Decentralization and

centralization in the context

of a global crisis

Bachelor’s Thesis 15 hp

Specialization: Management & Control

Department of Business Studies

Uppsala University

Spring Semester of 2021

Date of Submission: 2021-06-03

Wilma Falk

Karine Raundalen

Supervisor: Gunilla Myreteg

AbstractDecentralization versus centralization is a discussed subject within the field of management,

and it is about where control is allocated in the organization. This thesis aimed to contribute

with understanding of these two contrasting structures by a multiple-case study consisting of

Swedens’ decentralized, and Norway’s centralized national health care service in the context

of the coronavirus pandemic. Opportunities and challenges are studied within each

organizational model by studying the handling of the shortage of personal protective

equipment (PPE). The empirical findings showed that the allocation of control at regional

level in the organization of Sweden’s national health care resulted in opportunities to create

new forms of regional collaborations, and challenges of having to change the current

organizational model due to the complexity of the problem. In Norway, where control is

allocated at the national level, an opportunity was the establishing of a national purchase and

distribution system and to handle the problem proactively. For some parts of the local level,

implementation of directives given by central authorities turned out to be a challenge.

Key words: Centralization, decentralization, health-care services, public management,crisis, Covid-19

Preface

In a time that historically will be marked by the covid-19 pandemic we got to know each

other in different courses in business administration, and now we soon finish our bachelor

thesis, without having seen each other physically. The fact that we are sitting in two

respective countries that apply different models of control in national health care services

gave us inspiration to learn more. What perspectives to public management and control could

be obtained from the circumstances of the coronavirus crisis? In this way, the idea for the

thesis developed.

First we want to thank our supervisor Gunilla Myreteg for supporting us in the process of this

thesis. Thanks for your constructive questions and challenges. We also want to thank all other

students that have taken time to read our texts and come with valuable comments in the

seminars this spring.

Wilma Falk Karine Raundalen

Uppsala, May 2021 Tønsberg, May 2021

Table of Contents

1. Introduction 11.1 Problematization 21.2 Purpose and research question 31.3 Academic and practical relevance 3

2. Empirical background 52.1 National health care service 5

2.1.1 Personal protective equipment (PPE) 52.2 Sweden’s decentralized national health care service 5

2.2.1 National level 62.2.2 Regional and local level 62.2.3 Coordination by a political organization 7

2.3 Norway’s centralized national health care service 72.3.1 National level 82.3.2 Regional level 92.3.3 Local level 9

2.4 Allocation of control in Swedish and Norweigan health care 92.5 Principles of responsibilities in a crisis 10

3. Theory 123.1 Conceptual frameworks of decentralization and centralization 123.2 Theoretical opportunities and challenges related to decentralization 133.3 Theoretical opportunities and challenges related to centralization 133.4 Empirical evidences 14

4. Method 164.1 Qualitative research strategy 164.2 Multiple-case study design 16

4.2.1 Selection of cases 164.2.2 Situational context 174.2.3 Dimension of time 174.2.4 Abductive approach 174.2.5 Secondary sources 184.2.6 Collection of empirical data 184.2.7 Overview of chosen research design 19

4.3 Reflections on methodological choices 204.3.1 Secondary sources and related limitations 20

5. Empirical findings 225.1 Case study of Sweden’s national health care service 22

5.1.1 Critical access of PPE and regions request help from national level 225.1.2 Ad-hoc collaborations 235.1.3 Confusions regarding share of responsibilities 245.1.4 Variations among regions 24

5.2 Case study of Norway’s national health care service 255.2.1 Proactive phase 255.2.2 Reactive phase 265.2.3 Reported stability 27

6. Analysis 286.1 The Swedish national health care case 286.2 The Norwegian national health care case 306.3 The cases in relation to each other 33

7. Conclusions 357.1 Sweden 357.2 Norway 357.3 Further research 36

References 37

Table of Figures

Figure 1: The organization of Sweden’s national health care service 6

Figure 2: The organization of Norway’s national health care service 8

Figure 3: Allocation of control in Sweden’s vs. Norway’s national health care service 10

Figure 4: Research design 20

1. IntroductionOne of public managers´ most important tasks is to create appropriate organizational

structures that can provide institutional support and system stability, and a key aspect of this

issue is the chosen degree of centralization and decentralization (Andrews et al., 2007).

Centralization and decentralisation represent two contrasting organizational structures with

respect to where decisions are made in the governmental hierarchy (Tommasi &

Weinschelbaum, 2007). The concepts are relative, meaning that one can use terms such as

´weaker or stronger central planning´ (Cheema & Rondinelli, 2007) as a relative scale of how

much decentralized or centralized a system is.

Looking at the half past century from a global perspective, the trend was that most countries

increased centralization of government up until the 1960s and 1970s, while the trend after

this shifted towards decentralization and the giving of more responsibility to local

administrative units (Cheema & Rondinelli, 2007). Today, most countries are characterized

by having applied some degree of decentralisation (ibid.) but the subject is still debated

within the field of organization design (Kates & Galbraith, 2007). The national health care

service in Sweden and Norway was before 2002 decentralized in a similar manner. However,

since 2002, Norway reorganized its health care service towards a higher level of

centralization by allocating control that usually belonged to the regions up to the central

government (SML, 2019b). It is not the aim of this thesis to place the national health care

service in Sweden and Norway, respectively, on the exact scale of decentralization or

centralization, but there are notifiable differences in these two organizational designs which

will be presented.

The concepts of centralization and decentralization are often discussed with respect to

different opportunities and challenges, and performance outcomes such as equity, efficiency

and quality, in relation to public services (Robinson, 2007). The ongoing Covid-19 pandemic

has placed new demands on the national health care service (Begun & Jiang, 2020). Already

in the outbreak of the coronavirus, the World Health Organization (WHO) noticed sharp

price increases on necessary equipment, such as surgical masks, used by healthcare

professionals to protect themselves and their patients from the spread of infection. A later

identified global shortage of this necessary equipment, referred to as personal protective

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equipment, abbreviated PPE, was appointed by WHO to be one of the most urgent threats to

the ability to save lives in the pandemic. It is widely known that the shortage of PPE is

related to challenges of coordination and equal access around the world (Burki, 2020). By

looking further into the processes of how this has been handled in the cases of Sweden and

Norway, representing two different organizational and managerial designs, the aim is to

develop understanding of the decentralized and centralized organization.

1.1 ProblematizationWhether the authority to provide and the cost of provision should be made and financed by

central or local governments is a prominent question in relation to public services (Besley &

Coate, 2003). This is a matter of centralization or decentralization, which optimal proportion

Henri Fayol stated for more than seven decades ago would vary between different

organizations and depend on circumstances (Fells, 2000). For instance, centralized structures

are normally associated with relatively predictable circumstances while decentralized

structures are associated with complexity in the organizational surrounding (Treiblmaier,

2018). With health care services being a complex system to govern and control (Tien &

Goldschmidt-Clermont, 2009) one could expect that the same organizational structure would

be optimal for both the Swedish and the Norwegian national health care service. The

evidence in research, however, based on single countries transitioning from centralization to

decentralization of public services, or the other way around, show that it is hard to draw any

general conclusions whether a system for public services is better under centralization or

decentralization (Krajewski-Siuda & Romaniuk, 2008; Robinson, 2007; Ghuman & Singh,

2017).

Since the end of 2019, the national health care service has faced a new and surprising event

that has never been experienced before in modern times (svt Nyheter, 2020a; Celina et al.,

2020). The coronavirus pandemic is a global and long-term health crisis that is characterized

by “the complexity of its source, the speed of its spread and the unpredictability of its scale

and impact” (Begun & Jiang, 2020, p.2). Governmental decision-making during Covid-19

has been exceptionally difficult, strategic consequences are unknown (Atkins, 2020) and the

knowledge and facts about the virus are insufficient. The government needs to work out from

“what we know, what we think we know and what we hope we know” (UIB, 2020).

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Centralization and decentralization in relation to this new context has been studied by

(Hegele & Schnabel, 2021) who have compared federal decision-making during Covid-19

between several European countries with different levels of centralization and

decentralization. However, this with regards to aspects such as lockdown and quarantining,

not outcomes for specific public services such as the national health care service. As far as

these authors are concerned, there are no studies comparing centralization and

decentralization of public services in relation to a common crisis in general, for instance a

financial crisis, nor for the crisis of Covid-19. Among all aspects of demands national health

care services has been facing, the pandemic involves a massive lack of personal protective

equipment (PPE) which has been an unprecedented global problem (Burki, 2020; Celina et

al., 2020) needed to be solved in both Sweden and Norway. Based on the lack of research of

decentralization and centralization in relation to a crisis, the Covid-19 pandemic serves as a

unique opportunity to develop a deeper understanding of challenges and opportunities with

having a decentralized or a centralized organizational design. Accordingly, the cases of the

national health care service in Sweden and Norway will be further investigated.

1.2 Purpose and research question

This study aims to contribute with understanding of the decentralized and the centralized

organization. This is done by studying two cases with different structures and managerial

design; the Swedish decentralized national health care service, and the Norwegian centralized

national health care service, in the context of a new global crisis.

To fulfill the purpose of the study, the following research question has been formulated:

- What challenges and opportunities did the Swedish decentralized health care service

and the Norwegian centralized health care service experience when managing the

shortage of personal protective equipment (PPE) in the Covid-19 pandemic?

