Objectives, actors and accountability in quasi-markets: Studies of Swedish primary care

Abstract: Following public sector reforms inspired by New Public Management, new structures and processes intended for actors to coordinate their activities have been introduced in the public sectors in Northern Europe since the 1980s. Partly, the focus on structural change has evolved around creating market-like structures.Quasi-markets can be regarded as a structure for governance where market mechanisms should lead to improved quality, efficiency and responsiveness without adverse consequences for equity. Private and public providers who are publicly paid compete for citizens to use their services and citizens are free to choose a provider in line with their preferences. Also in Swedish primary, recent reforms involve expanded choice of provider for the population combined with freedom of establishment and privatization of providers. In this thesis, a theoretical model for governance in quasi-markets, taking into account actors, objectives and mechanisms of accountability is developed and empirical analyses related to objectives, actors and accountability in the context of Swedish primary care are conducted. Accountability is treated as a mechanism between principals and agents, where principals assess agents activities against their expectations on services and pass judgment on their conduct. In quasi-markets, providers (agents) are accountable for their conduct to both citizens and governments (principals). The accountability relationship between citizens and providers is choice. The accountability relationship between the government and providers is a horizontal accountability relationship, whereby governments provide resources and delegate power and responsibilities for collective objectives to providers by means of agreements or contracts. The theoretical model as well as the studies on Swedish primary care (three published articles) show that mechanisms for corrective action related to choice is not sufficient for quasi-markets to achieve its intended aims of improved quality, responsiveness and efficiency without adverse consequences for equity. Dual accountability relationships need to be established and maintained. Accountability relationships related to citizens are appropriate for objectives related to quality and responsiveness of services towards individuals. But traditional accountability relationships related to governments have to be maintained to avoid adverse consequences and to achieve traditional objectives related to other aspects of quality, efficient use of resources and equitable distribution of services.

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