Navigating knowledge and values in primary care governance

Abstract

This dissertation explores tensions between different forms of knowledge and values embedded within governance practices, aiming to contribute to more informed decision-making within purchaser governance in Swedish primary care. Purchaser governance has evolved within a landscape shaped by reform movements such as New Public Management (NPM), emphasising efficiency and performance; the system of Knowledge-Based Management, considered an operationalisation of Evidence-Based Practice (EBP); and the Trust Delegation’s inquiry, which promotes post-NPM values such as professionalism and autonomy. These divergent influences create challenges for purchasers, who must navigate competing demands. Grounded in Science and Technology Studies (STS) and guided by methodological relativism, this dissertation examines variations within the empirical material and uses theoretical concepts to illuminate these variations. Two articles focus on the National Guidelines on lifestyle habits, published by the National Board of Health and Welfare in 2011. These guidelines marked the first integration of public health knowledge into the National Guideline format. The articles highlight tensions arising during their development and in experiences of purchaser governance during implementation in Region Västmanland. The other two articles explore the types of knowledge and governance approaches employed in purchasers’ governance of primary care. One article examines the tension between Knowledge-Based Management and Trust-Based Management, while the other examines how contractual relationships between purchasers and providers involve different forms of responsibility, trust, and control. The findings suggest that the so called “policy-practice gap” that governance often seeks to bridge is better understood as interwoven tensions, in which knowledge, values, and goals are continuously negotiated. These navigations highlight the crucial role of professional judgment at the purchaser level