1.3 Academic and practical relevanceThe academic relevance of this research is that a widened understanding of the theoretical

associated challenges and opportunities with the concepts of centralization and

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decentralization is provided, as this is now studied in a new context of a long stretching crisis.

The practical relevance applies to national health care services and other big complex

organizations, on what can be expected challenges and opportunities with having the

respective organizational structure and managerial design in a similar crisis situation. A

contribution is therefore insights regarding how to be better prepared in the future in order to

manage, or even prevent, challenges that may occur.

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2. Empirical background

This section presents the organization of the Swedish and Norweign health care service, and

forms the basis for the upcoming empirical case studies.

2.1 National health care serviceA nation's health care service is a system built upon institutions, laws and services that aim to

strengthen people's health, give diagnoses, and treatment (SML, 2019b; Vårdgivarguiden,

2019). National health service consists of both private and public institutions available for

inhabitants. Regarding employment and utility of resources this is one of the largest sectors

of society (SML, 2019a; Europeiska kommissionen, 2017).

2.1.1 Personal protective equipment (PPE)

For work in health care, personal protective equipment, commonly referred to as PEE, is

important. During the coronavirus crisis, PPE is equipment worn by health care and their

patients to keep protection against covid-19. Personal protective equipment includes items

such as safety helmets, eye protection, clothing and face masks (United States Department of

Labor, 2021). In the time of the covid-19 pandemic, a global shortage of PPE has occurred

(WHO, 2020).

2.2 Sweden’s decentralized national health care serviceSweden’s national health care is organized at three political and administrative levels;

nationally, regionally and locally and additionally at a european level which constitutes the

structure of the Swedish model for public administration (Regeringskansliet, 2014). In

Sweden, the national health care service is decentralized meaning that the responsibilities lie

with regions and municipalities (Socialstyrelsen, 2020a). Figure 1, an own illustration, shows

the organization and administration of Sweden’s national health care system.

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Figure 1. The organization of Sweden’s national health care system which is governed at a national,regional and local level. It includes the care chain primary care, county care, and regional care thatinclude national specialized care. Own figure with illustrative inspiration from (NORDHELS, n.d)and (Merkur et al., 2012, fig.2, p.19).

2.2.1 National level

At the national level, the parliament and the government have the role to set and establish

regulations, guidelines and a political agenda for health and medical care. The Ministry of

Health and Social Affairs1 is responsible to politically fulfil the goals set by the parliament

and government politically and also to administrate the budgetary part addressed for public

health and medical care. The Ministry of Health and Social Affairs is responsible for a

number of government agencies (Vetenskapsrådet, 2017) that serves as expert bodies for the

nation, for example the National Board of Health and Welfare2 which is the government's

central supervisory authority (HealthManagement.org, 2010).

2.2.2 Regional and local level

Sweden has in total 21 regions with a County Administrative Board in each region, which is

the government's representative. The inhabitants in the particular region determine through

elections the politicians that will govern the region (Vetenskapsrådet, 2017). The regions are

responsible for their internal control, allocation of resources, planning, and organizing their

health care activities (Sveriges läkarförbund, 2021; Vetenskapsrådet, 2017). At the local

2 Swe. Socialstyrelsen.1 Swe. Socialdepartementet.

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level, there are in total 290 municipalities with similar responsibilities as the regional level,

for example by having their own politically elected local authorities (Vetenskapsrådet, 2017).

Distinctive for both the regional and local level is the so-called local- and regional

self-government3. It means that the regions and the municipalities are managing their own

activity with a considerable degree of anatomy but have to comply with the framework of the

national level. According to the principle of self-government, regions have the right to levy

their own taxes among their citizens. The regions decide the level of taxes whereas the state

decides on what the regions may levy taxes on. All regions are therefore self-financed to the

largest part but also receive state subsidies (SKR, 2021c). When it comes to national

specialised medical, it is fully financed by the state (Vetenskapsrådet, 2017).

Of the 21 regions, five of them collaborate in procurement and purchasing of medical

equipment by being members in a self-governing political organization called the Goods

Supply Board4. There are similar constellations between regions, such as the Purchasing

Committee5 between Sörmland Region and Västmanland Region (SR, 2020a;

Varuförsörjningen, 2020; Upphandlingsmyndigheten, 2020).

2.2.3 Coordination by a political organization

In Sweden’s decentralized health care system, an important actor is the politically run

organization named the Swedish Association of Local Authorities and Regions6 (SALAR).

The organization is a network and link for coordination between the national level and the

regional and local levels. All regions and municipalities are members of SALAR, making it

Sweden's largest employer's organisation (Statskontoret 2020; SKR, 2021d).

2.3 Norway’s centralized national health care service

The national health care service in Norway is also organized at three levels; national level,

regional level and local level. Figure 2 illustrates the centralized organization and

administration of the Norwegian system which is mainly financed by the state budget (SML,

2019a) and where the state has the overall operational responsibility of special health care

services (Regjeringen, 2020b).

6 Swe. Sveriges Kommuner och Regioner, SKR.5 Swe. Inköpsnämnden.4 Swe. Varuförsörjningsnämnden.3 Swe. Kommunalt självstyre.

7

Figure 2. The organization of Norway’s national health and medical care service at a national,regional and local level. Own figure with illustrative inspiration from (NORDHELS, n.d) and (Merkuret al., 2012, fig.2, p.19).

2.3.1 National level

At a national level, the Ministry of Health and Care Service7 controls the budgets, suggest

laws to the Parliament and control several agencies, among others the Directorate of Health8

and the Institute of Public Health9 (SML, 2019a). The Directorate of Health is strategic

advisers and a unit of competence (Helsedirektoratet, 2021) and the Institute of Public Health

is responsible for competence and knowledge (FHI, 2019). The Ministry of Health and Care

Service has the national responsibility for the content and development of health care services

through four regional health authorities that are owned by the state; South Eastern Norway

Regional Authority, Health Mid-Norway Regional Authority, West Norway Regional

Authority and North Norway Health Authority. Through these, the state governs and

controls the special health care, including university hospitals, regular hospitals, as well as

other health centres (SML, 2019a). In figure 2, the connection between national and regional

level is therefore illustrated by a thick line, and the regional health authorities will from now

on, to make the connection easier to understand, be referred to as subnational health

9 Nor. Folkehelseinstituttet.8 Nor. Helsedirektoratet.7 Nor. Helse- og Omsorgsdepartementet.

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authorities. The subnational health authorities also own an health organization, Health

Purchase10, that purchases equipment for the entire special healthcare at the regional level

(Sykehusinnkjop, 2020).

2.3.2 Regional level

At a regional level, Norway has 11 regions. They have, however, no operational

responsibility for special health care services in their geographical area since the health

institutions are under the control of the four subnational health authorities. But, all regions

have a County Governour11 that are the Parliament´s representatives whose tasks are to

monitor and inspect, coordinate and advise the municipalities in their region regarding health

service resolutions given by the state (SNL, 2021; Statsforvalteren, 2021).

2.3.3 Local level

At a local level the municipalities are responsible for planning, organizing and the providing

of primary health care services (including nursing, general practitioners and emergency

rooms) due to the Law of Municipalities (SML, 2019c). The municipalities are also

responsible for their own purchases of equipment (Sykehusinnkjøp, 2020). The primary

health care service is financed through taxes, personal fees and by the state budget (SML,

2019c) and the state oversees that municipalities are given similar financial conditions for

their operations (Regjeringen, 2021). The municipalities can cooperate with other

municipalities or with the state owned health centres regarding the solving of tasks, and the

state (through the County Governor) will make sure such cooperation finds place if necessary

(SML, 2019c).

2.4 Allocation of control in Swedish and Norweigan health careThe main difference between the decentralized national healthcare service of Sweden and the

centralized national healthcare service of Norway is the allocation of control. In Sweden there

is a strong regional and local self-government where the overall responsibility for the health

care services lies at the regional level (SKR, 2021b; Vetenskapsrådet, 2017). In Norway, it is

the central government, in other words the national level, that has the overall responsibility

for the national health care service. The state owns the four subnational health authorities and

11 Nor. Statsforvalter10 Nor. Sykehusinnkjøp

9

thus controls special health care at regional level, and the state also partly controls the local

level through the state governors (SML, 2019a; SML, 2019c). Another way to put it is that

the national healthcare service in Sweden is governed and administered locally, whereas

healthcare in Norway is nationally governed and administered, with some autonomy given to

the municipalities. Figure 3 illustrates the differences.

Figure 3. The allocation of control in national health and medical care of Sweden compared toNorway.

2.5 Principles of responsibilities in a crisisThe crisis management in Sweden and Norway respectively builds upon a set of principles

that explain responsibilities and overall goals under a situation of crisis. Sweden and Norway

have three principles in common. These are the principles of responsibility12, parity13 and

proximity14 (krisinformation.se, 2021; Regjeringen, 2019). In addition to these, Norway has a

fourth principle called the principle of collaboration (Regjeringen, 2019). The meaning of the

collaboration principle is however found in Sweden’s extended version of the responsibility

principle, namely that authorities and operations are responsible to collaborate with other

agents which can be across the sectoral boundaries (Bynander & Becker, 2017; Regjeringen,

2019).

14 Swe. Närhetsprincipen. / Nor. Nærhetsprinsippet.13 Swe. Likhetsprincipen. / Nor. Likhetsprinsippet.12 Swe. Ansvarsprincipen. / Nor. Ansvarsprinsippet.

