However, an unexpected perceived effect of the liberalization was, among participants from all the stakeholder groups, less access to prescription medicines in the pharmacies.

Conclusions: This study showed that the political organization participants had an ideological basis for their opinion. The political stakeholders did not have a clear view about what the liberalization should lead to, apart from abolishing the monopoly. The perceived effects are quite similar in the different stakeholder groups, and not as positive as were expected.

Keywords
community pharamcy, regulation, pharmacy policy, Sweden
National Category
Social and Clinical Pharmacy
Research subject
Social Pharmacy
Identifiers
urn:nbn:se:uu:diva-301433 (URN)10.1186/s12913-016-1637-6 (DOI)000381258500001 ()27519573 (PubMedID)
Projects
The monopoly experiment
Available from: 2016-08-23 Created: 2016-08-23 Last updated: 2019-03-24Bibliographically approved
4. Diversity as salvation?: A comparison of the diversity rationale in the Swedish pharmacy ownership liberalization reform and the primary care choice reform
Open this publication in new window or tab >>Diversity as salvation?: A comparison of the diversity rationale in the Swedish pharmacy ownership liberalization reform and the primary care choice reform
2019 (English)In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 123, no 5, p. 457-461Article in journal (Refereed) Published
Abstract [en]

Widespread liberalizing reform of the Swedish community pharmacy and primary care sectors took place in 2009–2010, including opening the market to private providers. One important rationale for the reforms was to increase diversity in the health-care system by providing more choices for individuals. The aim of this study was to increase the understanding how policy makers understood and defined diversity as a concept, and as a rationale for the reforms. The method used was document analysis of preparatory work and plenary parliament debate protocols. The results show that policy makers held vague and unclear definitions of diversity, which complicated its implementation. Diversity was sometimes seen as an effect of competition–a goal–while in other cases it was seen as a condition to be met in order to achieve competition–a means. Thus, policy makers viewed diversity both as a goal and as a means, making the underlying mechanisms unclear. The findings also revealed that policy makers failed to consistently demonstrate how the introduction of competition would lead to diversity.

Keywords
Community pharmacy, Community health care, Regulations, Liberalization, Sweden, Diversity
National Category
Pharmaceutical Sciences
Research subject
Social Pharmacy
Identifiers
urn:nbn:se:uu:diva-380072 (URN)10.1016/j.healthpol.2019.03.005 (DOI)000468719700003 ()30890380 (PubMedID)
Available from: 2019-03-23 Created: 2019-03-23 Last updated: 2019-06-24Bibliographically approved

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