Implementing quality of programmes in three Swedish county councils: the views of politicians, managers and doctors

This articles deals with quality assurance within the Swedish health care system at the regional and local levels. The overriding issue concerns the degree to which changes in Swedish health care in recent years with respect to increased freedom of choice for the individual, the purchaser-provider split and new forms of financial reimbursement have affected quality assurance. Special attention is directed toward the relationship between the political-administrative level in the county councils and the medical profession at the local level. Since political responsibility for health care is strongly decentralized and different organizational solutions can be found, Sweden offers a good opportunity for systematic comparisons within the health care sector. Following an overview of certain national initiatives with regard to the quality of health care, three Swedish county councils are compared. The aim is not to provide a general overview of the situation in Sweden with regard to quality assurance, but to compare the strategies and outcomes in county councils with different organizational configurations. The study is based on 35 interviews conducted in 1995 with health care politicians, health care administrators, hospital directors and clinical department heads. The article concludes that indirect incentives can be very strong factors in affecting care providers' active interest in quality assurance. This interest is aroused when providers feel they are in competition in that the number of patients decreases, or in that their activities are being called into question, such as in the form of discussions about possible structural changes in the county council.