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.