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Between Equity and Local Autonomy: A Governance Dilemma in Swedish Healthcare
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research. (Hälso- och sjukvårdsforskning)
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Both national equity in healthcare and the county councils’ local autonomy are important values supported by Swedish law. Politically it is a balancing act; how much freedom should the county councils have and to what extent should healthcare be equal throughout the country? The general aim of this dissertation, concerning political governance in Swedish healthcare, is to investigate the tensional values of national equity and local autonomy in the light of current trends in healthcare governance in Sweden. How is this tension manifested? Four studies are included in the dissertation. These studies show that the Swedish state is becoming more active in governing and regulating healthcare, for example by the use of informative governance and legislation, which increasingly rely on monitoring and evaluation of results that are made public. The findings show that the tension between national equity and local autonomy is manifested in increasing emphasis on national equity – or rather national equivalence – which is interpreted in terms of Swedish healthcare being recentralized. Delivery and financing of healthcare are still the responsibilities of the county councils. Planning and arranging – the setting of the regulatory framework – is increasingly taken over by the central state. Although power seems to be transferred from local level to central level, the county councils’ autonomy is only partially restricted, which means Swedish healthcare is still decentralized. However, if the recentralization process proceeds further, the county councils´ autonomy may be seriously challenged. Another challenge is to maintain or strengthen the procedures for democratic legitimacy through citizen participation at the local level. When local autonomy looses ground, it becomes more difficult to tailor healthcare according to local needs and conditions in the county councils, and decisions are taken at greater distance from the citizens.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis , 2012. , 74 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 731
Keyword [en]
healthcare, health policy, local autonomy, national equity, governance
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Public Administration Studies
Research subject
Health Care Research
Identifiers
URN: urn:nbn:se:uu:diva-162605ISBN: 978-91-554-8239-8 (print)OAI: oai:DiVA.org:uu-162605DiVA: diva2:461056
Public defence
2012-01-26, Museum Gustavianum, Auditorium Minus, Akademigatan 3, Uppsala, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2012-01-03 Created: 2011-12-01 Last updated: 2014-07-08Bibliographically approved
List of papers
1. Consequences of a decentralized healthcare governance model: measuring regional authority support for patient choice in Sweden
Open this publication in new window or tab >>Consequences of a decentralized healthcare governance model: measuring regional authority support for patient choice in Sweden
2008 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 67, no 2, 271-279 p.Article in journal (Refereed) Published
Abstract [en]

What are the implications of a decentralized model of healthcare governance? This case study on patient choice in Sweden is an attempt to shed light on this issue. Due to decentralization and constitutional rights of self-determination, the regional authorities in Sweden, called County Councils (CCs), have far-reaching rights to manage the healthcare sector. The fact that patient choice is considered to be a soft law or a soft governance regulation, opens it up to regional variation. To examine the CCs level of support of patient choice, an index is presented. The Patient Choice Index (PCI) shows that there is extensive variation among the CCs. To explain the causes of these variations, a number of hypotheses are tested. The analyses imply that ideology and economy, and more specifically the CCs' governing majorities and running net profits, are major explanations for the level of support. A number of conclusions can be drawn from the results of this study. In short, the CCs appear to act according to a local point of view, which means that there is no functioning national patient choice standard, and thus patients do not have equal access to healthcare and patients' rights are unevenly distributed. Furthermore, the CCs' financial conditions and governing majorities seem to undermine equivalent reform realization in a national context. In summary, the results of this study emphasize the conflict between regional self-governance and national equality, which is particularly visible in the decentralized Swedish healthcare model.

Keyword
Sweden, patient choice, equality, healthcare policy, healthcare politics, soft governance
National Category
Medical and Health Sciences
Research subject
Health Care Research
Identifiers
urn:nbn:se:uu:diva-17537 (URN)10.1016/j.socscimed.2008.03.025 (DOI)000257606400007 ()18450346 (PubMedID)
Available from: 2008-06-30 Created: 2008-06-30 Last updated: 2017-12-08Bibliographically approved
2. Conflict and Compliance in Swedish Health Care Governance: Soft Law in the ‘Shadow of Hierarchy’
Open this publication in new window or tab >>Conflict and Compliance in Swedish Health Care Governance: Soft Law in the ‘Shadow of Hierarchy’
2012 (English)In: Scandinavian Political Studies, ISSN 0080-6757, E-ISSN 1467-9477, Vol. 35, no 1, 48-70 p.Article in journal (Refereed) Published
Abstract [en]

Soft law, or non-legislative modes of policy making, is becoming increasingly common today. The Nordic countries have a long tradition soft law, not least in central–local relations, where non-binding agreements are frequently used to coordinate policies. A key question springing from soft law theory is that of compliance. Why do independent actors comply if they are not formally obliged to do so, and what happens if they do not comply? This article addresses the question of how compliance can be achieved during policy conflict between actors at different governing levels by investigating a case of health care reform in Sweden. An important finding in the study is that compliance was reached ‘in the shadow of hierarchy’. The central government resorted to the threat of regular legislation to force the county councils to comply. This finding points to the fact that sanctions and the presence of a hierarchical order may play an important role even in soft law governance. The study also shows that an additional important reason that the voluntary agreement between the county councils and central government was honoured in the end by both parties can be attributed to the efforts of a mediating actor: the organization representing the county councils in their negotiations with the government. Finally, the study also illustrates how various forms of informal social pressures such as shaming, peer pressure and moral responsibility can help enforce local compliance in a case of open policy conflict. Arguably, all these compliance mechanisms also have relevance outside the Nordic setting.

