Umeå University's logo

This article deals with agreements within healthcare in Sweden, a unitary state where responsibility for healthcare is decentralized to 21 regions with self-rule. The agreements are concluded by the central government and the Swedish Association of Local Authorities and Regions (SALAR). The literature categorizes agreements as a ‘soft’ policy instrument with participation as a crucial aspect. We investigate the process behind the agreements and focus on the participation of SALAR. Our material consists of interviews with respondents of SALAR and the Ministry of Health and Social Affairs. The findings suggest that the process is participatory, but not in all aspects. Differences are noticed during various phases. A conclusion is that the power relationship between the central government and SALAR is unequal. The results contribute to a more nuanced understanding of central–local relations in the era of multi-level governance, highlighting a power hierarchy.

Purpose – In Sweden, a decentralized unitary state, the 21 self-governing regions are responsible for healthcare. A governing tool in the relations between the central government and the regions is the use of “national agreements”. The literature describes agreements as soft policy instruments, meaning they are voluntary, nonbinding and lack detail. Our purpose is to analyse the content of national agreements in Swedish healthcare to explore their characteristics.

Design/methodology/approach – We use document analysis to investigate whether the content of the nationalagreements in Swedish healthcare is primarily general or specific in terms of stated goals, measures, disbursement and review. The analysis includes eight agreements from 2022.

Findings – The content varies in specificity and detail across agreements in healthcare, some being specificwhile others are more general and broadly formulated. An important conclusion is that agreements within the same policy area can have different characteristics. Agreements are inherently “soft”, but with potential variations in their application and consequences.

Originality/value – Due to their high level of detail and scope, agreements may pose a challenge to the principle of regional self-government. This could limit the regions’ discretion to set their own priorities and makenecessary adjustments, ultimately impacting both efficiency and accountability within healthcare.

Artikeln syftar till att analysera den författningsmässiga regleringen av de svenska kommunerna i en kontext av ett flernivåstyre. Vi menar att utvecklingen mot ett flernivåstyre har skapat en ökad diskrepans mellan den skrivna och den levande författningen. Denna diskrepans tar sig främst i uttryck i att allt fler välfärdsuppgifter har decentraliserats till regional och lokal nivå, samtidigt som det har skapats informella strukturer på central nivå för att koordinera själva styrningen över dessa uppgifter. Förutom att illustrera denna diskrepans är vår artikels bidrag också att redovisa författningspolitiken kring en tydligare precisering i grundlag av dels kommunernas ansvarsområden, dels samrådet mellan stat och kommun. Vi lyfter särskilt frågan om behovet av att reglera samrådet mellan stat och kommun med inspiration från lösningar i andra europeiska länder. 

This article aims to analyse the constitutional regulation of Swedish municipalities within the context of multi-level governance. We argue that this context has led to an increasing discrepancy between the ’written’ and the ’unwritten’ constitution. This discrepancy has primarily been seen in the growing decentralization of welfare tasks to municipalities. At the same time, informal structures have been created at the central level to coordinate the governance of these tasks. In addition to highlighting this discrepancy, the article also explores the constitutional debate regarding those issues. We discuss the need to address the formal mechanisms of subnational consultations at the central level. When comparing Sweden to its Nordic neighbours, these mechanisms are relatively underdeveloped, especially when considering the role of the local government association.