Department of Public Health and Caring Sciences, Uppsala University, Box 564, 751 22 Uppsala, Sweden.
Soc Sci Med. 2019 Sep;237:112464. doi: 10.1016/j.socscimed.2019.112464. Epub 2019 Jul 30.
Disinvestment in health services is seen as challenging by decision-makers as the public usually reacts strongly to rationing and retrenchments. Drawing on the literature on welfare state retrenchment - the reduction of public expenditure by cutting costs or spending - this article explores the development and implementation of a comprehensive retrenchment programme in one local health system in Sweden (a so-called region). According to theory, retrenchments are both electorally risky and institutionally difficult. Nonetheless, they take place and in the local health system we investigate, without too extensive public protest and without decision-makers having to resign. The main question in this qualitative study is: why and how was it possible to make such comprehensive retrenchments despite being unpopular and facing many political and institutional barriers? Interviews with 18 local politicians and public servants were carried out between January 18 and April 3, 2017, and analysed from the perspective of political strategy. They showed that the serious budget deficit, and a shared understanding of what the region's problems were, are important explanations for why the retrenchment programme was possible to develop and implement. Based on a thorough internal review of the health system, a crisis discourse developed which partly depoliticized the retrenchment programme. Justification and framing are keys to how it was possible. The retrenchment programme was justified by arguing that current service provision exceeded that in comparable regions, and framed as necessary saving the local health system and enhancing quality. Important strategies were thus to redefine the retrenchments and to blame-share, the latter through politicians and public servants claiming responsibility together after involving the clinic managers. In sum, our study shows that the retrenchment literature and theories on political strategy may be fruitfully applied to the health-care sector as well. By studying the local level, our findings contribute to the retrenchment literature, indicating that political strategy at the local level is more about justification and blame sharing, than blame avoidance.
决策者认为，对卫生服务的投资减少是一项挑战，因为公众通常对配给和裁员反应强烈。本文借鉴福利国家紧缩政策（通过削减成本或支出来减少公共支出）的文献，探讨了瑞典一个地方卫生系统（一个所谓的地区）全面紧缩计划的制定和实施。根据理论，紧缩政策在选举中存在风险，在制度上也存在困难。尽管如此，这些紧缩政策还是在我们调查的地方卫生系统中实施了，而且没有引起太大的公众抗议，也没有决策者因此辞职。这项定性研究的主要问题是：为什么以及如何在不受欢迎且面临许多政治和制度障碍的情况下实施如此全面的紧缩政策？2017 年 1 月 18 日至 4 月 3 日，对 18 名地方政治家和公务员进行了访谈，并从政治策略的角度进行了分析。结果表明，严重的预算赤字以及对该地区问题的共同理解，是实施紧缩计划的重要原因。在对卫生系统进行彻底的内部审查的基础上，制定了一项危机话语，部分使紧缩计划非政治化。有充分的理由和框架来解释为什么这是可能的。通过争辩当前的服务提供超过了可比地区，为紧缩计划提供了充分的理由，并将其框定为拯救当地卫生系统和提高质量的必要措施。因此，重要的策略是重新定义紧缩计划，并共同承担责任，即通过政治家和公务员在让诊所经理参与后共同承担责任，来推卸责任。总之，我们的研究表明，紧缩文献和政治策略理论也可以成功地应用于医疗保健部门。通过研究地方层面，我们的研究结果为紧缩文献做出了贡献，表明地方层面的政治策略更多的是关于理由和责任分担，而不是避免指责。