10

The message of the principle of responsibility is that the actor who is responsible for an

activity under normal conditions is also responsible for it under a crisis. The guidance in the

principle of parity is to minimize the difference in how activities are organized and located

during times of crisis, compared to normal times. By the proximity principle it is said that the

crisis should be handled where it occurs, by the actors who are closest to it

(krisinformation.se, 2021; Regjeringen, 2019).

Both Sweden and Norway have a national contingency plan for health related crises that

builds upon these principles. In Sweden, the National Board of Health and Social Affairs, as

well as the Public Health Agency, are responsible at the national level for contingency

planning. It lies with the regions to maintain emergency medical preparedness (Statskontoret,

2020), and the doctor responsible for disease control in each region will be responsible for

ensuring that the certain region has a pandemic emergency plan (Regeringskansliet, 2020). In

Norway, the state is responsible that a contingency plan exists within the special health care

service, and the municipalities are responsible for having a contingency plan related to the

primary health care service at local level. The Norwegian contingency plan gives the Ministry

of Health and Care Service even more authority to make decisions in crisis (Regjeringen,

2018).

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3. TheoryFollowing sections present the concepts of decentralization and centralization based on

literature in the field of research.

3.1 Conceptual frameworks of decentralization and centralization

Centralization versus decentralisation is a matter of where decisions are made within the

organizational structure and thus how an organization determines objectives and policies and

allocates resources (Andrews et al., 2007). Centralization refers to having power and

resources concentrated in the central government (Cheema & Rondinelli, 2007) as opposed to

decentralization, which imply the transferring of decision-making powers and resources to

local governments (Robinson, 2007). Put a bit differently; in a decentralized system, the

responsibility, power, authority and resources are transferred to local and intermediate units

of administration instead of being allocated at the top of the hierarchy (Ghuman & Singh,

2017; Cheema & Rondinelli, 2007; Green, 2009).

Decentralization and centralization are relative concepts and one can accordingly use terms

such as ´more or less centralized´ (Andrews et al., 2007). The level of centralization is

determined by two dimensions: “the hierarchy of authority and the degree participation in

decisionmaking” (ibid, p. 58). Hierarchy of authority is a way to describe to what extent the

organization has allocated the decision-making power at the higher levels of the hierarchy

whereas the participation in decisionmaking refers to the degree of how much involved

employees are when organizational policy is determined (ibid.). The level of decentralization

versus centralization is studied in both public and private sectors (ibid.) e.g., in relation to

public delivery of services such as health care (Robinson, 2007). Decentralization relates to

the government overseeing service provision without being directly involved in the delivery,

whereas in centralization government is directly involved (Cheema & Rondinelli, 2007). The

discussion regarding decentralization and centralization and its implication on quality and

functioning of the social sphere has been a topic since the 1980´s (Krajewski-Siuda &

Romaniuk, 2008).

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3.2 Theoretical opportunities and challenges related to decentralization

Decentralization is associated with two main advantages, namely, flexibility and possibilities

to adapt to local needs (Vargas Bustamante, 2010; Alonso et al., 2008). The argument is that

local governments know the local preferences better and that productivity regarding

education, health, etc., accordingly will be maximised if local governments are in control and

can allocate the scarce resources (Robinson, 2007). A leading rationale is also that

decision-making power at local levels will generate gains in terms of efficiency and quality,

as well as financial benefits (Ibid.) and that decisions are made and implemented more

quickly under decentralization (Cheema & Rondinelli, 2007). The improvement in quality

relates to the enhanced transparency and accountability resulting from more people

participating in decision-making and in the service provision processes (Ghuman & Singh,

2017; Robinson, 2007). Many discussions will highlight accountability as the prominent

advantage for decentralization (Tommasi, 2007). Other arguments are that decentralization

hinders bureaucratic bottlenecks, meaning delays arising from the central government

management and planning (Cheema & Rondinelli, 2007). Also, an assumed possibility is that

public service delivery will be more efficient, as well as service coverage being extended,

when more responsibility is given to the local administrational units (ibid). Associated

disadvantages, however, is the challenge to ensure coordination of decisions (Alonso et al.,

2008) and that it in general can be negative to allocate responsibility for the creation of health

policies to multiple institutions on different levels (Krajewski-Sjuda & Romaniuk, 2008).

Also, negative effects related to decentralization are competitiveness, duplication of work and

having many municipalities reinventing the wheel, as well as being unequipped as local units

to handle complex problems (De Vries, 2000).

3.3 Theoretical opportunities and challenges related to centralization

Centralization, on the other hand, implies uniformity of public spending to the districts

(Besley & Coate, 2003; De Vries, 2000) and may be favourably and effective under

circumstances when, for instance, rapid actions are needed or when it is desirable to have

homogenization of services across regions (Vargas Bustamante, 2010). Authors argue that

centralized systems are associated with important and far-reaching decisions, situations

which demand efficient and fast decision making (Treiblmaier, 2018) and that one main

advantage under centralization is that externalities are internalized (Tommasi, 2007). Also,

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centralization is associated with enhanced decisiveness, integration and cost-efficiency of

public services (De Vries, 2000). It is less costly to develop a plan or policy once, rather than

having multiple units all going through the same process (ibid.). Disadvantages are

considered to be high costs related to coordination, and information transmission, of

decisions that are made at the top government, and have to be integrated in the whole

organization. Another associated challenge is that the organization will have lower-level

managers that are incapable of making bigger decisions (Treiblmaier, 2018; De Vries, 2000).

Also, democratic deficit (Tommasi, 2007) and the ´one size fits all´- dictum for service

provision which does not adapt to the specific local needs (Ghuman & Singh, 2017; Vargas

Bustamante, 2010) are challenges related to centralization.

3.4 Empirical evidences

The evidence with respect to the effects of decentralization on public service delivery is

mixed (Cheema & Rondinelli, 2007; De Vries, 2000; Vargas Bustamante, 2010) and the

question whether health services in general really are better under decentralized or centralized

systems is more of an open question (Alves et al., 2013; Vargas Bustamante, 2010). In one

case study of Polish health service, a comparison between the two reforms suggested that

decentralization increased financial and organizational efficiency in the health system.

However, the authors said generalizations were not possible due to numerous additional

factors such as political conditions (Krajewski-Sjuda & Romaniuk, 2008). The same study

also showed that results regarding innovation in the activity of local decision-making would

vary between regions (ibid.). A meta-analysis of 32 studies done by Ghuman & Singh (2017),

by which all included studies (except for one) dated between the years of 2000-2011 and in

total covered nine Asian countries, found mixed evidence of how decentralizing impacted

public service deliveries. 13 studies showed a positive impact, 11 studies reported a negative

impact and eight studies revealed results that were mixed regarding measures such as

efficiency, administrational innovation and access. These studies are not, however, studied in

the same contexts, as they represent different populations, and are studied individually and

within different time frames. There are also factors such as domestic corruption and poverty

that affect the results in developing countries (ibid.). This is in line with Vargas Bustamante

(2010) saying that empirical conclusions on decentralization and centralization in health

services are ambivalent and not comparable.

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Robinson (2007) also aiming to explain the consequences of decentralization on service

delivery based on reviews from less-developed countries such as Latin American, Asian and

African countries, concluded that equity and quality of the access of education and health

services did not improve with decentralization. With equity, the study means a fair access of

services to all groups of the population and across regions and local units. And, along with

the studies above, he also pointed to political factors such as leadership and mobilisation as

important for results (Robinson, 2007). Cheema & Rondinelli (2007) say that although there

are arguments for decentralization being efficient, empirical relationships between various

development variables and decentralization have also often shown to be negative (Cheema &

Rondinelli, 2007). De Vries (2000) says that there are multiple theoretical arguments

regarding decentralization and decentralization but that they are ambiguous and that opinions

regarding what is det preferable system are subjective. And, since the pros and cons of

centralization and decentralization depend on multiple factors, the author suggests that

comparative studies are what is needed to reveal answers (De Vries, 2000).

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4. Method

The following chapter describes the research design of this study and ends with reflections on

methodological criticism.

4.1 Qualitative research strategy

The topic of this research is to find how Sweden’s and Norway’s different allocation of

control respond to managing the global shortage of PPE. As problem solving in a crisis is

complex, and because we want to gain a deeper understanding of decentralization and

centralization, we chose to use a qualitative strategy. Organizations such as health care

services are complex systems (Tien & Goldschmidt-Clermont, 2009), meaning that they must

handle dynamic circumstances (Ludwig & Houmanfar, 2010). Such complexity is often the

subject in qualitative research (Gummesson, 2004).

4.2 Multiple-case study designWithin the qualitative strategy, a common research design is the case study because this is

considered as suitable when the researcher is concerned with the features of a specific case,

such as a certain organization or event (Bell et al., 2019). This is the key strength of a case

study and corresponds to the possibilities for the researchers to identify the unique features of

a case and thus being able to understand how those can combine and be connected, and result

in a specific outcome (Lee & Saunders, 2017). This is relevant for the current study as it

takes an interest in investigating the unique nature and impacts of having one of the two

contrasting organizational structures of centralization and decentralization. As the chosen

cases in this study are the Swedish decentralized, and the Norweigan centralized, national

health care service, this will count as a multiple-case study (Bell et al., 2019).

4.2.1 Selection of cases

A main reason why we chose exactly those two cases; the national health care system in

Sweden and Norway, is that we are one Swedish and one Norwegian author, which was

considered as a unique possibility to understand data in connection to these specific cases.

