Neoliberal reforms in Nordic primary care: can social equity be preserved?

The Nordic countries are known for their publicly financed, solidaristic health care systems, where the role of the state traditionally has been strong. In these systems, social equity has long been a central political principle, which has been manifested both in equal access to care and attempts to reduce differences in health outcomes between social groups. Despite this policy legacy, neoliberal ideas promoting market competition, privatization and consumer choice came to exert a strong influence in Nordic health care after the 1990s. As a result, the provision of care (particularly primary care) has come to be organized like welfare markets, which implies that the provision of social services is undertaken by a mixture of public and private organizations competing for public funding. The Nordic welfare markets, even though different in their specific forms, reflects an attempt to combine a solidaristic financing structure with a neoliberally inspired model for care provision. Despite such efforts, there are indications of access to care having become less egalitarian in the wake of market reforms. In addition, social equity is undermined by the growing social and ethnic divisions in the Nordic countries, which became manifest not least during the COVID-19 pandemic, where mortality rates were significantly higher in immigrant communities than among the population at large. In this paper, neo-liberal reforms in primary care is critically analyzed in three Nordic cases; Sweden, Norway and Denmark. The aim is to understand in what ways such reforms came to exhibit different combinations of state and market elements in the three cases and what shifts in values they represent. Notably, market reforms have been most radical in Sweden, which went from a system of virtual public monopoly on primary care provision to welfare markets dominated by large private equity firms. In Denmark and Norway, the primary care markets are still dominated by self-employed GPs. By tracing policy choices and reform outcomes in the three cases between 1990 and the early 2020s, the paper seeks to uncover how previous policy institutions shaped neoliberally inspired reforms during this period. In particular, it investigates how long-standing goals of social equity and public governance were weighed against new means to enhance efficiency and consumer orientation through market competition and how policy choices came to reflect different ways to integrate these conflicting goals.