Consequences of a decentralized healthcare governance model: Measuring regional authority support for patient choice in Sweden

doi:10.1016/j.socscimed.2008.03.025

Social Science & Medicine

Volume 67, Issue 2, July 2008, Pages 271-279

https://doi.org/10.1016/j.socscimed.2008.03.025 Get rights and content

Abstract

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.

Introduction

In Sweden, as well as in other Scandinavian countries, healthcare has always been a central part of the welfare state. Universalistic and solidaristic welfare programs comprise the main guiding principle in this type of welfare regime, often described as ‘social democratic’ (Esping-Andersen, 1990). The political agenda, principles and guidelines for healthcare are established by the central government. However, the Swedish central government is not involved in the actual production of healthcare. Instead, almost all healthcare in Sweden is administered by regional political authorities called County Councils (CCs). The CCs are governed by democratically elected assemblies and have far-reaching constitutional rights to manage the healthcare sector as well as to levy taxes to finance the provision of healthcare (Glenngård, Hjalte, Svensson, Anell, & Bankauskaite, 2005). From a European perspective, the Swedish healthcare system must be considered highly decentralized.

In Europe, decentralization has been on the political agenda for the past decade. However, the concept of decentralization is often used vaguely. From a healthcare perspective it is important to distinguish between responsibilities for the delivery, financing and arranging/planning of healthcare (Vrangbaeck, 2007). In Sweden, all these functions are decentralized. The CCs are responsible for the actual healthcare delivery, both private and public, and carry out the planning of regional healthcare functions. Regarding healthcare financing, the main part is funded through local taxation. State grants are the second largest source of funding, partly earmarked for special healthcare reforms and initiatives.

Further, since the beginning of the 1990s the Swedish healthcare system has gone through a rather extensive de-regulation and privatization. At the same time, gradually, the Swedish state has handed over more and more power to the CCs (SALAR, 2006). This power decentralization has taken place without a public debate on possible outcomes. Ideally, central government should act as a guarantor of central values such as efficiency, equality and countrywide equivalence. However, how to maintain healthcare equality while strengthening local and regional political power has not until recently been thoroughly debated by politicians. Consequently, the constitutional interaction between state supremacy and local self-determination within the Swedish healthcare context, especially in terms of outcomes and effects, needs further problematization. The fact that local governments are subordinate to central government at the same time as they are autonomous and enjoy self-determination might result in a diffuse distribution of power and a diffuse distribution of responsibilities, which might affect actual healthcare provision. For example, a Government Official Report from 2007 indicates countrywide equivalence inadequacies and proposes enhanced state steering to handle the problem (Ansvarskommittén, 2007:10).

This article is an attempt to measure the effects of decentralized healthcare when it comes to the fulfilment of a certain patient right reform. Despite the number of theoretical frameworks for decentralization, few researchers have measured the scope and extent of decentralization within healthcare (Saltman, Bankauskaite, & Vrangbaeck, 2007). In this study decentralization and the national–local relationship will be measured through a reform that has increased patient choice in Sweden. Historically, patients have been restricted to seeking care at the medical facility nearest them. Consequently, the flexibility of the individual patient has been limited and patients have had few opportunities to influence the caregiving process. Therefore, the introduction of choice of healthcare provider in the beginning of the 1990s must be considered a new phenomenon in the Swedish healthcare context. By the year 2000, the Patient Choice Recommendation (PCR) was updated and extended. In short, patient choice implies countrywide choice of primary and secondary specialist caregiver, both public and private. The only restriction is that the home CC is always financially responsible for patients who seek care across CC boarders. Contrary to the other Scandinavian countries, Sweden has chosen not to legislate patients' rights but to build the implementation of patient choice on a ‘voluntary agreement’ between each CC and the Federation of County Councils (FCC), the latter being a co-ordinating agency for all CCs.

Thus, although patient choice in Sweden is a national reform and healthcare on equal terms is regarded as a national right, it is provided by regional authorities. This might lead to a lack of homogeneity of the regulatory framework and different prerequisites for choice between CCs. The aim of this article is to investigate whether the County Councils differ regarding their support of the PCR, and if so, to explain the causes of this variation. In a broader perspective, this article is an attempt to understand the implications of a decentralized model of healthcare governance through a specific case, the Swedish PCR. The results of this study are linked to discourses of local self-determination, healthcare governance, policy implementation and outcomes of healthcare organization.

