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Sandberg, J., Persson, B. & Garpenby, P. (2019). The dilemma of knowledge use in political decision-making: National Guidelines in a Swedish priority-setting context. Health Economics, Policy and Law, 14(4), 425-442
Open this publication in new window or tab >>The dilemma of knowledge use in political decision-making: National Guidelines in a Swedish priority-setting context
2019 (English)In: Health Economics, Policy and Law, ISSN 1744-1331, E-ISSN 1744-134X, Vol. 14, no 4, p. 425-442Article in journal (Refereed) Published
Abstract [en]

There is a growing recognition of the importance of evidence to support allocative policy decisions in health care. This study is based on interviews with politicians in four regional health authorities in Sweden. Drawing on theories of strategic use of knowledge, the article analyses how politicians perceive and make use of expert knowledge represented by the National Guidelines, embracing both a scientific and a political rationale. As health care is an organisation with a dual basis for legitimacy – at the same time a political and an action organisation – it affects knowledge use. We investigate how the context of health care priority setting influences the conditions for knowledge use among regional politicians. Our findings illustrate the dilemma of political decision-makers and how they prefer to use expert knowledge. The politicians use this policy instrument in a legitimising fashion, as it will fit into the current political debate on more equal care. As an instrument for resource allocation the politicians noted that ‘facts’ per se could not provide them with a sufficient basis for legitimising their governing of health care. The dualistic organisational context makes knowledge important as a political weapon in negotiations with the medical profession.

Place, publisher, year, edition, pages
Cambridge University Press, 2019
Keywords
Expert knowledge, Policy making, Health policy, knowledge utilization
National Category
Social Sciences Interdisciplinary
Identifiers
urn:nbn:se:liu:diva-149919 (URN)10.1017/S1744133118000233 (DOI)000482431400001 ()29986792 (PubMedID)2-s2.0-85049867288 (Scopus ID)
Available from: 2018-08-06 Created: 2018-08-06 Last updated: 2019-09-09Bibliographically approved
Broqvist, M., Sandman, L., Garpenby, P. & Krevers, B. (2018). The meaning of severity - do citizenś views correspond to a severity framework based on ethical principles for priority setting?. Health Policy, 122(6), 630-637, Article ID S0168-8510(18)30081-2.
Open this publication in new window or tab >>The meaning of severity - do citizenś views correspond to a severity framework based on ethical principles for priority setting?
2018 (English)In: Health Policy, ISSN 0168-8510, E-ISSN 1872-6054, Vol. 122, no 6, p. 630-637, article id S0168-8510(18)30081-2Article in journal (Refereed) Published
Abstract [en]

The importance for governments of establishing ethical principles and criteria for priority setting in line with social values, has been emphasised. The risk of such criteria not being operationalised and instead replaced by de-contextualised priority-setting tools, has been noted. The aim of this article was to compare whether citizenś views are in line with how a criterion derived from parliamentary-decided ethical principles have been interpreted into a framework for evaluating severity levels, in resource allocation situations in Sweden. Interviews were conducted with 15 citizens and analysed by directed content analysis. The results showed that the multi-factorial aspects that participants considered as relevant for evaluating severity, were similar to those used by professionals in the Severity Framework, but added some refinements on what to consider when taking these aspects into account. Findings of similarities, such as in our study, could have the potential to strengthen the internal legitimacy among professionals, to use such a priority-setting tool, and enable politicians to communicate the justifiability of how severity is decided. The study also disclosed new aspects regarding severity, of which some are ethically disputed, implying that our results also reveal the need for ongoing ethical discussions in publicly-funded healthcare systems.

