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Background: Priority-setting models have the potential to enhance transparency and support decision-making under conditions of resource scarcity; however, their practical application remains limited, particularly in large-scale decommissioning programmes. This article examines department managers' perceptions of using a National Model for Transparent Prioritization (NMTP) at their clinics during the implementation of a decommissioning programme. In addition, the study explores whether the model contributes to fair priority setting and to procedural and substantive legitimacy.

Methods: A convergent mixed-methods design was employed, integrating quantitative and qualitative data from a survey (n = 33) and semi-structured interviews (n = 22). The analysis addressed six questions grouped into two overarching themes: (1) the model's use and contribution (adoption, exclusion, and inclusion of care) and (2) the model's legitimacy (acceptance, justification, and fairness of priorities).

Results: Department managers expressed varying perceptions of the NMTP. Approximately half of them considered the time and resources required to be justified and perceived that the model ensured patients with the greatest needs were given the highest priority. About one third agreed that the NMTP was accepted as a tool for prioritization and resource allocation, and a similar proportion reported that the NMTP had been used to exclude care that was previously provided.

Conclusions: Department managers perceived that the NMTP facilitated the application of the Swedish ethical guidelines; however, they also identified several challenges associated with its use in the context of a large-scale decommissioning programme, including time constraints, a substantial initial threshold, demanding evidence requirements, and insufficient alignment with national objectives. Furthermore, resistance encountered within clinical units may have been attributable to limited stakeholder engagement.

Background

Caesarean section on maternal request (CSMR) raises ethical and clinical challenges despite Sweden’s low overall caesarean section (CS) rate. National written recommendations are restrictive, yet regional differences suggest unequal care. While previous research has focused on women and healthcare professionals, little is known about the views on CSMR of policymakers and other key stakeholders. The aim of this study was to investigate how stakeholders in the Swedish healthcare system view CSMR in relation to medical considerations, individual autonomy and societal values.

Methods

A qualitative study with an inductive approach was conducted using reflexive thematic analysis of semi-structured interviews. Sixteen stakeholders were recruited, including regional politicians, policymakers, national authority representatives, and members from organisations and associations with relevant interest and expertise in the field.

Results

Five themes were generated: (1) Caesarean section is a valid way of giving birth for some; (2) The right to choose and the decision process are complex issues; (3) Individual options for childbirth are desirable; (4) There is a lack of trust in maternity care; (5) Economic and ethical challenges in maternity care exist. The participants viewed CSMR as a legitimate option for some women, despite the increased medical risks, which were considered concerning but not disqualifying. Support and guidance in decision-making were considered essential by the participants. They valued continuity in care and emotional support highly. The participants expressed the views that distrust in Swedish maternity care was linked to media portrayals and inconsistent handling of CSMR. Economic and ethical concerns included questions of resource allocation and the scope of public healthcare responsibilities. The option to pay privately for a planned CS was broadly rejected by the participants.

Conclusions

This study highlights the complexity of CSMR and its varied perspectives. While individual risks may be low, population-level risks could rise with increased prevalence, and the perception of risk varies depending on perspective. Both medical and psychological risks should inform decisions, with counselling seen as crucial by the participants. Continuity of midwife care models may offer an alternative to CSMR for some. Stakeholders are key to ensuring clear guidelines, equal care, and trust in the system.

This article investigates how the institutional conditions of multi-level contexts are accommodated in central-local governance by analyzing policy agreements in the Swedish healthcare sector. These policy agreements have developed in recent decades, and are today an instrument mix that constitutes a new way for the national government to govern the decentralized healthcare sector. In the study, this new instrument mix is related to the decentralized unitary context of Sweden by investigating how steering and cooperation are combined in the formulation and composition of three policy agreements. The results show how adaptable steering is made possible by opportunities for continuous communication and a shared administrative structure between regional and national actors. Furthermore, through flexibility in the roles of involved actors, particularly the national government, the policy agreements allow for consensus-making and a sense of togetherness between governmental levels. Arguably, this shows how instrument mixes can accommodate steering and cooperation in ways that can be important for central-local governance in the future. Also, the study relates to recent scholarly work on the relation between governmental levels in unitary contexts which, until recently, has been largely neglected.

To understand patient and public involvement (PPI) and its potential impact in the healthcare services more comprehensively, the social science literature on public participation in governing public services must be integrated with the health science literature. To facilitate planning and evaluation of PPI-activities, the aim of this article is to review conceptual discussions of involvement/participation and impact, and summarize and integrate these in a way that advances the conceptual understanding of impact of PPI in healthcare services. Based on the review, we present a conceptual integration chart of impact areas, categories and types. There are three overarching areas: (i) impact on individuals; (ii) impact on the health system; and (iii) impact on decision-making processes and society. The overarching areas contain the categories: (i) citizens, patients, and decision-makers; (ii) service provision, and public health; and (iii) decision-making, policy and state, and public and society. Under these categories, the most commonly encountered impact types are presented.

