Pursuing the objectives of support to providers and external accountability through enabling controls - a study of governance models in Swedish primary care

BACKGROUND: The purpose of this study was to contribute to knowledge about what is regarded as an appropriate governance model in welfare markets in healthcare, from the perspective of government. The study draws on a framework about governance in healthcare systems as a continuous process of priority setting, monitoring and accountability. It relates to various dimensions of management controls; a view on management controls as a package with interdependence between different controls, a use of management controls as coercive or enabling, and implications of involving providers in the design of control systems. METHODS: The empirical material is limited to experiences of governance models used in Swedish primary care. Data from the 21 county councils responsible for organizing and financing healthcare in Sweden was gathered during 2016–2017 through a survey, interviews and document review. Data was analyzed using conventional content analysis. RESULTS: According to the county councils, governance is a continuous process. Four controls are used in all county councils: contracts, reimbursement systems, dialogue and performance measurement systems (PMS). The appropriateness of different controls is associated with their interdependence, e.g. the more formalized the use of dialogue, the more enabling the use of PMS. An appropriate governance model should on the one hand support innovations and quality improvements and on the other hand ensure external accountability for the use of allocated resources and adherence to agreements. The interviewed representatives described the intended role as both coercive and enabling but in favor of enabling. Using management controls in a way that improves the providers’ attitude towards and capacity to achieve the assigned task of delivering high-quality healthcare was described as central. CONCLUSIONS: An appropriate governance model in healthcare systems should enable governments to combine two roles: to force compliance with agreements to ensure external accountability for the use of allocated resources and to offer support to learning and quality improvement in the healthcare system. Governance can be regarded as a continuous process where several management controls operate as a package and the appropriateness of different controls is associated with their interdependence. An appropriate governance model should, from the perspective of government, encompass a high level of formalization of both coercive and enabling types of control but with greater emphasis on enabling types. Governments may pursue the objectives of support to providers and external accountability in healthcare systems by using management controls in enabling ways.