Anna Hallberg: Central-local governance of Swedish healthcare: Steering and coordination in a decentralized unitary state

Abstract

Healthcare governance is regarded as essential to a healthcare system’s capacity to address various challenges, but also often criticized for being dysfunctional and overly complex. One factor underlying such complexity is that healthcare systems are embedded in the broader institutional context of states and, by that, are subject to their rules related to decentralization and local self-governing. This gives rise to central-local governance that can be difficult to evaluate and understand. This thesis aims to extend the understanding of central-local governance of Swedish healthcare by investigating how different forms of governance are shaped by the institutional context, in particular, the decentralization to a self-governing regional level within a unitary state. The thesis also aims to contribute to the literature on governance in unitary states as well as multi-level healthcare governance by exploring and specifying the complex national and sectoral institutional context that the Swedish decentralized unitary state and the healthcare sector together constitute.

In four empirical studies, administrative coordination, agreements, and legislation in Swedish healthcare are investigated through interviews and documents. In studies I and IV, challenges to, as well as the subtle interaction patterns of, central-local administrative coordination are elucidated. Furthermore, study II adds to prior research on policy agreements involving the Swedish Association of Local Authorities and Regions (SALAR) by exhibiting how steering as well as cooperation are accommodated in this policy instrument mix. Finally, our understanding of legislation is extended in study III by showing how recentralization comes about through developed problem formulations and legitimizations in centralizing legal proposals over time.

Taken together, the thesis specifies the underlying institutional conditions of healthcare governance in Sweden by conceptualizing a central-local dimension, and by highlighting three aspects of the Swedish decentralized unitary state – interdependence, hierarchy, and a dual role of the regions vis-à-vis national actors. Furthermore, the implications of these aspects for the governance of the healthcare sector are investigated in greater depth than has been done before, thereby extending our understanding of central–local governance and the conditions under which it operates.