The chosen cases are perceived as solid representatives of the two structures we want to

investigate, as the Swedish health care service implies far-reaching decentralization by a

strong self-governance (SKR, 2021b) and the Norweigan system has been centralized for

16

almost twenty years (SML, 2019b). However, more than two cases could have been chosen in

order to eventually gain even more understanding, but the approach has been to select the

cases we assume one could learn most from. This way of selecting cases is conventional with

Bell et al. (2019). As stated by Gagnon (2010) the number of cases should be limited in order

to be able to investigate each case in sufficient depth. This has been taken into account. A

risk with being one author from each country is that the argumentation may not be fully

impartial, but it has been the aim of the authors to approach the cases neutrally.

4.2.2 Situational context

What characterizes case studies in general are that cases are bound to a specific system or

context, and multiple-case studies specifically focus on a certain situation or phenomenon

(Bell et al., 2019). The two cases of Sweden and Norway are both bound to national health

care systems and share the situation of the shortage of PPE during the Covid-19 pandemic.

To choose a context of a crisis, and the experience of shortage of PPE, is a way to capture

interesting aspects of what is the main focus of this study, namely, the different allocation of

control in the organizations. The design is therefore to explore two different cases, while they

deal with the same situational problem.

4.2.3 Dimension of time

The problem area of interest corresponds to a process of decisions and actions that enfolds

over time, which is the reason why a part of the research design is to focus on a certain time

period. Investigation of the topic led to a suitable time period from the 1st of January to 30th

of September, 2020. By this we could study the early phase in the pandemic with the

proactive handling of the issue of PPE, as well as the critical phase, the way until the problem

of PPE was assumed to be in a more stable stage. To capture what we call a proactive and

reactive phase, we chose the 11th of March as a point of reference. This is when WHO

declared the spread of the coronavirus as a pandemic (WHO, 2020).

4.2.4 Abductive approachA study in the field of qualitative research is usually associated with mixing an inductive and

a deductive way of linking research and theory, meaning there is a back and forth process

between theory and research, called a abductive approach. In the abductive approach the

component of induction means that the researcher has a primarily determined theoretical

framework which is, due to the aspect of deduction, iteratively adjusted in the course of

17

empirical research (Bell et al., 2019). The aim of an abductive approach is to develop

understanding of existing theories rather than generate new ones (Dubois & Gadde, 2002).

Therefore, since the thesis strived for gaining deeper understanding for the cases in question,

the relation between theory and empirical findings was chosen to be abductive. The choosing

of the abductive approach also relates to an important aspect in the research design which is

to be open minded, as it was uncertain what information that was available at this moment in

time of the pandemic. Moreover, the chosen abductive link between theory and research was

useful since the pandemic in nearly all aspects has challenged prior knowledge, and few

experiences could be used to navigate what was required of national health care services

including managing safety equipment.

4.2.5 Secondary sources

Examples of qualitative sources of data are observations, interviews, and secondary analysis

(Bell et al., 2019) among which the latter is used in this study. Secondary analysis means the

analysis of data that is collected by other researchers and organizations who probably aren't

involved in the project. Secondary sources in this study consist of public available documents

and reports written by for example the government, other authorities, and organizations in the

respective country. The other type of secondary sources being used is media outputs, i.e.

newspapers. The motivation for choosing secondary sources relates to some of the known

advantages with this source of data. Secondary sources minimize the risk of non-response

(Bell et al., 2019) which otherwise was assumed to be relatively high because of the hectic

time for the health sector due to the pandemic. Also, secondary sources are known to be a

time efficient way of collecting data (ibid.) and the feature of time efficiency made it possible

to grasp the bigger picture in both cases. Finally, as the intention of this study was to focus on

main public events, secondary sources were considered as the best option.

4.2.6 Collection of empirical data

To gather information and empirical material, the basis has been a structure of questions

which worked as a guideline. Such a structure, or framework, for conducting a case study is

supported by Lee and Saunders (2017) and with inspiration from Flinders University (2020)

the following questions were produced for identifying key issues in each case:

- How is the problem solved? Who is solving the problem?

- What type of actions are taken? What actors are being involved?

18

- Are actions, or procedures, in line with existing policies and routines or are there

ad-hoc changes?

- Are there consequences of the actions taken?

In order to capture challenges and possibilities of the handling of PPE in both cases, we typed

in general keywords such as “PPE decisions” (in the respective language) when searching for

data. We would then, for instance, find a public report giving some descriptions of challenges

or decisions being made, which lead us further on new specific searches to find more

information related to the previous article or report. By this, we could check if the

information was evident and verified in other sources also, as well as it brought us to new

information and thus further in the investigation.

4.2.7 Overview of chosen research designThe research design, shown in figure 4 includes a first step of pre-research of the topic and

the two involved cases. This pre-research was used to give the overall features of each case,

compiled in an empirical background in chapter 2, also to identify a suitable time period of

consideration (1 January - 30 September, 2020). A pre-understanding in this way led to a

possible, but primarily, theoretical framework that was allowed to be justified until all

empirical data was collected. Data collection took place in two steps where the second step

had the function to complement the data collected in the first step. Bell et al. (2019) explain

that such a way of collecting data is needed in qualitative research since interpretation of data

at an early step in the process often leads to a need for further data. With the conducted data,

empirical case descriptions were written, which are presented in chapter 5. Those were

analysed separately in relation to the theoretical framework, but also understood in relation to

each other, because of the interest of decentralization and centralization. Lee and Saunders

(2017) refer to such choices of individual analysis by saying that cases have values in

themselves. However, case studies can be designed using a comparative approach (Bell et al.,

2019). As we consider that another important dimension of understanding comes from a

comparison of the cases, some similar decisions are compared in relation to timing in the

final part of the analysis.

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Figure 4. Research design, own illustration with inspiration from Reddy and Agrawal (2021).

4.3 Reflections on methodological choices

When choosing a case study design it is important to state that the aim is not to generalize the

findings but to contribute with deeper understanding in the research topic from particular

cases (Bell et al., 2019; Lee & Saunders, 2017). The abductive approach clarifies that it is

neither the goal to test certain theories. This is essential as the critique regarding case studies

highlights that in some research, theories have been tested deductively without having data

that fully supports theories (Dubois & Gadde, 2002). Transparency and authenticity are

criterion in qualitative research (Bell et al., 2019) which is intended to be fulfilled through a

systematic research design, concerning data collection and processing.

4.3.1 Secondary sources and related limitationsSecondary sources are criticised because such data are written by another person, based on

that person's interests, which leads to a risk of missing objectivity in aspects (Bell et al.,

2019). The risk of false information can be reduced by searching for, and using, original

sources to the furthest extent (Thurén, 2005) and that is applied. This is done by primarily

basing the case descriptions on information published by federal authorities themselves.

When it comes to media sources, it is more difficult to assess authenticity (Bell et al., 2019).

Therefore, in this study, several media papers are reviewed in relation to each other. Another

risk by using secondary data to investigate these specific cases of centralized and

20

decentralized government, is that the centralized system by its design might avoid reporting

about certain disagreements, and that lower level units do not use their voice against

authorities. The image of the situation might therefore be flawed and one sided in its public

presentation. Sweden, on the other hand, with more independant actors due to self

governance of regions and municipalities, may report more of what has not been functioning

with the national handling of the problem. This may have affected our conclusions. Also,

there is a risk that we have missed several reports in our research. We cannot ensure that all

the important sources are found and that we did not miss anything.

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5. Empirical findingsThe following two sections give empirical case descriptions of Sweden’s and Norway’s

handling of the shortage of PPE, respectively, presented chronologically during the time

frame of 1st January – 30th September 2020. The 11th of March is used in both cases as a

point of reference to divide between a proactive and a reactive phase.

5.1 Case study of Sweden’s national health care service

5.1.1 Critical access of PPE and regions request help from national levelThe regions buys protective equipment and other medical materials mainly on the Chinese

market. In the middle of February, one can see that Swedish Medtech, an interest organization

cooperating with Chinese suppliers, forecasted the shortage of PPE. At that time, the Chinese

authorities had decided to reduce the country’s export due to an increased spread of Covid-19

in China (SR, 2020d). Later on, at the end of February, the government decided to sign the

EU Joint Procurement Agreement (JPA) on PPE, launched by the European Commission that

organises tenders with contracting parties in the industry of PPE (Regeringen, 2020c;

Medtech Europe, 2020). On the 3th of March, WHO declared a world wide shortage of PPE

(WHO, 2020) and soon thereafter the National Board of Health and Social Affairs established

that it had affected 71 hospitals in Sweden (DN, 2020b).

On the 11th of March, WHO declared Covid-19 as a pandemic (krisinformation.se, 2020)

and two days after, the Prime Minister, Stefan Löfven, and the Minister of Social Affairs,

Lena Hallengren, received a formal request15 from the three largest and most Corona- affected

regions. The regions stated that they could not wait for a EU-wide procurement of PPE

(Region Stockholm, Region Västra Götaland, Region Skåne, 2020). With all regions trading

on the Chinese market, and fighting among others over the scarce supply, had all led to fierce

competition between regions (svt Nyheter, 2020b). This situation is confirmed by Swedish

MedTech saying that they have identified regions purchasing huge volumes similar to

attempts of bunkering PPE (SvD, 2020). Now the regions requested that the government

should take a national responsibility and management over the supply and prioritization of

protective equipment among regions since the availability of PPE was seen as the most

critical factor for managing the coronavirus. A collaboration between regions and the

15 Swe. hemställan.

22

National Board of Health and Social Affairs and the Swedish Civil Contingencies Agency

was also requested (Region Stockholm, Region Västra Götaland, Region Skåne, 2020). Based

on the formal request, the Government decided on the 16th of March that the National Board

of Health and Welfare (NBHW) take a national responsibility for the shortage of protective

equipment as long as required, including a possibility for the NBHW to distribute, and if

needed redistribute, PPE between regions and municipalities (Regeringen, 2020c). NBHW

made purchases and supported coordination and distribution with other actors and authorities.