Section snippets

Patient choice in Swedish healthcare – A way to empower patients

The trend toward increased patient choice has been observed in other Scandinavian countries as well as in England (Dawson et al., 2004, Exworthy and Peckham, 2006). Across western Europe, objectives as well as implementation and impact of choice policies have varied (Thomson & Dixon, 2006). In Sweden, as in the other Scandinavian countries, the most important political motive behind the introduction of patient choice, besides healthcare efficiency, was to empower the patient (Vrangbaeck &

Governing the Swedish healthcare system – State–local relations

As mentioned above, from a European perspective the Swedish healthcare system is highly decentralized. The CCs' responsibility for the provision of healthcare as well as their local self-determination is stated in the 1982 Health and Medical Services Act as well as in the Swedish constitution (Swedish Code of Statutes). Still, the central government has the overall responsibility for healthcare, for instance the right to legislate. This way of organizing the relations between different

Methods

The aim of this article is to investigate whether the County Councils differ regarding their support of the PCR and explain this variation. It is important to point out that the actual outcomes for individual patients, e.g. how patients actually choose, is not investigated in this article. Instead, the attention is on the decision-making levels formulating rules and regulations within the healthcare sector (Fig. 1). This study focuses on the choice of secondary specialists. There is one main

Are the County Councils choice-supportive?

Examining the PCI result, two main features appear: (1) extensive variation among the CCs and (2) geographical variation. Fig. 1 presents the PCI along a geographical dimension, from southern to northern Sweden. The most striking feature, besides the extensive variation, is that the negative attitude regarding patient choice increases northward. In other words, the northern CCs restrain patient choice more than the southern CCs do. Another characteristic is that the CCs in the three southern

What explains the variation between the County Councils?

Having shown extensive variation and geographical variation, the next step is to investigate the differences in support of the PCR. Why do the CCs act so differently?

From a general understanding of the organization, functioning and managing of the Swedish healthcare system, a number of hypotheses (i.e. tentative explanations for the variations) facilitate the analysis. First, CCs with a poor economy probably act more negatively regarding patient choice since it is more expensive when patients

Adjusting for confounding variables – Partial correlations

Sometimes statistical correlations disappear when adjusting for influences from other variables. Thus, after adjusting for other variables: Do the observed statistical correlations between economy, ideology, population density and the PCI remain? Are the statistical correlations valid and independent of one another?

At the bivariate level, two variables measuring the CCs' economy significantly correlate to the PCI. Table 3 illustrates that after adjusting for the other significant variables, the

Discussion

The PCI shows that there is great variation among the CCs when it comes to level of support for the PCR. Some of the CCs have taken serious action in order to help patients choose healthcare providers; they have, for instance, introduced generous rules of referral. More precisely, this means that patients' place of residence determines their actual ability to choose healthcare provider. For instance, it is easier for patients living in southern Sweden to choose a care provider in another CCs

Acknowledgements

We would like to express our gratitude toward the civil servants in the Swedish County Councils that have provided us with some of the data and information that have been used in this paper. We would also like to thank the Swedish Research Council for funding.

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Consequences of a decentralized healthcare governance model: Measuring regional authority support for patient choice in Sweden

Abstract

Introduction

Section snippets

Patient choice in Swedish healthcare – A way to empower patients

Governing the Swedish healthcare system – State–local relations

Methods

Are the County Councils choice-supportive?

What explains the variation between the County Councils?

Adjusting for confounding variables – Partial correlations

Discussion

Acknowledgements

Självstyrets mervärde: argument för den lokala och regionala demokratin

Nordic region-building in a European perspective

Doing quantitative research in the social sciences: an integrated approach to research design, measurement and statistics

An introduction to medical statistics

Välfärdsstatens nya ansikte: demokrati och marknadsreformer inom den offentliga sektorn

The choice revolution: privatization of Swedish welfare services in the 1990s

Social Policy & Administration

Vem styr vården? Organisation och politisk styrning inom svensk sjukvård. [Who is governing healthcare? Organization and political steering in Swedish healthcare]

Is patient choice an effective mechanism to reduce waiting times?

Applied Health Economics & Health Policy

The three worlds of welfare capitalism

Access, choice and travel: implications for health policy

Social Policy and Administration

Health systems in transition: Sweden

Maximum waiting-time guarantee – a remedy to long waiting lists?: assessment of the Swedish waiting-time guarantee policy 1992–1996