Place, publisher, year, edition, pages
Elsevier, 2018
Keywords
Citizens views, Directed content analysis, Ethical principles, Priority setting, Severity of ill health, Sweden
National Category
Medical Ethics
Identifiers
urn:nbn:se:liu:diva-147772 (URN)10.1016/j.healthpol.2018.04.005 (DOI)000438479000010 ()29728287 (PubMedID)
Available from: 2018-05-14 Created: 2018-05-14 Last updated: 2019-06-27
Garpenby, P. (2016). Kunskapsstyrning: Mångtydig styrform som behöver studeras. In: Martin Henriksson (Ed.), Perspektiv på utvärdering, prioritering, implementering och hälsoekonomi: En hyllningsskrift till Per Carlsson (pp. 30-37). Linköping: Linköping University Electronic Press
Open this publication in new window or tab >>Kunskapsstyrning: Mångtydig styrform som behöver studeras
2016 (Swedish)In: Perspektiv på utvärdering, prioritering, implementering och hälsoekonomi: En hyllningsskrift till Per Carlsson / [ed] Martin Henriksson, Linköping: Linköping University Electronic Press, 2016, p. 30-37Chapter in book (Other academic)
Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2016
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-145591 (URN)9789176857441 (ISBN)
Available from: 2018-03-07 Created: 2018-03-07 Last updated: 2018-03-15Bibliographically approved
Garpenby, P. & Nedlund, A.-C. (2016). Political strategies in difficult times - The "backstage" experience of Swedish politicians on formal priority setting in healthcare. Social Science and Medicine, 163, 63-70
Open this publication in new window or tab >>Political strategies in difficult times - The "backstage" experience of Swedish politicians on formal priority setting in healthcare
2016 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 163, p. 63-70Article in journal (Refereed) Published
Abstract [en]

This paper contributes to the knowledge on the governing of healthcare in a democratic context in times of austerity. Resource allocation in healthcare is a highly political issue but the political nature of healthcare is not always made clear and the role of politicians is often obscure. The absence of politicians in rationing/disinvestment arrangements is usually explained with blame-shifting arguments; they prefer to delegate "the burden of responsibility" to administrative agencies or professionals. Drawing on a case where Swedish regional politicians involved themselves in setting priorities at a more detailed level than previously, the findings suggest that the subject of "blame avoidance" is more complicated than usually assumed. A qualitative case study was designed, involving semi-structured interviews with 14 regionally elected politicians in one Swedish health authority, conducted in June 2011. The interviews were analysed through a thematic analysis in accordance with the "framework approach" by Ritchie and Lewis. Findings show that an overarching strategy among the politicians was to appear united and to suppress conflict, which served to underpin the vital strategy of bringing the medical profession into the process. A key finding is the importance that politicians, when appearing "backstage", attach to the prevention of blame from the medical profession. This case illustrates that one has to take into account that priority settings requires various types of skills and knowledges - not only technical but also political and social. Another important lesson points toward the need to broaden the political leadership repertoire, as leadership in the case of priority setting is not about politicians being all in or all out. The results suggest that in a priority-setting process it is of importance to have politics on-board at an early stage to secure loyalty to the process, although not necessarily being involved in all details.

Place, publisher, year, edition, pages
Saunders Elsevier, 2016
Keywords
Blame avoidance; Healthcare; Interview; Leadership; Legitimacy; Political strategies; Priority setting; Sweden
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-130800 (URN)10.1016/j.socscimed.2016.06.046 (DOI)000381958300008 ()27404909 (PubMedID)
Note

Funding agencies: Swedish National Centre for Priority Setting in Health Care

Available from: 2016-08-24 Created: 2016-08-24 Last updated: 2017-11-28
Garpenby, P. (2015). Evidensbaserade policybeslut i hälso- och sjukvård: Redovisning av nio strategier. Linköping: Linköping University Electronic Press
Open this publication in new window or tab >>Evidensbaserade policybeslut i hälso- och sjukvård: Redovisning av nio strategier
2015 (Swedish)Report (Other academic)
Abstract [sv]

I Sverige har betydelsen av en ”kunskapsbaserad hälso- och sjukvård” betonats i officiella dokument, t.ex. den s.k. Dagmaröverenskommelsen mellan staten och sjukvårdshuvudmännen, åtminstone sedan mitten av 1990-talet. Utgångspunkten för ett evidensbaserat beslutsfattande för organisering, inriktning och fördelning av resurser i samhället (det som på engelska benämns evidence-based policy eller EBP) är att det är önskvärt att i högre grad påverka både administrativt och politiskt beslutsfattande med ”evidens”.

Den faktiska kunskapen om hur EBP verkligen fungerar är begränsad. Befintliga översiktsartiklar pekar ut två områden som väsentliga för att påverka förutsättningarna att tillämpa EBP, nämligen: (a) personliga relationer och kontakter mellan producenter av forskning och användare av forskningsresultat och (b) åtgärder för att göra forskningsresultaten tydliga och lättillgängliga så att dessa kan användas.

