Politics of Horizontal Public Sector Coordination - The Case of Frail Elderly Policy in Sweden 2008-18

The quality of care for frail elderly people is highly dependent on the coordination of health care and social services by responsible agencies and organizations. In theory, such public sector coordination can be done through hierarchy, markets, networks, and collaboration. In Sweden, coordination of frail elderly politics is traditionally made through multi-level networks and collaboration in local-regional coordination bodies. Although Swedish local governments are by law obliged to coordinate these social services with regional county government health care, how this is done has been up to the local and regional authorities themselves to decide. This has led to the development of a complex, more or less spontaneous growth of governance networks and collaboration through local-regional coordination bodies, sometimes shaped by partnerships through local-regional government associations stretching across county borders, or residing within the borders of a single county. These coordination bodies contain politicians and administrators representing local government’s social services and regional government’s health care, public and private service providers, and representatives of local-regional associations and citizen interest organizations. However, during the last decade this decentralized model of coordinating organization and processes for quality is increasingly challenged by national governance efforts to balance or centralize coordination trough hierarchy and markets. Since 2008, national government by law enable coordination by forcing regional county government to implement markets for health care, and give incentives to local governments that implement corresponding local markets for elder care, combined with the introduction of national audit through yearly updated performance indicator measurement systems. Given the complex pattern of horizontal management in the governance of frail elderly peoples’ services, coordination more strictly through hierarchy has also been imposed by national government. In 2010, a five year comprehensive program for coordinated social and health care for frail elderly was introduced with the aim to centralize and balance political governance through instruments of hierarchy and networks of state authorities and national interest organizations. The goal was to achieve a sustainable coordinated quality for frail elderly in need of both social services and health care, equally distributed across Sweden. However, recent research indicates remaining significant differences between local-regional bodies in their perception of quality coordination. By analyzing the Swedish case of ways to coordinate governance for a closer proximity to the needs of frail elderly people, the purpose of this paper is to develop a theoretical framework based on previously suggested conceptualization of the politics of public sector coordination, and to apply this framework in an analysis of policy change 2008-18. The research questions are: How have the description of the policy problem, values and recommendations changed during the last decade? How is the implementation of the new policy assumed to effect politics of horizontal management, local-regional political leadership and collaborative governance? The paper is part of the Sustainable Quality Coordination project How to coordinate governance of social services and health care for frail elderly persons, funded by FORTE (Swedish Research Council for Health, Working Life and Welfare) within the initiative Research on the quality, organization and processes of welfare.