Open the black box: paradoxes and lacunas in Swedish health care reforms

The idea of using contracting-out as a means for improving public administration dates back to the 1850s, but was then found to be infeasible. The same idea has now become a major building-block in Sweden's health care reforms. Driven by a productivity-focused political discourse and the premises of neoclassical economics, these reforms ignore motivational structures among health care staff. The result may be a delegitimizing of the welfare state from within--either through the extinction of care rationality and its replacement by wage rationality, or, at worst, through the spread of a commercial spirit among health care staff and/or staff frustration at the unavoidable downward adjustments in remuneration rates. The author points to three strategic choices that arise when insights from a labor-process perspective are taken into consideration.