I rapporten presenteras nio strategier med utgångspunkt i evidensen, i relationen mellan producent av evidens och beslutsfattare respektive kunskapen om villkoren för det kollektiva beslutsfattandet.

En skiljelinje går mellan strategier som har en mer avgränsad syn på vad som utgör evidens — fokus ligger vanligtvis på forskningsresultat — och sådana strategier som bygger på antaganden om att EBP främjas genom en breddad syn på vad som utgör evidens. Strategier som betonar vikten av att producenterna av evidens ökar sin kunskap om beslutsfattarnas villkor, inklusive vilka institutionella och politiska faktorer som kan påverka användandet av evidens, innebär ett steg bort från det smala perspektivet på EBP. Ett ytterligare breddat perspektiv utgör sådana strategier som fokuserar på framtagningen och användningen av evidens vid komplexa och ”krångliga” problem (wicked problem), där beslutsfattaren f.f.a tillämpar ett ledarskap för att mer förutsättningslöst identifiera evidens med hjälp av en mångfald aktörer.

En breddad syn på evidens vid kollektivt beslutsfattande behöver dock inte innebära att forskningsgenererad kunskap ges en underordnad roll. Det kan istället tolkas som att det krävs en mer avancerad förståelse för hur olika kunskapsformer kan komplettera varandra vid kollektivt beslutsfattande i samhällsfrågor.

Abstract [en]

In Sweden, the importance of a "knowledge-based health care" has been emphasized in official documents and agreements between the government and the regional health authorities, at least since the mid- 1990s. Within the concept of evidence-based policy (EBP), however there is a much broader ambition than merely to substantiate the clinical part of health service decision-making with evidence. The intention behind EBP is to increase the influence of “evidence” in both administrative and political decision-making.

Available review articles indicate that the actual knowledge about how to promote EBP is very limited. The few articles that exist point in the same direction, namely that two areas essential: (a) personal relationships and contacts between producers of research and users of research and (b) measures to make research results clear and accessible so that their use will increase.

This report presents nine different strategies to enhance EBP: those that focus on the evidence base, the interaction between producers and users of evidence, and increased understanding of the conditions prevailing in collective decision-making. A distinction should be made between approaches that have a limited view of what constitutes evidence – the focus is usually on research evidence - and those strategies that are based on assumptions that EBP is best promoted through a broader view of what constitutes evidence. Strategies that bring together producers and users of evidence, where for example "knowledge broker" is one form, constitutes a more interactive approach.

A further expanded perspective on EBP is through strategies that focus on the development and use of evidence in relation to complex or "wicked" problems”. Here the decision maker is not only expected to use evidence but to apply a leadership to unconditionally identify evidence, using a multiplicity of actors. A broader view on the evidence base in collective decision-making need not entail that research-generated knowledge is given a limited role. It may instead be interpreted as a reason to advance the understanding of how different forms of knowledge can serve as complementary input in collective decisionmaking in a democratic society.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2015. p. 50
Series
CMT Report, ISSN 0283-1228, E-ISSN 1653-7556 ; 2015:3
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-124233 (URN)LIU CMT RA/1503 (Local ID)LIU CMT RA/1503 (Archive number)LIU CMT RA/1503 (OAI)
Available from: 2016-01-22 Created: 2016-01-22 Last updated: 2018-01-25Bibliographically approved
Broqvist, M. & Garpenby, P. (2015). It takes a giraffe to see the big picture - Citizens' view on decision makers in health care rationing. Social Science and Medicine, 128, 301-308
Open this publication in new window or tab >>It takes a giraffe to see the big picture - Citizens' view on decision makers in health care rationing
2015 (English)In: Social Science and Medicine, ISSN 0277-9536, E-ISSN 1873-5347, Vol. 128, p. 301-308Article in journal (Refereed) Published
Abstract [en]

