Still ‘skiing their own race’ on New Public Management implementation? Patient choice and policy change in the Finnish and Swedish health-care systems

Abstract

This article applies an agenda-setting approach to the impact of New Public Management on health-care reform in Sweden and Finland (1993–2016). A system-level view of agenda setting and New Public Management implementation is used to order the historical data derived from literature reviews of each health reform process. New Public Management is viewed as a hybrid concept rooted in the search for efficiency gains and cost containment but, here, generating system preservation and system change strategies, characterised as ‘public competition’ and ‘choice and marketisation’. Sweden and Finland are viewed as ‘pragmatic modernisers’ in the public management literature. Health-care system reform in each country was based on similar problems and similar policy ‘solutions’, and was promoted by similar actors, while the implementation of choice and marketisation again saw windows of opportunity open in a similar manner in each. Policy divergence nevertheless occurred. We identify three key reasons for this, relating to the site and pervasiveness of conflict, the impact of party systems, and administrative openness to outside ideas. Sweden’s conflictual politics produced stalemate while consensual Finland produced radical policy change. Point for practitioners: • Finland and Sweden wanted to modernise rather than overturn the traditional welfare settlement with New Public Management implementation. • Similar policy problems emerged and similar solutions were forwarded, often by similar actors and for similar reasons. • In both countries, powerful centre-right government correlates with the promotion of fundamental ‘choice and marketisation’ policies. • National differences in New Public Management implementation remain.