The regions and municipalities had still, however, to provide themselves with routines for

purchases and coordination of PPE. There have been complimentary deliveries from NBHW

to the regions and municipalities from March 2020 and forward based upon situational

reports from regions and municipalities (Socialstyrelsen, 2020).

Another formal request was received by the government on the 30 of March. This request

was sent from the county administrative boards16 about giving them a mandate to collect

documentation from the regions and municipalities to fulfil a coordination process that aimed

to help the NBHW in getting a comprehensive perception of the need of PPE in regions and

municipalities. The county administrative boards had decided on a collaboration with the

National Board of Health and Welfare, the Swedish Civil Contingencies Agency and the

Swedish Association of Local Authorities and Regions. Upon this the Government

commissioned the county administrative boards on the 3 of April to assist the NBHW

(Regeringen, 2020a).

In the beginning of April, it is reported that there must be better coordination in order to

ensure that all health care units can have access to the products where it is needed (DN,

2020a). To manage the shortage of PPE, the government gave the Swedish Work

Environment Authority17 on the 7 of April a task to ensure that there are procedures for

providing non-CE marked18 PPE (Regeringen, 2020b).

5.1.2 Ad-hoc collaborations

Stockholm, Göteborg, Malmö, and Uppsala decided on the 8 of April to collaborate in

purchases and financing of PPE (Uppsala Kommun, 2020a). Municipalities have agreed on a

18 label for fulfillment of safety requirements (Arbetsmiljöverket, 2012).17 Swe. Arbetsmiljöverket.16 Swe. länsstyrelserna.

23

common structure for purchasing, prioritization, stockpiling, and distribution of protective

equipment (Länsstyrelsen Östergötland, 2020; Länsstyrelsen Stockholm, 2020; Uppsala

Kommun, 2020b). The problems with municipalities and regions competing in purchases of

equipment resulted in collaboration where they jointly, via an internet portal, bought and

distributed scarce goods. This was, however, functioning first at the end of May, three months

into the pandemic (SR, 2020c).

5.1.3 Confusions regarding share of responsibilitiesThe NBHW´ s assignment to ensure the access of protective equipment was a task this

national authority had not worked with earlier. Expressions such as “The National Board of

Health and Welfare becomes a national purchasing centre” were communicated.

Municipalities have asked the Board if municipalities needed to send their equipment to the

Board, or if they could use it on their own. The National Board of Health and Social Affairs

believes that it was clear that the principle of responsibility yielded, meaning that the Board

considered that their role was to support and coordinate, and if necessary, fill the gaps that

arose (Statskontoret, 2020). It has also been emphasized that the government at several times

has included the Swedish Association of Local Authorities and Regions (SALAR) in

commissions even though this is an interest organization having no formal responsibilities in

a crisis (Statskontoret 2020; SKR, 2021a).

5.1.4 Variations among regionsIn June, the National Board of Health and Welfare stated that it is first now they can see a

reliable supply with regard to the authorities' responsibility to meet urgent needs in

municipalities and regions (SR, 2020c). Also in June it was announced that there is still a

shortage of protective equipment especially in home care service and for those working in the

Stockholm region (Kommunal, 2020). Moreover, the need for national warehousing of PPE

was examined by the NBHW on behalf of the government in July (Socialstyrelsen, 2020b).

All assessments of the NBHW were based on different scenarios of the spread of infection

during the autumn and was carried out in collaboration with the Swedish Public Health

Agency, the County Administrative Boards, the Medical Products Agency and the Swedish

Civil Contingencies Agency, and with SALAR. In September, the assessment reported was

that there is no need for warehousing of PPE on a national level, regardless of scenario.

However, the NBHW indicated large differences in stockpiling levels among regions

(Socialstyrelsen, 2020b). Almost all municipalities had, at that time, stocks with PPE but with

24

variation in a range of a capacity of several months to just a few weeks (SR, 2020b).

5.2 Case study of Norway’s national health care service

5.2.1 Proactive phaseAccording to the contingency plan, the Ministry of Health and Care Service decided on the

31st of January 2020 to delegate the task of coordinating the work of healthcare to the

Directorate of Health in cooperation with other federal authorities (Regjeringen, 2020a). In

early February, it was reported that The Directorate of Health emailed the hospitals and asked

them to describe their storage of PPE, and to reply the day after (Filternyheter, 2020). After a

few days more, the Directorate of Health met with the four subnational health authorities,

hearing that the hospitals had equipment for approximately one month of normal use. The

national purchaser for special health care, Health Purchase, was asked therefore to check the

condition of the storage of their wholesalers (ibid).

During the second half of February, the Directorate of Health emailed the four subnational

health authorities to do immediate actions to secure a rational use of PPE (Helsedirektoratet,

2020a). The Government also established a new law the 28th of February that gave the the

Ministry of Health and Care Service authority to establish rules for the sake of preventing

lack of equipment when that was needed (Regjeringen, 2020c). After the 3th of March, when

WHO declared a world wide shortage of PPE (WHO, 2020), the four subnational health

authorities became responsible through Health Purchase to make national purchases of PPE

(Helsedirektoratet, 2020a). This decision was made the 6th of March by the Ministry of

Health and Care Service and the Directorate of Health, and ment that the Health Purchase

should extend their responsibility to not only include purchases for hospitals and special

health care, but also the municipalities (Sykehusinnkjop, 2020). The subnational South

Eastern Health Authority became nationally responsible for the coordination and distribution

of PPE to both special healthcare at regional level and to the municipalities at local level

(Helsedirektoratet 2020a). The Directorate of Health also decided on the 6th of March that

Health Purchase was allowed to make exceptions from certain requirements included in the

CE-mark when purchasing corona crisis related PPE, in order to have more options and meet

the needs (Helsedirektoratet, 2020g). On the 11th of March, WHO declared Covid-19 as a

pandemic (krisinformation.se, 2020).

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5.2.2 Reactive phaseOn the 12th of March, the day after WHO´s declaration, the Directorate of Health sent a letter

to all municipalities and county governors asking them to report what were the acute needs

for PPE in the following weeks. The Directorate of Health would then give this information,

as well as the criteria for distribution, to the Health Purchase. A permanent solution regarding

distribution and ordering of PPE was under construction (Helsedirektoratet, 2020e).

In the second half of March 2020, the Health Purchase was officially in "red" preparation

mode, meaning that 100% of focus and action was on the purchase of PPE (and drugs) related

to the corona pandemic. On the 16th of March, the subnational South Eastern Health

Authority asked "everyone" to contribute, e.g. dentists, veterinarians etc. First and foremost,

it was now facemasks that were most crucial (Helsedirektoratet 2020f). A week later a plane

with 1 million face masks arrived in Norway and trailers transported the equipment to the

storage room at the subnational South Eastern Health Authority to be further distributed out

to hospitals and municipalities from there (Moderne transport, 2020; Aftenposten, 2020). The

Minister of Health, Bent Høie, said they were now working day and night to ensure imports

as well as domestic production. Reports from the municipalities have shown that some have

run empty of PPE, but the state said they were working on new provisions (Mtlogistikk,

2020). There were still needs in hospitals and municipalities even though more deliveries

were coming and local production increased (Aftenposten, 2020). Plenty of domestic

suppliers were contacting the authorities about them having equipment, but not all received a

reply by the state due to the number, which Bent Høie apologizes (ibid). The consequences of

this, however, are not known.

On the 27th of March, the Directorate of Health reported that a new national system for

ordering and distribution of PPE was established. Municipalities could report their needs and

the Directorate of Health and the county governor would further make the priorities on how

the distribution was going to be shared. The distribution to hospitals and municipalities was

done by the subnational health authorities. The “key of share” regarding national purchase of

PPE was as follows: 70% to hospitals, 10 % kept as a buffer, 20 % to the municipalities. The

buffer would be used if needed (Helsedirektoratet, 2020f). In the beginning of April hospitals

and municipalities all over the country received PPE distributed from the national storage

room (Helse Sør-Øst, 2020; NTB kommunikasjon, 2020). In cooperation with among others

the Ministry of Foreign Affairs, the subnational South Eastern Health Authority had its own

26

airline to transport and received now the third plane (since 22nd March) with equipment,

counting for over 10 million face masks, half a million protective coats, etc., in total. Trailers

from Europe were also coming with PPE. The Director of the subnational South Eastern

Health Authority said the provision was caused by the Health Purchase´s ability to make

deals with many countries on the behalf of the nation (ibid; ibid). The 8th of April the

Directorate of Health emails to the municipalities and County Governors that they have

received complaints from general practitioners that they do not receive PPE provided by the

national system (Helsedirektoratet, 2020c). The Directorate of Health asks the County

Governors to make sure the municipalities prioritises them as much as other health units

(ibid.).