Previous studies show that citizens usually prefer physicians as decision makers for rationing in health care, while politicians are downgraded. The findings are far from clear-cut due to methodological differences, and as the results are context sensitive they cannot easily be transferred between countries. Drawing on methodological experiences from previous research, this paper aims to identify and describe different ways Swedish citizens understand and experience decision makers for rationing in health care, exclusively on the programme level. We intend to address several challenges that arise when studying citizens' views on rationing by (a) using a method that allows for reflection, (b) using the respondents' nomination of decision makers, and (c) clearly identifying the rationing level. We used phenomenography, a qualitative method for studying variations and changes in perceiving phenomena. Open-ended interviews were conducted with 14 Swedish citizens selected by standard criteria (e.g. age) and by their attitude towards rationing. The main finding was that respondents viewed politicians as more legitimate decision makers in contrast to the results in most other studies. Interestingly, physicians, politicians, and citizens were all associated with some kind of risk related to self-interest in relation to rationing. A collaborative solution for decision making was preferred where the views of different actors were considered important. The fact that politicians were seen as appropriate decision makers could be explained by several factors: the respondents' new insights about necessary trade-offs at the programme level, awareness of the importance of an overview of different health care needs, awareness about self-interest among different categories of decision-makers, including physicians, and the national context of long-term political accountability for health care in Sweden. This study points to the importance of being aware of contextual and methodological issues in relation to research on how citizens experience arrangements for rationing in health care.

Place, publisher, year, edition, pages
Elsevier, 2015
Keywords
Sweden Health care Rationing Programme level Decision maker Citizens' view Interview Phenomenography
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-115129 (URN)10.1016/j.socscimed.2015.01.043 (DOI)000351323500037 ()25638017 (PubMedID)
Note

The authors gratefully acknowledge the contribution made by the participants in this study. This study was supported by the Swedish Federation of County Councils Research Program on Change Processes in Health Care and the Swedish National Centre for Priority Setting in Health Care.

Available from: 2015-03-09 Created: 2015-03-09 Last updated: 2018-04-03
Kalkan, A., Sandberg, J. & Garpenby, P. (2015). Management by Knowledge in Practice: Implementation of National Healthcare Guidelines in Sweden. Social Policy & Administration, 49(7), 911-927
Open this publication in new window or tab >>Management by Knowledge in Practice: Implementation of National Healthcare Guidelines in Sweden
2015 (English)In: Social Policy & Administration, ISSN 0144-5596, E-ISSN 1467-9515, Vol. 49, no 7, p. 911-927Article in journal (Refereed) Published
Abstract [en]

In the last ten years, the concept of management by knowledge has gained growing attention inSwedish healthcare, as well as internationally. In Sweden, the most prominent example ofmanagement by knowledge is the National Guidelines, aimed at influencing both clinical andpolitical decision-making in the health sector. The objective of this article is to explore the response among four Swedish county councils to the National Guidelines for Cardiac Care (NGCC). Empirical material was collected through 155 expert interviews with the target groups of the NGCC, politicians, administrators and clinical managers. Analysis of the responses to this multifaceted policy instrument was addressed by drawing on implementation theory (Matland 1995) and institutional theory (Oliver 1991). The NGCC are primarily based on the voluntary diffusion of norms. The county councils are a long way from having adapted all the means suggested by the National Board of Health and Welfare (NBHW): explicit prioritization, healthcare programmes and dialogue between the various actor groups. The high degree of ambiguity in the content of the NGCC, the inherent conflict and the multiplicity and uncertainty in the context of the county councils, have often resulted in avoidance and compromise. The strategic responses we observe can be viewed as an attempt to balance multiple constituents and achieve the various internal organizational goals. The ambiguity and conflict inherent in the policy of the NGCC influence the strategic responses made by the organization. The question remains how far management by knowledge can be applied in a political context.

