Still ‘skiing their own race’ on New Public Management implementation? Patient choice and policy change in the Finnish and Swedish health-care systems
| DOI | 10.1177/0020852318801498 |
| Author | Daniel Rauhut,Christopher J. Smith |
| Date | 01 March 2019 |
| Published date | 01 March 2019 |
| Subject Matter | Special Issue Articles |
Article
International
Review of
Administrative
Sciences
Still ‘skiing their own
race’ on New Public
Management
implementation?
Patient choice and
policy change in the
Finnish and Swedish
health-care systems
Christopher J. Smith
University of Tampere, Finland
Daniel Rauhut
University of Eastern Finland, Finland
Abstract
This article applies an agenda-setting approach to the impact of New Public
Management on health-care reform in Sweden and Finland (1993–2016). A system-
level view of agenda setting and New Public Management implementation is used to
order the historical data derived from literature reviews of each health reform process.
New Public Management is viewed as a hybrid concept rooted in the search for
efficiency gains and cost containment but, here, generating system preservation and
system change strategies, characterised as ‘public competition’ and ‘choice and
marketisation’. Sweden and Finland are viewed as ‘pragmatic modernisers’ in the
public management literature. Health-care system reform in each country was based
on similar problems and similar policy ‘solutions’, and was promoted by similar actors,
while the implementation of choice and marketisation again saw windows of opportu-
nity open in a similar manner in each. Policy divergence nevertheless occurred.
Corresponding author:
Daniel Rauhut, University of Eastern Finland, Karelian Institute, PO Box 111, Yliopistokatu 2, FI-80101
Joensuu, Finland.
Email: daniel.rauhut@uef.fi
International Review of
Administrative Sciences
2019, Vol. 85(1) 62–79
!The Author(s) 2019
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/0020852318801498
journals.sagepub.com/home/ras
We identify three key reasons for this, relating to the site and pervasiveness of conflict,
the impact of party systems, and administrative openness to outside ideas. Sweden’s
conflictual politics produced stalemate while consensual Finland produced radical
policy change.
Point for practitioners
•Finland and Sweden wanted to modernise rather than overturn the traditional
welfare settlement with New Public Management implementation.
•Similar policy problems emerged and similar solutions were forwarded, often by
similar actors and for similar reasons.
•In both countries, powerful centre-right government correlates with the promotion
of fundamental ‘choice and marketisation’ policies.
•National differences in New Public Management implementation remain.
Keywords
Finland, health care, Multiple Streams Analysis, New Public Management transitions,
patient choice, Sweden
Introduction: ideas and interests
Constrained by imperfect knowledge, time pressure and ambiguity, how do policy-
makers choose? Using Kingdon’s (1984) Multiple Streams Analysis (MSA) model,
Zahariadis (1995, 2003) addressed this in relation to privatisation in Britain and
France. Similarly, we apply MSA to the impact of New Public Management
(NPM) on health-care reform in Sweden and Finland. A system-level view of
NPM implementation is used to order the historical data derived from literature
reviews of each health sector reform process (1993–2016). We show how differen-
tial outcomes, even under similar circumstances, were generated. Following Green-
Pedersen and Walgrave (2014), our focus is on agenda change at the systemic level,
on the ‘conflict of conflicts’ (Schattschneider, 1960) rather than on specific agenda-
setting decisions relating to individual policies.
Finland and Sweden adopted NPM tools in the late 1980s to modernise their
public administrations in a ‘service-oriented’ direction (Dahlgren, 2008; Pollitt and
Bouckaert, 2003; Temmes, 1998). These changes were pragmatic and ad hoc in
nature, and did not initially impact service provision.
Cost containment emerged, particularly in Finland (Lehto et al., 2014; Saltman
and Teperi, 2016), in response to the early 1990s’ Nordic economic crisis. Health
spending recovered, but both countries continued to experience problems with
access to primary care given the decentralised nature of their health systems
(Tynkkynen et al., 2016; Vrangbaek et al., 2012). NPM-inspired policy solutions,
focusing on cost containment and efficiency (Lyttkens, 2010), were extended to
Smith and Rauhut 63
To continue reading
Request your trial