Experiences of Introducing a Quasi–Market in Swedish Primary Care: Fulfilment of Overall Objectives and Assessment of Provider Activities

Health care as any other public service is subject to many potentially conflicting objectives and many actors. Over time, the traditional goal of health care systems of distributive justice has been accompanied by other objectives and health care reforms have developed accordingly. One type of reform in countries with publicly funded health care has evolved around replacing monopolistic state providers with competition among providers and choice for individuals: quasi-markets have been introduced. This new structure of governance, involving a mix of mechanisms for corrective action, seems to be appropriate for achieving a mix of objectives. New accountability relationships between providers and citizens are appropriate for holding providers to account for new objectives related to accessibility, quality as perceived by patients and responsiveness of services towards individuals. These objectives are visible to individuals at their point of contact with the provider. Such accountability relationships are not enough to achieve all overall objectives. It is necessary to establish and maintain dual accountability relationships with providers. Accountability relationships between providers and governments have to be maintained to achieve traditional objectives related to other aspects of quality, efficient management of resources and equitable distribution of services.