The Introduction of Choice in Scandinavian Hospital Systems. Arguments and Policy Processes in the Danish and the Norwegian Case

This paper describes a comparative study between free choice of hospital in Denmark and Norway. The starting point for the study is that the Scandinavian health care system has historically been dominated by a decentralized welfare state tradition. There has been a strong emphasis on equity and regional democratic control through the county institutions. To introduce free choice of hospital in this type of system is a challenge for a number of existing perceptions, structures and procedures in the Scandinavian system. From a system level perspective the planning capacity and the strong link between a given regional population and chosen level of public service are weakened. From a user perspective the relationship between the individual citizen and the health care system changes in the sense that patients become more empowered, when they can choose hospital. With this starting point the paper present an analysis of the arguments and the policy process for introducing free choice in the two countries. The analysis is made from two theoretical perspectives. First, from a rational perspective and second from a garbage can perspective. The results of the study show that even if there are large similarities between the two countries there are also large differences. That concerns timing, rhetoric and content of legislation. The explanation to the differences can help us to understand who it was possible to introduce free choice of hospital in the two countries. In Denmark it was possible because of the general consensus on the fashionable idea of choice that opened a political window for action. While in the Norwegian case it was possible because the government wanted to put pressure on the health sector in order to create better planning and use of resources. In Denmark the initial implementation of choice was adjusted to the dominant policy objectives of macroeconomic control through regional planning, while in Norway the chosen solution reflects a more limited concern for expenditure control and a greater willingness to experiment