To ensure older individuals actively engage in healthcare service development and policymaking, it is crucial to counteract declining social and civic participation with age. It is also necessary to clarify the potential and impact of participatory activities. This study examines citizen participation among older adults in Swedish health policy development. Using Thurston et al.‘s (2005) holistic framework, the study analyzes pensioner councils (PCs) in politically governed healthcare regions. Through 13 interviews and six years of PC meeting minutes, findings from a deductive content analysis suggest that PCs build trust and foster deeper dialogues between older adults and politicians, due to their long-term nature. A trusting relationship between citizens and decision-makers may benefit society at large by enhancing the legitimacy of policy decisions. Although achieving direct policy impact is challenging, these councils serve vital participatory and deliberative democratic functions, contributing to a stronger policy community and increased transparency in the democratic process. This study highlights the complexities of assessing PCs solely based on policy influence and immediately evident outcomes, emphasizing their role in promoting democratic values, while also drawing attention to the tension between participatory and representative democracy.

Background: Caesarean section on maternal request (CSMR) is a complex ethical issue. Sweden is an intriguing case for studying CSMR due to its restrictive policy that curtail women autonomous choice regarding the mode of birth, despite overall policy developments aiming to strengthen patients' rights, promote person-centred care, and adopt a more individualized approach. This study aims to understand how the tension surrounding CSMR is manifested in Swedish media. An ethical principles approach is used to investigate what image of CSMR is created and conveyed to the public and what main arguments are used for and against CSMR.

Methods: This study covers news media and specialist press material in Sweden between March 2019 and March 2024. Searches were carried out in Retriever Research and resulted in 188 search hits. The content analysis had both an inductive and a deductive approach based on Beauchamp and Childress's four ethical principles: respect for autonomy, non-maleficence, beneficence, and justice.

Results: The analysis reveals a struggle in Swedish media over how to approach CSMR, touching on all ethical principles. Regarding autonomy, the debate focuses on whether CSMR is a medical decision about non-indicated surgery or a private choice. In terms of non-maleficence-which is the health professionals' main concern-the media highlights conflicts over interpreting risks associated with caesarean section and vaginal birth. Beneficence involves a tension between portraying vaginal birth as healthy and normal versus caesarean section as a method to protect sexual and bodily function. As regards justice, CSMR is portrayed as a challenge to the fundamental needs-principle in the healthcare system.

Conclusions: Ultimately, the ethical principles approach to analyzing the media portrayal of CSMR in Sweden highlights the need for decision guidelines and practices that are more open to a woman's own evaluation of different risks while also encouraging critical reflection on the underlying factors shaping treatment preferences for both women and healthcare professionals.

Background

Today, person-centred care is seen as a cornerstone of health policy and practice, but accommodating individual patient preferences can be challenging, for example involving caesarean section on maternal request (CSMR). The aim of this study was to explore Swedish health professionals' perspectives on CSMR and analyse them with regard to potential conflicts that may arise from person-centred care, specifically in relation to shared decision-making.

Methods

A qualitative study using both inductive and deductive content analysis was conducted based on semi-structured interviews. It was based on a purposeful sampling of 12 health professionals: seven obstetricians, three midwives and two neonatologists working at different hospitals in southern and central Sweden. The interviews were recorded either in a telephone call or in a video conference call, and audio files were deleted after transcription.

Results

In the interviews, twelve types of expressions (sub-categories) of five types of conflicts (categories) between shared decision-making and CSMR emerged. Most health professionals agreed in principle that women have the right to decide over their own body, but did not believe this included the right to choose surgery without medical indications (patient autonomy). The health professionals also expressed that they had to consider not only the woman's current preferences and health but also her future health, which could be negatively impacted by a CSMR (treatment quality and patient safety). Furthermore, the health professionals did not consider costs in the individual decision, but thought CSMR might lead to crowding-out effects (avoiding treatments that harm others). Although the health professionals emphasised that every CSMR request was addressed individually, they referred to different strategies for avoiding arbitrariness (equality and non-discrimination). Lastly, they described that CSMR entailed a multifaceted decision being individual yet collective, and the use of birth contracts in order to increase a woman's sense of security (an uncomplicated decision-making process).

