Responsibility beyond accountability: Navigating trust and control in Swedish primary care purchasing

In the wake of critiques of New Public Management and evidence-based medicine, alongside concerns about welfare fraud, demands for trust, control, and evidence risk being framed as existential either-or choices. This paper rethinks healthcare governance beyond such polarisation by combining Antje Vetterlein's concepts of responsibility and responsibilisation with Guido Möllering's distinction between the duality and dualism of trust and control. Using abductive document analysis, we examine contract documents regulating purchaser-provider relations in all twenty-one Swedish regions (2025), focusing empirically on improving continuity of care. We show how contracts articulate moral and causal responsibility and how follow-up arrangements specify who judges responsibility and on what grounds. From this analysis, we derive three ideal-type governance modes: delegated (centring moral responsibility and professional discretion), formalised (defining causal responsibilities with codified metrics and consequences), and negotiated (processing responsibility through dialogue and mutual adjustment). Across modes, trust and control are typically interdependent (duality) and can be mutually reinforcing. When positive expectations break down (e.g., suspected welfare fraud), they flip into opposing forces (dualism). We conclude that governance choices are ultimately choices about responsibility. Different configurations of responsibility not only organise trust and control in distinct ways but also shape what it means to act as a responsible provider. Navigating governance is therefore not about choosing trust or control, but about deciding how responsibility should be organised and cultivated. A key finding is that dialogic arrangements can cultivate moral responsibility without displacing causal responsibilities.