Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
Arctic Research Center (Arcum) at Umeå University, Umeå, Sweden.
BMC Health Serv Res. 2023 Nov 9;23(1):1226. doi: 10.1186/s12913-023-10212-4.
In line with international trends acknowledging the importance of Primary Health Care (PHC) for improving population health and reducing health inequalities, the Swedish health system is undergoing a restructuring towards the coordinated development of a modern, equitable, accessible, and effective system, with PHC principles and functions at its core. Since discursive analyses of documents underpinning PHC reforms are scarce in Sweden and beyond, the aim of this study was to explore how the reorientation towards good quality and local health care has been represented in official government reports.
Based on a policy-as-discourse analysis, four Swedish Government Official Reports underpinning the good quality and local health care reform were interrogated following four questions of Bacchi's "What's the Problem Represented to be?" (WPR) approach. By applying the first WPR question, concrete proposals guiding the reorientation were identified, analyzed and thematized into candidate problem representations. These problem representations were then analyzed in relation to previous empirical and conceptual research considering WPR questions two and three, which resulted in the development of three problem representations. Potential silences that the problem representations might produce were then identified by applying WPR question four.
The three problem representations connected the Swedish health system "problem" to a narrow mission, a siloed structure, and a front-line service disconnected, especially from the needs and preferences of individual patients. By representing the problem along these lines, the analysis also illustrated how the policy reorientation towards good quality and local health care risk silencing important PHC aspects such as health promotion, equitable access, and human resources.
The results from this study indicate that as discursively framed within concrete proposals, government official reports in Sweden represent the health system problem in particular ways and with these problem representations overlooking several aspects that are central to a health system characterized by PHC principles and functions. In the continued reorientation towards good quality and local health care, these silences might need to be acknowledged.
为了遵循国际趋势，认识到初级卫生保健（PHC）对改善人口健康和减少健康不平等的重要性，瑞典的卫生系统正在进行结构调整，以协调发展一个现代、公平、可及和有效的系统，以 PHC 原则和功能为核心。由于瑞典和其他国家对支持 PHC 改革的文件进行话语分析的情况很少，因此本研究旨在探讨重新关注高质量和当地卫生保健是如何在政府官方报告中体现的。
基于政策话语分析，本文通过 Bacchi 的“问题代表什么？”（WPR）方法的四个问题，对支持高质量和当地卫生保健改革的四份瑞典政府官方报告进行了质询。通过应用第一个 WPR 问题，确定了指导重新定位的具体建议，并对其进行了分析和主题化，形成了候选问题表述。然后，根据前两个 WPR 问题的分析，考虑到先前的实证和概念研究，对这些问题表述进行了分析，从而形成了三个问题表述。通过应用第四个 WPR 问题，确定了这些问题表述可能产生的潜在沉默。
这三个问题表述将瑞典卫生系统的“问题”与狭隘的使命、孤立的结构以及与一线服务脱节联系起来，尤其是与个别患者的需求和偏好脱节。通过沿着这些路线来表述问题，分析还说明了，政策向高质量和当地卫生保健的重新定位如何有可能使 PHC 的一些重要方面（如健康促进、公平获得和人力资源）被忽视。
本研究的结果表明，正如在具体建议中所论述的那样，瑞典政府官方报告以特定的方式来论述卫生系统的问题，而这些问题表述忽视了 PHC 原则和功能所构成的卫生系统的几个核心方面。在继续向高质量和当地卫生保健重新定位的过程中，这些沉默可能需要被承认。
