A Discursive Shift - Commissioned Reports in Swedish Health Care Governance

Background: Over the course of several decades, the organization of health care in Sweden, as in many other countries, has changed, from a dominant logic of professional dominance and political control towards managerial control through market mechanisms. A crucial motive was to increase cost efficiency. The Swedish government, as well as regional-level agencies, regularly commissions expert reports that are supposed to form the basis for decisions regarding governance, organization and control models of the health care system.Aim: The aim of this study was a) to perform a descriptive mapping of commissioned reports on Swedish health care governance and b) to perform an in-depth content analysis of a strategic sample of such reports.Method: Initially, 106 reports from both national and regional levels were gathered and analysed. A matrix was constructed, consisting of questions on who had commissioned the report, who had produced it, what problems the report set out to solve and what solutions were suggested. Further, questions were posed on whether the report was research-based and whether ethical assumptions and arguments were presented. Thereafter, a strategic sample of 36 reports was selected for an in-depth analysis, using thematic content analysis. Results: The mapping showed that the aim of the reports varied from giving an overview and to investigating effects and consequences of new steering forms, to more concrete goals, such as suggesting improvement measures. Most of the authors involved were administrators; only in rare cases were they from academic disciplines. Experts with academic degrees were in most cases from economics or business studies. The content analysis resulted in an overarching theme, Dominant discourses, and three categories: Equity as geographical sameness, Knowledge-based management and Management based on trust. Discussion: The analysed reports varied in form and content. They were mostly produced by administrators, but in some cases with input from academic researchers. The contents mirrored dominant discourses of the time but could also express conflicting values and goals. The analysis revealed examples of standardization in care, characterized by requirements to follow national guidelines, but also examples of requests for increased respect for professionals’ competence and experience.Conclusion: The great number of reports implies that the system risks requesting more information than it can handle. Further, it might result in reports where the same message is repeated in different documents, or create conflicts of interest and value tensions between different suggestions. In sum, our analysis showed a discursive shift of two trends or dominant discourses in the analysed reports, from increased standardization to arguments for trust in the system.

Working Toward Network Governance: Local Actors’ Strategies for Navigating Tensions in Localized Health Care Governance

Although network governance has become increasingly popular in both research and practice, its anticipated benefits do not always materialize. Although literature on network governance acknowledges the challenges that result from its introduction, scholars tend to assume these challenges can be managed and rarely analyze how the different participating actors (strategically) react to the tensions surrounding its establishment. As such, the process of how “networking” actors establish, maintain, and negotiate a network remains understudied. In light of these shortcomings, this article zooms in on how actors, in their collaboration efforts with network partners, navigate the tensions between (a) their discretionary space and the parameters set by a central policymaker, and (b) their pursuit of both integration and differentiation. This ethnographic case analysis contributes by, first, revealing how local actors demonstrate agency in maneuvering between these tensions in everyday practice by adopting three strategies—that is, overwhelmed deflection, situational segmentation, and strategic reappropriation—and, second, by revealing how these tensions interact and subsequently affect the implementation of policies in networks.

Legitimating complementary therapies in the NHS: Campaigning, care and epistemic labour

Questions of legitimacy loom large in debates about the funding and regulation of complementary and alternative medicine (CAM) in contemporary health systems. CAM’s growth in popularity is often portrayed as a potential clash between clinical, state and scientific legitimacies and legitimacy derived from the broader public. CAM’s ‘publics’, however, are often backgrounded in studies of the legitimacy of CAM and present only as a barometer of the legitimating efforts of others. This article foregrounds the epistemic work of one public’s effort to legitimate CAM within the UK’s National Health Service: the campaign to ‘save’ Glasgow’s Centre for Integrative Care (CIC). Campaigners skilfully intertwined ‘experiential’ knowledge of the value of CIC care with ‘credentialed’ knowledge regarding best clinical and managerial practice. They did so in ways that were pragmatic as well as purist, reformist as well as oppositional. We argue for legitimation as negotiated practice over legitimacy as a stable state, and as labour borne by various publics as they insert themselves into matrices of knowledge production and decision-making within wider health care governance.

Global Prison Health Care Governance and Health Equity: A Critical Lack of Evidence

The large and growing population of people who experience incarceration makes prison health an essential component of public health and a critical setting for reducing health inequities. People who experience incarceration have a high burden of physical and mental health care needs and have poor health outcomes. Addressing these health disparities requires effective governance and accountability for prison health care services, including delivery of quality care in custody and effective integration with community health services. Despite the importance of prison health care governance, little is known about how prison health services are structured and funded or the methods and processes by which they are held accountable. A number of national and subnational jurisdictions have moved prison health care services under their ministry of health, in alignment with recommendations by the World Health Organization and the United Nations Office on Drugs and Crime. However, there is a critical lack of evidence on current governance models and an urgent need for evaluation and research, particularly in low- and middle-income countries. Here we discuss why understanding and implementing effective prison health governance models is a critical component of addressing health inequities at the global level.