Steering health and social care through quasi-markets

Municipalities and county councils try a multitude of different strategies when they design and steer health and social care markets to ensure that goals such as quality and equity are met. Depending on the strategies used, different problems arise. The aim of this thesis is to examine how local authorities can design quasi-markets in a way that achieves public goals such as equity and high quality. To answer the aim, four empirical studies were carried out. The studies show that when designing a market by contracting-out through public procurement, the issues lay primarily at specifying and defining what is meant by quality before a service is privatized. This is especially difficult to do concerning soft areas such as elder- and healthcare. If this is not done properly, it can lead to crucial issues for monitoring quality since the contracting authority cannot hold the provider responsible for delivering an aspect of a service if that aspect is not specified in the contract. When a market is designed as in the patient choice systems in primary care, it creates a whole other set of difficulties for the local governments. Here, it is not as important to specify quality beforehand in the contracts since quality monitoring is done retrospectively by both the counties themselves as well as the patients who with their choices can monitor quality by punishing providers with poor quality by registering with another provider. Instead, the crucial problem is how to design reimbursement system that will lead to an equal access to health care. In this respect, the county councils utilize different methods. However, despite these measures, the primary care choice reform have led to inequity, both geographical inequity in regards to where new private primary health care centres are located but also, to a larger degree, socio-economic inequity relating to what kind of socio-economic groups of individuals are registered with private PHCCs. In other words, county councils do not manage to fully counteract risk selection behaviour by the design of their reimbursement system which could imply issues with unequal access to health care