Freedom of choice or cost efficiency? The implementation of a free-choice market system in community mental health services in Sweden

Table 1.

Conventional content analysis (Graneheim and Lundman 2004)Directed content analysis (Hsieh and Shannon 2005)Meaning unitClusterCodeCategoryTheme‘Everyone (providers) double themselves. They look at others and wonder, “What do they have?” This makes everything turn out similar instead of a variety to choose from.’ (Day centre staff, 2)Decreased variety of supplyDecreased freedom of choiceFreedom of choiceThe function of the market

Table 2.

Policy intentions (SOU 2008:15)Expectations before the reformExperiences after the reform1. Increased freedom of choice

• Enthusiasm about upcoming user freedom of choice (m, f)*

• Assumed that users would stay with their local provider (m, f)

• Too early to evaluate (m)

• Restrictions of individual freedom of choice in the system (f)

2. Increased power

• Feared that restrictions were going to decrease users' ability to influence how much time to attend (f), when to attend (f), and which providers to choose from (m)

• Limited change opportunities; few new providers (f)

3. Increased diversity of service

• Hoped for development through competition (m, f)

• No expectations of new providers (m) or changes in content (m)

• Few new providers (m, f)

• Failure of profiling; duplication rather than specialization (m, f)

4. Increased quality of service

• Hoped for higher quality at the same or lower price (m)

• Expected no development of public-run activities (m)

• No financial compensation for motivational work in the upcoming system (f)

• Hard for non-public providers to survive financially (m)

• Complementation, not competition (f)

5. Increased efficiency of service

• Hoped for increased cooperation between public and non-profit organisations (m)

• Worried about absence of money needed for the implementation process (m)

• Measurements of resources, not users' needs, to design the system (f)

• Cost effectiveness through time units (f)

• Focus on economy, not content (f)

• ‘Balanced budget’ catch phrase (m)

• Closure of meeting places (m)

• Limited number of time units approved (f)

• It is all about money (f)

• Budgetary control was moved upwards (f)