Momentum of Coordination Reform: Changing Rehabilitation Policies and Practices? A Critical Discourse Analysis

Background: The Norwegian Coordination Reform was implemented in 2012 as an open-ended, progressing reform. It aims to orient all systems and services towards assisting individuals with coping with life or restoring normal functioning in coordinated manners, changing budget allocations and task sharing between specialist and municipal health care levels. Reflecting both medical and socio-political discourse, the reform’s White Paper resonates with the main principles of rehabilitation and increases its focus. However, the reform’s influence on the conceptualization and practice of rehabilitation has been uncertain. Henceforth, this thesis is an analysis of rehabilitation discourse in the context of Coordination Reform. Purpose: The purpose of the thesis is to discuss the ways current logics of health policies affect how the meaning of rehabilitation is constructed. Aim is to critically explore rehabilitation meaningmaking on the level of discourse by analyzing language use in political documents and among rehabilitation professionals. Design: The study applies critical discourse analysis (CDA). Data included two Norwegian White Papers submitted in 1999 and 2009 (White Paper No. 21, “Responsibility and Coping: Towards a Holistic Rehabilitation Policy” (St.meld. nr. 21 (1998-99)) and White Paper No. 47, “Coordination Reform. Proper Treatment – At the Right Place and the Right Time” (St.meld. nr. 47 (2008-2009)), and 176 pages of transcribed interviews with 19 rehabilitation professionals conducted in 2015. Findings and discussion: The thesis’ three research articles were written on the basis of policy documents (Article I), on interviews with rehabilitation professionals (Article II), and on an analytical synthesis of the two sets of primary analyses (Article III). The analysis of the policy documents revealed a discourse of reaction, a discourse of action and a discourse of pro-action. These are based in different positioning of the medical and socio-political conceptual models, and reflect whether rehabilitation is a service provided after occurred illness or injury, as an active and effective stance by all individuals concerned, or as health promoting and preventive approaches. The analysis of the transcribed interviews showed that rehabilitation is construed in four ways: As a catalyst for a meaningful living, as professional performance, as constraint factor, and as a normative stimulus for independence. The interview discourses reflect different positioning of the subjects involved and the different goals which relates to rehabilitation processes. The synthesis of the analyses of policy documents and transcribed interviews identified two nodal discourses: Rehabilitation as a clinical practice and rehabilitation as a management practice. These discourses serve different purposes, as the first is based in traditional medical science as a means for political action and relates to the body as an object that is a matter to government policies and practices. The other relies on the individual as a subject of life regulation governance. The management perspective of rehabilitation has gained force in the reform initiated constraint in service availability, including shorter stays with rapid discharge from hospitals to municipalities or home, and the policy emphasis on independency and self-management. The synthesis suggests that the reform strategies are fundamental to understanding the logic of current rehabilitation discourses