5.2.3 Reported stabilityThe Directorate of Health wrote on their page early September 2020 regarding the supply of

PPE: "This far, we have managed to solve the task, even though there was a serious lack of

equipment in March and April." And, "240 of the 356 municipalities in the country reported

in the end of March and beginning of April about a lack of protective equipment." But, "there

is no lack of protective equipment in Norwegian healthcare today." (Helsedirektoratet,

2020a). On the 23th of September, the Directorate of Health informed that municipalities and

hospitals again would be responsible for their own purchases from 1 january 2021, as

ordinary, and that the national health authorities at the same time would build a solid national

storage in case of future delivery problems (Helsedirektoratet, 2020b; VG, 2020). The

municipalities were asked to order equipment and build storages that would cover 8 month of

use, i. e. August 2021, which would be financially covered by the state (ibid).

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6. Analysis

In this chapter the cases are firstly analyzed separately and then in relation to each other.

6.1 The Swedish national health care case

In Sweden, the empirical findings show that no decision from the state (besides signing the

JPA) to prevent the lack of PPE has been made before the 11th of March when the pandemic

was declared. That it was the regional level reacting to the problem of PPE first is in line with

the decentralized organization with control and responsibility being allocated at the regional

level (Ghuman & Singh, 2017; Cheema & Rondinelli, 2007; Green, 2009) and also in line

with the expected share of responsibility in the Swedish system according to the contingency

plan. The fact that the regions needed to send a formal request to the government indicates a

bottom-up chain of order as well as a reactive approach at the national level in solving the

shortage of PPE. The process of sending the formal request can be interpreted as having the

consequence of delays of important decisions since it theoretically would be possible to start

the process of solving the problem with PPE before the 11th of March, as the problem was

forecasted by Swedish MedTech. Also, that the county administrative boards at regional level

later in the spring needed to ask for permission when they saw the need of collecting

documentation from regions and municipalities to know the different needs for PPE, is

another example of delays in potential immediate actions. In this way, the empirical material

points to a challenge related to the regions being responsible in the crisis, and that there is a

negative relation between decentralization and rapid decision-making, as seen in some earlier

studies (Cheema & Rondinelli, 2007).

An indication of the formal request from the regional level in March is that the current

organizational model was not working when facing this specific circumstance of a crisis. If it

had, the regions could still have been independent in their management of the shortage of

PPE. The critical situation of the limited access of PPE affected the entire care chain and was

in several aspects a complex problem, for which it is a theoretically known challenge for

regional and local units to be equipped for (De Vries, 2000). Since the regional and local

level was not able to manage the problem, help was required. A consequence of this was that

the existing organizational model had to be reorganized in order to have a central

management of supply and distribution of PPE. This is a challenge in itself, which is evident

by some municipalities being confused about their own self-government in relation to the

28

new authority of the National Board of Health and Welfare. The confusion can be understood

as a consequence of this being a significant change in how power is usually allocated in the

system and that the National Board of Health and Welfare never had had such responsibility

before. This can explain why the government involved the Swedish Association of Local

Authorities and Regions. There were differing opinions on who were accountable for the

ambiguity in responsibility. This contradicts the assumption that accountability is a prominent

advantage for decentralization (Tommasi, 2007) as it was unclear among actors who was the

accountable one in the crisis. All of this suggests that it has been challenging to have

responsibilities allocated on multiple levels, with regard to health care policies, which is in

line with Krajewski-Sjuda & Romaniuk (2008).

The empirical findings show that there was fierce competition between the regions competing

about the same deliveries, which is the reason why they asked the National Board of Health

and Welfare for help initially, and why they also started to collaborate with each other

regarding purchases and distributions. This is in line with theoretically negative effects of

decentralization, which is competitiveness (De Vries, 2000), which is also evident by the

regions buying huge amounts of PPE. However, the regional and local level showed to be

aware of the risk of the dysfunctional effect of competition since it was one of their

arguments for a national responsibility. A possible explanation of this is that the national

crisis principles of responsibility, including collaboration, plays an important role, and that

collaboration and awareness of competition developed and limited the competition. The

structure for common purchases that already existed before the crisis among certain regions

can also have limited the competition.

According to theory, decentralization is positively associated with more people participating

in decision-making and in the service provision processes (Ghuman & Singh, 2017;

Robinson, 2007). The case, however, proves that this has been a challenge to have many

actors in the handling of a crisis, that the regions in discussions with other regions had to

come to a conclusion that help from the state was needed. This can be regarded as a

time-consuming process that can have affected the pace of the development of the crisis

handling negatively. Having many actors putting together a common system, can also explain

why the internet portal was not ready before 3 month into the pandemic. On the other hand,

many actors involved and participating are also proven in the case to be helpful for

developing new solutions. For example, the common and local structures of procurement and

29

prioritization, as distribution keys, as well as the internet portal developed to manage

collaboration between regions. This shows flexibility and an ability to find adapted solutions

to local needs which in theory is found to be a common possibility for the decentralized

organization (Vargas Bustamante, 2010; Alonso et al., 2008).

In March it was reported that hospitals in Sweden were affected by the shortage of PPE. Even

though the National Board of Health and Welfare saw that a reliable supply of PPE was in

place during the summer, and that the urgent needs were now possible to meet, it was also

reported that there still was a shortage of PPE in June, as well as a wide variety in stockpiling

levels among municipalities in September. This indicates that the most critical phase was

stabilized but that the needs within the health care service did not become fully met during

the time period in this study, and that the situation accordingly was not under full control.

6.2 The Norwegian national health care case

The authorities in Norway were able to take rapid actions toward preventing a shortage of

PPE by a delegation of operational responsibility to the Directorate of Health already in

January. The possibility of the National Board of Health and Welfare to delegate this control

was in line with the Norwegian contingency plan. That the Directorate of Health soon

emailed hospitals and contacted the four subnational health authorities to get an overview

over the situation of how much PPE that was at hand, can be explained as a consequence of

the centralized authority´s responsibility and possibility to control and get information from

the whole health care service. Having an organization with allocated power at the top, few

actors with decision-making authority and few actors being involved in the determination of

policies (Robinson, 2007) is a possible explanation why units such as the Health Purchase

and the subnational health authorities have been implementing the directives from the

Directorate of Health regarding national purchases and distribution without resistance evident

in the data. The empirical findings give no signs of unhealthy competition between units.

This can be a consequence of the uniformity of public spending to the districts which the

centralized organization is associated with (Besley & Coate, 2003; De Vries, 2000) and that

the state is responsible to ensure equity through the subnational health authorities.

The empirical findings show that the state has taken actions regarding the managing and

controlling of PPE on the behalf of the nation in an early phase, which is evident by having

30

multiple decisions taken before the 11th of March when the pandemic was declared. The fast

decision-making that is associated with the centralized organization (Treiblmaier, 2018) is in

this case thus evident through the prominent proactive handling of the problem. The case

description does not show confusions or unclarity, nor opposing opinions, among actors about

what is their respective responsibility in the handling of the crisis. This can be explained by

directives being firmly given by the Directorate of health, and by the centralized

organizational model with its vertical chain of command from top to bottom and units down

in the hierarchy having limited autonomy and decision-making power, as well as being

familiar with a position under central control (Cheema & Rondinelli, 2007). Time consuming

discussions have therefore been avoided, due to few actors being involved, which is in line

with the argument that centralization is characterized by enhanced decisiveness (De Vries,

2000).

That the state controls subnational health centres led to the ability of close cooperation

between the national and regional level in the crisis, and also with the local level, through the

state governor or the direct communication from the Directorate of Health. The possibility to

create a national system for the distribution of PPE in the crisis and thus ensure equity in the

share of the scarce resources throughout the organization can be understood as a consequence

of the centralized organizational model already being familiar with cooperating and

organizing the special health care. By having a centralized purchase unit, Health Purchase,

already established on the behalf of the special health care, only a small change in

responsibility and a little modification in the current organization model was required in

order to have a national purchaser for the entire health care service which also included the

municipalities. The empirical findings indicate that having such a big actor working on the

behalf of the country, with lots of expertise and contacts in several countries, among others

resulted in several deliveries by a state governed airplane with important amounts of PPE in a

critical phase. These national big scale purchases can be understood as a possibility and a

consequence of having the control allocated centrally, as higher levels in the organization are

assumed to be more equipped to handle complex problems (De Vries, 2000).

According to theory, centralization is associated with challenges with delays due to

bureaucratic bottlenecks (Cheema & Rondinelli, 2007). An example of this in the case of

Norway is the fact that the National Board of Health and Welfare could not handle all the

replies from domestic suppliers that wanted to contribute with PPE provision. The

31

consequences of this, however, are not found, whether this was a consequence of prioritizing,

or that useful suppliers that potentially could have led to greater provision of PPE in the

national health care service could not do so because of lack of capacity in the central

government to handle all the cases. A challenge is therefore that the centralized

organizational model with few actors involved in policy making (Robinson, 2007) backfired

in this area of crisis solving. Also, the findings show that in some municipalities, general

practitioners did not receive PPE from the national purchase system because of failed

coordination within the municipalities. A possible explanation of this is that decisions that are

made at the top government to some degree have had challenges in being integrated in the

whole organization (Treiblmaier, 2018; De Vries, 2000).

The empirical findings also show that there have been some municipalities running empty of

PPE in March, and that there was a lack of PPE especially in March and the beginning of

April in the municipalities. A possible explanation why the municipalities were most

affected, is that the decision regarding the “key of share” made by the central authority was

not fair, meaning that 20 % of the national purchases to the municipalities was not sufficient.