Place, publisher, year, edition, pages
John Wiley & Sons, 2015
Keywords
Policy implementation; Institutional pressure; Strategic responses; Swedish National Guidelines
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-113304 (URN)10.1111/spol.12102 (DOI)000368267400006 ()
Available from: 2015-01-15 Created: 2015-01-15 Last updated: 2018-11-09Bibliographically approved
Nedlund, A.-C. & Garpenby, P. (2014). Priority Setting as a Game of Blame? Political Leadership in Health Care Priority Setting. In: : . Paper presented at 10th International conference on Priorities in Health Care, Melbourne, Australien.
Open this publication in new window or tab >>Priority Setting as a Game of Blame? Political Leadership in Health Care Priority Setting
2014 (English)Conference paper, Poster (with or without abstract) (Refereed)
National Category
Health Care Service and Management, Health Policy and Services and Health Economy
Identifiers
urn:nbn:se:liu:diva-119291 (URN)
Conference
10th International conference on Priorities in Health Care, Melbourne, Australien
Available from: 2015-06-12 Created: 2015-06-12 Last updated: 2016-03-11
Nedlund, A.-C. & Garpenby, P. (2014). Puzzling about problems: the ambiguous search for an evidence-based strategy for handling influx of health technology. Policy sciences, 47(4), 367-386
Open this publication in new window or tab >>Puzzling about problems: the ambiguous search for an evidence-based strategy for handling influx of health technology
2014 (English)In: Policy sciences, ISSN 0032-2687, E-ISSN 1573-0891, Vol. 47, no 4, p. 367-386Article in journal (Refereed) Published
Abstract [en]

This paper focuses on problem frame differences among actors (members of an advisory body, senior administrators and clinical unit managers) who are concerned with the introduction of new health technology at the regional level in Sweden. It explores issues related to problem framing, puzzling, powering, participation and the various rationales articulated in the ambiguous search for an evidence-based strategy to handle the influx of new technologies. The Health Technology Advisory Committee (HTAC) was established in one Swedish county council in 2004 with the intention of controlling both the introduction of health technology and supporting policy decision and clinical practice by promoting the use of best evidence. The HTAC followed a scientific rationality dominated by one problem frame, although the problematic situation, as it was framed by all the actor groups, was highly complex and not solely a matter of evidence. This paper illustrates how problem frame differences shape the puzzling of a policy problem and how the different distinguishable policy styles are dependent on who is participating and who is not participating in the puzzling.

Place, publisher, year, edition, pages
Springer, 2014
Keywords
Evidence-based policy, Problem frames, Policy practice, Policy style, Health technology, Sweden
National Category
Political Science Medical and Health Sciences Medical Engineering
Identifiers
urn:nbn:se:liu:diva-108717 (URN)10.1007/s11077-014-9198-1 (DOI)000345094200003 ()
Available from: 2014-07-01 Created: 2014-07-01 Last updated: 2017-12-05
Broqvist, M. & Garpenby, P. (2014). To accept, or not to accept, that is the question: citizen reactions to rationing. Health Expectations, 17(1), 82-92
Open this publication in new window or tab >>To accept, or not to accept, that is the question: citizen reactions to rationing
2014 (English)In: Health Expectations, ISSN 1369-6513, E-ISSN 1369-7625, Vol. 17, no 1, p. 82-92Article in journal (Refereed) Published
Abstract [en]

Background  The publicly financed health service in Sweden has come under increasing pressure, forcing policy makers to consider restrictions. Objective  To describe different perceptions of rationing, in particular, what citizens themselves believe influences their acceptance of having to stand aside for others in a public health service. Design  Qualitative interviews, analysed by phenomenography, describing perceptions by different categories. Setting and participants  Purposeful sample of 14 Swedish citizens, based on demographic criteria and attitudes towards allocation in health care. Results  Participants expressed high awareness of limitations in public resources and the necessity of rationing. Acceptance of rationing could increase or decrease, depending on one's (i) awareness that healthcare resources are limited, (ii) endorsement of universal health care, (iii) knowledge and acceptance of the principles guiding rationing and (iv) knowledge about alternatives to public health services. Conclusions  This study suggests that decision makers should be more explicit in describing the dilemma of resource limitations in a publicly funded healthcare system. Openness enables citizens to gain the insight to make informed decisions, i.e. to use public services or to 'opt out' of the public sector solution if they consider rationing decisions unacceptable.

Place, publisher, year, edition, pages
John Wiley & Sons, 2014
Keywords
citizen perspective, phenomenography, priority setting, rationing, Sweden
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-104308 (URN)10.1111/j.1369-7625.2011.00734.x (DOI)000330647300010 ()22032636 (PubMedID)
Available from: 2014-02-14 Created: 2014-02-14 Last updated: 2018-04-03
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0002-3300-5516

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