Conclusions

The complex landscape for handling CSMR in Sweden, arising from a restrictive approach centred on collective and standardised solutions alongside a simultaneous shift towards person-centred care and individual decision-making, was evident in the health professionals' reasoning. Although most health professionals emphasised that the mode of delivery is ultimately a professional decision, they still strived towards shared decision-making through information and support. Given the different views on CSMR, it is of utmost importance for healthcare professionals and women to reach a consensus on how to address this issue and to discuss what patient autonomy and shared decision-making mean in this specific context.

BackgroundCare and support for children and youth with mental ill health have become more specialized and are provided by an increasing number of stakeholders. As a result, services are often fragmented, inefficient and unco-ordinated, with negative consequences for the service user and their family. Enhanced collaboration could lead to improved care and support but requires a shared understanding and a joint problem formulation between involved stakeholders to commence. The aim of this study was to explore different stakeholders' perceived problems associated with delivering care and support to children and youth with mental ill health and to discuss how the perceived problems relate to collaboration.MethodsA qualitative descriptive study was conducted, using short statements of perceived problems written by stakeholders involved in the care and support of children and youth with mental ill health during an inter-organizational workshop. The 26 stakeholders represented school and student health, primary health care, specialist care, social services, and different service user organizations. Data were collected during February 2020. Inductive content analysis with a summative approach was used when analysing the data.ResultsThe perceived problems were summarized in a model consisting of four main categories: Resources and governance; Collaboration and co-ordination; Knowledge and competence; and Stigma and confidence, containing 24 subcategories. These categories and subcategories were distributed over three levels: Societal level, Organizational level and Individual level. The perceived problems were shared on the category level but to some extent varied between stakeholder groups on the subcategory level. The perceived problems were either directly or indirectly related to collaboration.ConclusionsThe perceived problems often acted as barriers to achieving successful collaboration. The problems were distributed on all three levels in the developed model, indicating a complex problem. Even though the perceived problems were shared by stakeholders on an overall level, the findings indicate that the stakeholders did not have a completely shared understanding of the perceived problems, as they tended to focus on aspects most relevant to their own organization or perceptions. The challenge is to find which perceived problems are appropriate for inter-organization problem-solving and which can be solved within individual organizations.

Decommissioning programmes pose a substantial risk of failure compared to other change processes in healthcare. A better understanding of the challenges associated with change processes initiated by resource scarcity faced by healthcare managers is crucial. This study describes and compares department and unit managers' experiences during the implementation of a large-scale decommissioning programme in a Swedish region. A survey was developed and a cross-sectional study was performed, measuring 172 healthcare managers' experiences of (1) the region's leadership, (2) their own participation and (3) their own commitment and responsibility during the implementation of the decommissioning programme. Respondents were 50 department managers and 122 unit managers (93% and 58% response rate, respectively). There was a significant difference between department and unit managers in their experiences of the region's leadership and their own participation in the decommissioning programme. Unit managers were more dissatisfied with the way it developed compared to department managers. For example, unit managers reported a lower level of leadership support, incentives to participate, and that their knowledge and skills were not fully utilised. Involvement of unit managers in a more fruitful way might enhance the results of decommissioning programmes. This study highlights a key actor in this context: the unit manager.

Introduction

In many tax-based healthcare systems, policymakers have introduced reforms that promote provider competition with the intention of improving the quality and efficiency. Healthcare competition is usually defined spatially, with local markets often being identified as a circle around each provider. We argue that existing local market definitions can be improved to better capture actual local markets. For pro-competition reforms to potentially lead to the gains envisioned by policymakers, a crucial condition is the actual emergence of competitive markets. However, limited research has been conducted on competition in primary care markets, despite primary care constituting a vital part of a healthcare system.

Aim

The study aims to contribute to the debate on how to define local markets geographically and to examine provider competition in Swedish primary care.

Methods

A cross-sectional study was conducted using data on all individuals and all primary care providers in Sweden. Local markets were defined as: fixed radius (1 km and 3 km); variable radius; and variable shape—our new local market definition that allows markets to vary in both size and shape. Competition was measured using the Herfindahl-Hirschman index and a count of the number of competitors within the local market.

Results

Fixed radius markets fail to capture variation within and across geographical areas. The variable radius and variable shape markets are similar but do not always identify the same competitors or level of competition. Furthermore, competition levels vary significantly in Swedish primary care. Many providers operate in monopoly markets, whereas others face high competition.

Conclusions

While the variable shape approach has the potential to better capture actual markets and more accurately identify competitors, further analyses are needed. Moreover, Swedish policymakers are advised to decide whether to still pursue competition and if so, take measures to improve local market conditions in monopolies.