Keyword
health policy, soft law, Sweden
National Category
Political Science Health Care Service and Management, Health Policy and Services and Health Economy
Research subject
Health Care Research
Identifiers
urn:nbn:se:uu:diva-125473 (URN)10.1111/j.1467-9477.2011.00279.x (DOI)000298742700003 ()
Available from: 2010-05-19 Created: 2010-05-19 Last updated: 2017-12-12Bibliographically approved
3. Recentralizing healthcare through evidence-based guidelines – striving for national equity in Sweden
Open this publication in new window or tab >>Recentralizing healthcare through evidence-based guidelines – striving for national equity in Sweden
2014 (English)In: BMC Health Services Research, ISSN 1472-6963, E-ISSN 1472-6963, Vol. 14, 509- p.Article in journal (Refereed) Published
Abstract [en]

Background: The Swedish government has increasingly begun to rely on so called informative governance when regulating healthcare. The question this article sets out to answer is: considered to be “the backbone” of the Swedish state’s strategy for informative governance in healthcare, what kind of regulatory arrangement is the evidence-based National Guidelines? Together with national medical registries and an extensive system of quality and efficiency indicators, the National Guidelines constitutes Sweden’s quality management system. Methods: A framework for evaluating and comparing regulatory arrangements was used. It asks for instance: what is the purpose of the regulation and are regulation methods oriented towards deterrence or compliance? Results: The Swedish National Guidelines is a regulatory arrangement intended to govern the prioritizations of alldecision makers – politicians and administrators in the self-governing county councils as well as healthcare professionals – through a compliance model backed up by top-down benchmarking and built-in mechanisms for monitoring. It is thus an instrument for the central state to steer local political authorities. The purpose is to achieve equitable and cost-effective healthcare. Conclusions: This article suggests that the use of evidence-based guidelines in Swedish healthcare should be seen in the light of Sweden’s constitutional setting, with several autonomous levels of political authority negotiating the scope for their decision-making power. As decision-making capacity is relocated to the central government – from the democratically elected county councils responsible for financing and provision of healthcare – the Swedish National Guidelines is part of an ongoing process of healthcare recentralization in Sweden, reducing the scope for local decision-making. This represents a new aspect of evidence-based medicine (EBM) and clinical practice guidelines (CPGs).

Keyword
EBM, CPG, guidelines, evidence, Sweden, local demcracy, primary care, health policy, citizen, patient
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Public Administration Studies
Research subject
Health Care Research
Identifiers
urn:nbn:se:uu:diva-162604 (URN)10.1186/s12913-014-0509-1 (DOI)000348416600001 ()25370710 (PubMedID)
Available from: 2011-12-01 Created: 2011-12-01 Last updated: 2017-12-08Bibliographically approved
4. The trade-off between choice and equity: Swedish policymakers’ arguments when introducing patient choice
Open this publication in new window or tab >>The trade-off between choice and equity: Swedish policymakers’ arguments when introducing patient choice
2013 (English)In: Journal of European Social Policy, ISSN 0958-9287, E-ISSN 1461-7269, Vol. 23, no 2, 192-209 p.Article in journal (Refereed) Published
Abstract [en]

How do policymakers deal with the tension between choice and equity in healthcare? An analysis and critical examination of Swedish policymakers' arguments when introducing legislated choice of primary care provider in 2010 shows that even when deciding on a reform with a potentially great impact on distribution of health resources, implications for equity were not systematically addressed. Effects with regards to current patterns of healthcare consumption in the population as well as existing inequalities in health outcomes were not adequately addressed. Neither was the primary are choice reform, which is based on the values of consumerism and individual choice, problematized in relation to current healthcare legislation such as the Health and Medical Services Act. Given that the values of equity and social solidarity have had such a prominent place in Swedish health policy and discourse in past decades, this is a surprising finding. In conclusion, we argue that because inequalities in health constitute one of the main challenges for public health today, the impact of healthcare reforms on equity should receive more attention in policymaking.

Keyword
choice, equity, Sweden, health policy
National Category
Health Care Service and Management, Health Policy and Services and Health Economy Public Administration Studies
Research subject
Health Care Research
Identifiers
urn:nbn:se:uu:diva-162603 (URN)10.1177/0958928712463158 (DOI)000318521200006 ()
Available from: 2011-12-01 Created: 2011-12-01 Last updated: 2017-12-08Bibliographically approved

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