Consequences of a decentralized healthcare governance model: Measuring regional authority support for patient choice in Sweden Mio Fredriksson * , Ulrika Winblad Health Services Research, Department of Public Health and Caring Sciences, Uppsala University, Uppsala Science Park, 751 85 Uppsala, Sweden article info Article history: Available online 30 April 2008 Keywords: Sweden Patient choice Equality Healthcare policy Healthcare politics Soft governance abstract What are the implications of a decentralized model of healthcare governance? This case study on patient choice in Sweden is an attempt to shed light on this issue. Due to decen- tralization and constitutional rights of self-determination, the regional authorities in Sweden, called County Councils (CCs), have far-reaching rights to manage the healthcare sector. The fact that patient choice is considered to be a soft law or a soft governance reg- ulation, opens it up to regional variation. To examine the CCs level of support of patient choice, an index is presented. The Patient Choice Index (PCI) shows that there is extensive variation among the CCs. To explain the causes of these variations, a number of hypotheses are tested. The analyses imply that ideology and economy, and more specifically the CCs’ governing majorities and running net profits, are major explanations for the level of support. A number of conclusions can be drawn from the results of this study. In short, the CCs appear to act according to a local point of view, which means that there is no functioning national patient choice standard, and thus patients do not have equal access to healthcare and patients’ rights are unevenly distributed. Furthermore, the CCs’ financial conditions and governing majorities seem to undermine equivalent reform realization in a national context. In summary, the results of this study emphasize the conflict between regional self-governance and national equality, which is particularly visible in the decentralized Swedish healthcare model. Ó 2008 Elsevier Ltd. All rights reserved. Introduction In Sweden, as well as in other Scandinavian countries, healthcare has always been a central part of the welfare state. Universalistic and solidaristic welfare programs comprise the main guiding principle in this type of welfare regime, often described as ‘social democratic’ (Esping- Andersen, 1990). The political agenda, principles and guidelines for healthcare are established by the central government. However, the Swedish central government is not involved in the actual production of healthcare. Instead, almost all healthcare in Sweden is administered by regional political authorities called County Councils (CCs). The CCs are governed by democratically elected assemblies and have far-reaching constitutional rights to manage the healthcare sector as well as to levy taxes to finance the provision of healthcare (Glenngård, Hjalte, Svensson, Anell, & Bankauskaite, 2005). From a European perspective, the Swedish healthcare system must be considered highly decentralized. In Europe, decentralization has been on the political agenda for the past decade. However, the concept of decen- tralization is often used vaguely. From a healthcare perspec- tive it is important to distinguish between responsibilities for the delivery, financing and arranging/planning of healthcare (Vrangbaeck, 2007). In Sweden, all these func- tions are decentralized. The CCs are responsible for the ac- tual healthcare delivery, both private and public, and carry * Corresponding author. Tel.: þ46 186113575; fax: þ46 18506404. E-mail address: Mio.Fredriksson@pubcare.uu.se (M. Fredriksson). Contents lists available at ScienceDirect Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed 0277-9536/$ – see front matter Ó 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2008.03.025 Social Science & Medicine 67 (2008) 271–279