This is in line with centralization not focusing on adapting to the specific local needs

(Ghuman & Singh, 2017; Vargas Bustamante, 2010). The distribution, however, was based on

the information and numbers received by authorities from hospitals and municipalities. Also,

the County Governour in every region, which is closer to local level, decided the specific

share of PPE to the municipalities within a region. A possible explanation for the lack is also

that there was simply not enough PPE and thus impossible to avoid lack even with another

key of share. A final possibility of the centralized system identified in the case is that the

state, among others through the national purchase system, paid for the unusual expenses

related to PPE. This is in line with one of the advantages of centralization, namely that

externalities are internalized (Tommasi, 2007). This also made it possible to give a directive

in September that all municipalities should now themselves prepare a storage of PPE for a

certain time frame of use, as this would be covered by the state.

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6.3 The cases in relation to each other

Both systems needed to solve the same problem; to provide PPE to all units within the

national health care service. However, some outcomes in the management of the new crisis

situation differ between the two cases and can be discussed in relation to having their

respective organizational model.

In Norway, there is a prominent proactive fase with the situation being handled centrally from

the very start with multiple action steps taken before the WHO declared the Covid-19 as a

pandemic the 11th of March. This differs from the case of Sweden, which shows no evidence

of such a proactive phase. Even though the Swedish national health service is controlled by

the regions, which also goes for crisis according to the contingency plan, the need for central

help in order to solve the shortage of PPE turned out to be needed in the Swedish national

health care also. However, due to the decentralized model, this required relatively bigger

changes compared to Norway, as well as more communication back and forward within and

between levels before actions of control allocations were taken. Thus, when looking at the

cases in relation to each other, some of the similar decisions have been taken earlier in

Norway than in Sweden. For instance:

- In Sweden, the first decision to allocate control and the main responsibility of PPE

supply to a central authority was made by the government on the 16th of March to the

National Board of health and Welfare. In Norway, this was done more than 6 weeks

earlier, the 31st of january, by the Ministry of Health and Care Service to the

Directorate of Health. A possible explanation for this is that the centralized system in

Norway already had an actor with the authority to allocate such control.

- At the end of March, the county administrative boards in Sweden were given a right

to collect documentation from the regions and municipalities to help the National

Board of health and Welfare with the work of coordinating. In Norway, work with

getting descriptions of storages at hospitals startet more than one month prior, in early

February, as this was already a centralized responsibility.

- Regarding the CE-mark which ensures certain requirements to be fulfilled in the PPE

purchase, the Swedish government made a decision about exceptions from this on the

7th of April. One month earlier, the 6th of March, The Directorate of Health decided

that the Health Purchase was allowed to make exceptions regarding the same.

33

- In Norway, complimentary deliveries from the Ministry of Health and Care Service to

the municipalities are reported in March and a national purchase and distribution

solution in Norway was also started in the beginning of March. Distribution from the

National Board of Health and Welfare in Sweden is reported in March as well. The

purchase and distribution collaboration among regions and municipalities in Sweden

started at the end of May.

- In June, it was reported that Sweden experienced a reliable supply from central

authority to meet urgent needs in municipalities and regions, but there is still a

shortage of PPE in certain places. In Norway, it is reported that the critical phase was

during March and the beginning of April.

According to the decisions listed above which shows a development over time, it has been

possible in Norway to make earlier and more rapid decisions, compared to Sweden. In

circumstances of the shortage of PPE, such rapid actions can be argued to be preferable,

which is why the centralized model can be seen as an advantage. Accordingly, for this

specific context of a crisis, this aligns the associated possibilities of centralization which is

fast decision-making, and thus not aligning with theory saying that decisions are made more

quickly under decentralization (Treiblmaier, 2018; Cheema & Rondinelli, 2007).

There are, however, other factors which do not depend on the decentralized or the centralized

organizational model (Krajewski-Sjuda & Romaniuk, 2008; Robinson, 2007; De Vries, 2000)

that may have affected the outcomes. For instance, different strategic choices regarding the

pandemic in large may have affected the chronology of important decisions. Also, why the

Swedish case did not show a proactive phase with early decisions can be explained by the

fact that Sweden is a part of the EU and thus trusted the joint procurement agreement. The

prominent proactive phase in the Norwegian case can depend on their non-membership in the

EU and that the government thus needed to actively solve the problem itself.

34

7. Conclusions

The question this thesis aimed to answer was what challenges and opportunities the Swedish

decentralized health care service and the Norwegian centralized health care service

experienced when managing the shortage of personal protective equipment (PPE) in the

Covid-19 pandemic. Based on the analysis the following conclusions are made:

7.1 Sweden

The case shows opportunities within the decentralized Swedish health care service to be

flexible outside of what are the usual responsibilities and routines by new forms of regional

and local collaborations being established during the crisis. Also, the principles of crisis

management reduced competition of PPE. The opportunity of delegating responsibilities

based on current needs was evident, however, related to challenges. To have regions being

accountable for a national and global crisis was a problem too complex to handle at regional

level, and help from the national level was needed. This included a change in current

organizational model, and time-consuming processes of formal requests and related

decisions. The change in allocation of control with a new national authority involved led to

confusions in a system that usually has a strong regional- and local self-governance.

7.2 NorwayThe empirical findings indicate certain opportunities by having a centralized organizational

and managerial design when handling a global crisis and the shortage of PPE. Having one

main actor involved in central decision-making in the crisis, along with an already existing

top-down chain of command, made rapid decision-making and clear delegations of

operational responsibilities possible already from an early phase, including a prominent

proactive handling of the problem. By a small modification in the current organization model

a national purchase system and supply of PPE was possible to establish on the behalf of the

whole healthcare system. An identified challenge is that certain municipalities at local level

showed incomplete integration of the directives given by the state regarding distribution of

PPE.

35

7.3 Further research

The system perspective applied to healthcare in this study can be supplemented with research

on the impacts on decentralization and centralization on manager level within national health

care services. Interviews with managers at hospitals and health care centers as well as with

managers at different governmental levels can add even more practical understanding on

processes of decision-making, equity, and responsibilities. This is relevant for the shortage of

PPE, however, there are additional processes related to the coronavirus pandemic that are

relevant and needed to be considered in further research to to gain an even deeper, and

comprehensive, understanding of different organization designs in perspective of the crisis.

Such pandemic related processes are infection control and vaccination. There is a

consideration between investigating the subject in real time, as in this study, or after the

pandemic when knowledge and experience are more in state of maturity. Some research sheds

light on what worked well, and less well in the pandemic. Therefore, it would have been

interesting to; (1) compile what was learned from the H1N1-virus (the swine flu influenza

pandemic between 2009-2011); (2) what of these lessons were brought into the management

of the corona pandemic, and (3) there are discussions and decisions about how to be prepared

and able to manage pandemics in the future.

36

References

Abimbola, S., Baatiema, L., & Bigdeli, M. (2019). The impacts of decentralization on healthsystem equity, efficiency and resilience: a realist synthesis of the evidence. HealthPolicy and Planning. Oxford Academic, 34(8), 605–617.https://doi.org/10.1093/heapol/czz055

Aftenposten. (2020). Kommunene i Oslo og Viken trenger over én million munnbind ogsmittefrakker. Retrieved 06 02, 2021, fromhttps://www.aftenposten.no/norge/i/mRjRPL/kommunene-i-oslo-og-viken-trenger-over-en-million-munnbind-og-smittefr

Alonso, R., Dessein, W., & Matouschek, N. (2008). When Does Coordination RequireCentralization? The American Economic Review, 98(1), 145-179.https://dx.doi.org/10.2139/ssrn.921639

Alves, J., Peralta, S., & Perelman, J. (2013). Efficiency and equity consequences ofdecentralization in health: an economic perspective. Revista Portuguesa de SaúdePública, 21(1), 74-83. https://doi.org/10.1016/j.rpsp.2013.01.002

Andrews, R., Boyne, G. A., Law, J., & Walker, R. M. (2007). Centralization, OrganizationalStrategy, and Public Service Performance. Journal of Public Administration Researchand Theory, 19(1), 57-80. https://doi.org/10.1093/jopart/mum039

Arbetsmiljöverket. (2012). CE-märkning. Retrieved 06 02, 2021, fromhttps://www.av.se/produktion-industri-och-logistik/produktutformning-och-ce-markning/

Atkins. (2020). Hvorfor er beslutninger vanskelige? Retrieved 04 23, 2021, fromhttp://atkinsglobal.no/hvorfor-er-beslutninger-vanskelige/

Begun, J. W., & Jiang, J. (2020). Health Care Management During Covid-19: Insights fromComplexity Science. NEJM Catalyst Innovations in Care Delivery, 1-12.10.1056/CAT.20.0541

Bell, E., Bryman, A., & Harley, B. (2019). Business Research Methods. Oxford UniversityPress.

