Competition, Choice and Geographical Equity in a Social Democratic Welfare State

Marketization has become an epidemic in health care policy around the world. According to critics, the marketization trend in health policy represents a threat to the values of solidarity and equity. Others have argued that as long as the financing of health care systems remains public, or publicly controlled, the principle of solidarity is protected and the question of who provides the services becomes less important. An often overlooked aspect in this debate is the geographical dimension of equity. When the public planning is replaced by a market logic, where private providers can decide independently where to establish, there is a risk that access to health services becomes more unequal, especially in rural areas that are less likely to attract new providers.

In this paper we explore the effects of marketization policies in rural health care provision by examining the case of Sweden, where a market-orienting reform based on the principles of competition, patient choice and the right of free establishment by private care providers was introduced in 2010. The findings demonstrate the difficulties involved in introducing market dynamics in health care provision in rural areas, as these reforms did not only threaten existing resource allocation systems based on health needs, but also undercut attempts by local policy makers to arrange for care provision in remote locations through planning and coordination. Theoretically, the paper addresses scholarly debates concerning NPM and its implications for social equity as well as literatures on rural health and geographical equity within modern welfare states.