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Conflict and Compliance in Swedish Health Care Governance: Soft Law in the ‘Shadow of Hierarchy’
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
Uppsala University, Disciplinary Domain of Humanities and Social Sciences, Faculty of Social Sciences, Department of Government.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Public Health and Caring Sciences, Health Services Research.
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.

Place, publisher, year, edition, pages
2012. Vol. 35, no 1, 48-70 p.
Keyword [en]
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: urn:nbn:se:uu:diva-125473DOI: 10.1111/j.1467-9477.2011.00279.xISI: 000298742700003OAI: oai:DiVA.org:uu-125473DiVA: diva2:319713
Available from: 2010-05-19 Created: 2010-05-19 Last updated: 2017-12-12Bibliographically approved
In thesis
1. Between Equity and Local Autonomy: A Governance Dilemma in Swedish Healthcare
Open this publication in new window or tab >>Between Equity and Local Autonomy: A Governance Dilemma in Swedish Healthcare
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
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:nbn:se:uu:diva-162605 (URN)978-91-554-8239-8 (ISBN)
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

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Fredriksson, MioBlomqvist, PaulaWinblad, Ulrika

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