Deeply Rooted Traditions and the Will to Change-Problematic Conflicts in Three Swedish Health Care Organizations

Article excerpt

The Need for Change in Swedish Health Care Organizations

The health care sector in Sweden has had two major problems to deal with during the last decade. The first is long waiting lists at hospitals, and the second is recurrent deficits in operating statements. On one hand there is a need for increased treatment and more surgeries, and on the other it is increasingly difficult to finance the operations. For some of the health care entities, the financial development has resulted in an equity ratio close to zero and a rather weak financial position.

In Sweden the county councils are responsible for the major part of the health care services. The regions and the councils can be regarded as large health care organizations governed by directly elected politicians. The constitution states that these organizations are autonomous; thereby the politicians (and managers) have the opportunity to make, and responsibility for making, necessary changes. But the regions and councils are not independent of the State. The government controls some of their financial resources and the National Board of Health and Welfare some of their operations.

If change is not initiated and implemented by the actors in the organizations' subunits, the responsible politicians and managers have to engineer it. Political decisions about priorities and cutbacks seem to be necessary, but for this to happen two conditions must be fulfilled. The first is that politicians and top managers that are responsible for producing the foundations for the decisions are aware of the problem. Lack of awareness can of course cause an unwanted status quo. The second is that they must have the strength to implement measures. It is not hard to imagine that there can be resistance against top-level decisions in health care organizations. Politicians and managers must be able to control the implementation process. This reasoning means that there are three situations where necessary measures will not be taken:

1. When politicians and managers lack awareness of the problem-in spite of implementation strength.

2. When politicians and managers lack the strength to implement measures-in spite of awareness of the problem.

3. When politicians and managers lack both awareness and strength.

Our overall research question is, Which are the constraints to implementing change? Our contribution to an already well-investigated question is a consequence of the way we illuminate the described phenomenon and our theoretical perspective.

Purpose, Case, and Method

The purpose of this article is to explain why necessary change has not occurred in Swedish health care organizations. The analysis is based on an institutional perspective and is limited to intra-organizational impediments to change. More specifically we are investigating whether the lack of change can be explained by lack of awareness of the problem, lack of strength to engineer change, or both in the executive health care organization management.

In order to answer the question, three case studies have been carried out. Case studies are appropriate when a phenomenon needs to be investigated in depth, and our judgment is that there was need for deep understanding of the development in a few health care organizations rather than shallow understanding of several.

For our case studies we wanted three health care organizations that fitted well in the general description of the problems in the health care organization sector. We found that Dalarna, Gavleborg, and Vastmanland matched this criterion. They had all faced a period of more than ten years of financial stress and long waiting lists for surgeries and treatments. There was (and had been for some time) need for change, but change had not occurred. The three counties are geographically located in the middle of Sweden and have approximately a quarter of a million inhabitants each. …