Balancing competing rationales in priority-setting in primary healthcare - an interview study on political governance

Publicly funded healthcare systems struggle to govern and determine how finite resources should be allocated in relation to political goals within a pre-determined budget. Primary healthcare (PHC) has a central multipurpose function, not least in terms of political strategies, but PHC governance is still largely underexplored. The aim is to explore how politicians responsible for making decisions pertaining to healthcare coverage navigate the governance of public PHC and disentangle it in the form of narratives based on different types of underlying rationales.

Semi-structured interviews were conducted with 15 politicians from 3 Swedish regional healthcare authorities. The data were analysed abductively based on scientific, clinical and cultural rationales using thematic content analysis.

Our study provides insights into how PHC's multipurpose function implicates tensions between politicians' different responsibilities regarding healthcare coverage. It shows how politicians navigate various coexisting rationales, with some being more dominant than others and where tensions also exist between them. In this balancing act, they create narratives addressing different stakeholders and priority-setting dilemmas, reflecting the diverse rationales. Our study reveals that politicians play a crucial role in PHC governance and priorities, balancing rationales that might otherwise become overly dominant.

This paper contributes new knowledge by displaying how politicians balance tensions within and between rationales through different narratives regarding goals/commissions, problematic situations and preferred solutions in PHC governance.