The Decentralized Path Challenged? Nordic Health Care Reforms in Comparison

In this paper we present alternatives for describing and explaining the developments of Nordic health care in general and hospitals in particular. The backdrop is the Norwegian hospital reform of 2002, a reform that seems to part with predominant conceptions of health care as a local political responsibility. Although Norway, Sweden and Denmark appear to have been on similar pathways with a history of relatively decentralized and welfare-oriented health care systems, there are differences among them that should not be overlooked. The idea is to look at how slightly different development dynamics and actor constellations may produce different results, e.g. as a consequence of reforms. One question raised is whether current development patterns signify a break with the Nordic decentralized path in healthcare organization. We argue that it is necessary to understand how the decentralized path was created in each case in order to understand the dilemmas involved in the contemporary governances structures, with a possible trend towards the unmaking of the traditional model of decentralized welfare provision. We focus on the emergence of neo-liberal ideas such as purchaserprovider models, extended patients’ choice, and activity-based funding, and why such models and experiments gained a stronger impact in Sweden than in Norway and Denmark. Norway’s reform is a delayed reform, but it is also a reform pointing in a new direction. It was delayed in the sense that much of what is now introduced has been introduced previously in other countries, particularly in Sweden. The reform is also innovative, however, due to its emphasis on state ownership, and it thus represents a challenge to the Nordic decentralized model of health care. Denmark’s uniqueness consists in not having undertaken any major reform yet, although healthcare has become an increasingly contested topic in Denmark, and something may be about to happen. Concluding that reform dynamics has played out somewhat differently in each case, we discuss the prospects of an end of the decentralized political-professional regimes. The emerging regime, exemplified by Norway, may not accurately be described as a combination of ‘managers and markets’ (a term used to characterize the situation in the United States), but rather as a regime of managers and state enterprises that compete with each other under public-professional stewardship