Besley, T., & Coate, S. (2003). Centralized versus decentralized provision of local publicgoods: a political economy approach. Journal of Public Economics, 87(12),2611-2637. https://doi.org/10.1016/S0047-2727(02)00141-X

Burki, T. (2020). Global shortage of personal protective equipment. Elsevier Ltd., 20(7),785-786. 10.1016/S1473-3099(20)30501-6

Bynander, F., & Becker, P. (2017). The System for Crisis Management in Sweden:Collaborative, Conformist, Contradictory. Handbook of Disaster Risk Reduction andManagement.https://www.researchgate.net/publication/320044706_The_System_for_Crisis_Management_in_Sweden_Collaborative_Conformist_Contradictory

Cheema, G. S., & Rondinelli, D. A. (2007). Decentralizing Governance: Emerging Conceptsand Practices. Brookings Institution Press.https://ebookcentral.proquest.com/lib/uu/detail.action?docID=296555

Dargaville, T., Spann, K., & Celina, M. (2020). Opinion to adress the personal protectiveequipment shortage in the global community during the COVID-19 outbreak. PolymDegrad Stab, 176(109162). https://doi.org/10.1016/j.polymdegradstab.2020.109162

De Vries, M. S. (2000). The rise and fall of decentralization: A comparative analysisofarguments and practices in European countries. European Journal of PoliticalResearch, 193–224. https://doi.org/10.1023/A:1007149327245

37

DN. (2020a). Ledare: Coronakrisen blottar svenska systemfel. Dagens Nyheter. Retrieved 0524, 2021, from https://www.dn.se/ledare/coronakrisen-blottar-svenska-systemfel/

DN. (2020b). Skyddsmaterial och antibiotika räcker inte åt alla – hemligt hur stor bristen är.Dagens Nyheter. Retrieved 05 24, 2021, fromhttps://www.dn.se/nyheter/sverige/skyddsmaterial-och-antibiotika-racker-inte-at-alla-hemligt-hur-stor-bristen-ar/

Dubois, A., & Gadde, L.-E. (2002). Systematic combining: an abductive approach to caseresearch. Journal of business research, 553-560. 10.1016/S0148-2963(00)00195-8

Europeiska kommissionen. (2017). State of Health in the EU, Sverige Landprofil hälsa 2017.European Observatory on Health Systems and Policies, 1-16.https://ec.europa.eu/health/sites/default/files/state/docs/chp_sv_swedish.pdf

Fells, M. J. (2000). Fayol stands the test of time. Journal of Management History (Archive),6(8), 345-360. https://doi-org.ezproxy.its.uu.se/10.1108/13552520010359379

FHI. (2019). Vision of the Norwegian Institute of Public Health. Norwegian Institute ofPublic Health. Retrieved 04 20, 2021, fromhttps://www.fhi.no/en/about/this-is-the-norwegian-institute-of-public-health/fhis-organisasjon-og-visjon/

Filternyheter. (2020). MASKEDRAMAET: «Smittevernutstyret vi har rekker til vakta imorgen, men så er det tomt!». Retrieved 06 02, 2021, fromhttps://filternyheter.no/maskedramaet-sa-kaotisk-var-mangelen-pa-smittevernutstyr-i-norge/

Flinders University. (2020). CASE STUDIES. Retrieved 05 24, 2021, fromhttps://students.flinders.edu.au/content/dam/student/slc/case-studies.pdf

Gagnon, Y.-C. (2010). The case study as research method: A practical handbook.Amsterdam, the Netherlands: PUQ.

Ghuman, B.S., & Singh, R. (2017). Decentralization and delivery of public services in Asia.Policy and Society, 32(1), 7-21. https://doi.org/10.1016/j.polsoc.2013.02.001

Green, K. (2009). Decentralization and Good Governance: The Case of Indonesia. SSRN.https://papers.ssrn.com/sol3/papers.cfm?abstract_id=1493345

Gummesson, E. (2004). Kunskapande Metoder inom Samhällsvetenskapen. Studentlitteratur:Lund.

HealthManagement.org. (2010). Overview of the Healthcare Systems in the Nordic Countries.Retrieved 06 02, 2021, fromhttps://healthmanagement.org/c/it/issuearticle/overview-of-the-healthcare-systems-in-the-nordic-countries

Hegele, Y., & Schnabel, J. (2021). Federalism and the management of the COVID-19 crisis:centralisation, decentralisation and (non-)coordination. West European Politics.https://doi-org.ezproxy.its.uu.se/10.1080/01402382.2021.1873529

Helsedirektoratet. (2020a). Ingen mangel på smittevernutstyr. Helsedirektoratet. Retrieved 0420, 2020, fromhttps://www.helsedirektoratet.no/nyheter/ingen-mangel-pa-smittevernutstyr

Helsedirektoratet. (2020b). Innkjøp av personlig smittevernutstyr (PVU) i kommuner – tilbaketil ordinære ansvarsforhold fra nyttår. Retrieved 04 28, 2021, fromhttps://www.helsedirektoratet.no/tema/beredskap-og-krisehandtering/koronavirus/anbefalinger-og-beslutninger/Innkj%C3%B8p%20av%20personlig%20smittevernutstyr%20(PVU)%20i%20kommuner%20%E2%80%93%20tilbake%20til%20ordin%C3%A6re%20ansvarsforhold.pdf/_/attachmen

Helsedirektoratet. (2020c). Kommunenes ansvar for å fordele smittevernutstyr til fastleger.Retrieved 05 31, 2021, fromhttps://www.helsedirektoratet.no/tema/beredskap-og-krisehandtering/koronavirus/anb

38

efalinger-og-beslutninger/Kommunenes%20ansvar%20for%20%C3%A5%20fordele%20smittevernutstyr%20til%20fastleger.pdf/_/attachment/inline/1193505d-e76e-44cf-b071-9649938d1908:65d10

Helsedirektoratet. (2020d). Koordinering av innkjøp og fordeling av personligsmittevernutstyr til helseforetak og den kommunale helse- og omsorgstjenesten.Retrieved 04 20, 2021, fromhttps://www.helsedirektoratet.no/tema/beredskap-og-krisehandtering/koronavirus/anbefalinger-og-beslutninger/Koordinering%20av%20innkj%C3%B8p%20og%20fordeling%20av%20personlig%20smittevernutstyr%20-%20til%20kommuner.pdf/_/attachment/inline/8b792e78-9e41-4c1

Helsedirektoratet. (2020e). Nasjonal dugnad på leveranse av smittevernutstyr.Helsedirektoratet. Retrieved 04 22, 2021, fromhttps://www.helsedirektoratet.no/nyheter/nasjonal-dugnad-pa-leveranse-av-smittevernutstyr

Helsedirektoratet. (2020f). Nytt system for distribusjon av verneutstyr. Helsedirektoratet.Retrieved 04 22, 2021, fromhttps://www.helsedirektoratet.no/nyheter/nytt-system-for-distribusjon-av-verneutstyr

Helsedirektoratet. (2020g). Vedtak om unntak fra kravene gitt i gjeldende regelverk vedanskaffelse av smittevernutstyr. Retrieved 04 20, 2021, fromhttps://www.helsedirektoratet.no/tema/beredskap-og-krisehandtering/koronavirus/anbefalinger-og-beslutninger/Vedtak%20om%20unntak%20fra%20kravene%20gitt%20i%20gjeldende%20regelverk%20ved%20anskaffelse%20av%20smittevernutstyr.pdf/_/attachment/inline/d89e1050

Helsedirektoratet. (2021). About the Norwegian Directorate of Health. Helsedirektoratet.Retrieved 04 20, 2021, fromhttps://www.helsedirektoratet.no/english/about-the-norwegian-directorate-of-health#publicmandate

Helse Sør-Øst. (2020). Smittevernutstyr på vei ut til hele landet. Helse Sør-Øst. Retrieved 0519, 2021, fromhttps://www.helse-sorost.no/nyheter/smittevernutstyr-pa-vei-ut-til-hele-landet

Helse Sør-Øst. (2021). Ett år med pandemi. Retrieved 04 23, 2021, fromhttps://www.helse-sorost.no/nyheter/ett-ar-med-pandemi

Kates, A., & Galbraith, J. R. (2007). Designing Your Organization: Using the STAR Model toSolve 5 Critical Design Challenges. San Francisco: Jossey-Bass.

Kommunal. (2020). Fortsatt stor brist på skyddsutrustning i äldreomsorgen. Retrieved 05 24,2021, fromhttps://www.kommunal.se/nyhet/fortsatt-stor-brist-pa-skyddsutrustning-i-aldreomsorgen

Krajewski-Siuda, K., & Romaniuk, P. (2008). Poland—an “experimental range” for healthcare system changes. Two reforms: decentralization and centralization and theirconsequences. Journal of Public Health, 16, 61–70.https://rd-springer-com.ezproxy.its.uu.se/article/10.1007/s10389-007-0118-0

krisinformation.se. (2021). Så fungerar krishanteringen av coronaviruset i Sverige.krisinformation.se Krisinformation från svenska myndigheter. Retrieved 04 25, 2021,fromhttps://www.krisinformation.se/detta-kan-handa/handelser-och-storningar/20192/myndigheterna-om-det-nya-coronaviruset/sa-gar-krishanteringen-till

Länsstyrelsen Östergötland. (2020). Regionalt samarbete ger resultat: Nya leveranser avskyddsutrustning till kommunernas vårdboenden. Retrieved 05 24, 2021, fromhttps://www.lansstyrelsen.se/stockholm/om-oss/pressrum/nyheter/nyheter---stockhol

39

m/2020-04-17-regionalt-samarbete-ger-resultat-nya-leveranser-av-skyddsutrustning-till-kommunernas-vardboenden.html

Länsstyrelsen Stockholm. (2020). Regionalt samarbete ger resultat: Nya leveranser avskyddsutrustning till kommunernas vårdboenden. Länsstyrelsen Stockholm. Retrieved05 24, 2021, fromhttps://www.lansstyrelsen.se/ostergotland/om-oss/nyheter-och-press/nyheter---ostergotland/2020-04-30-tillgang-till-skyddsutrustning-samordnas-i-lanet.html

Lee, B., & Saunders, M. (2017). Conducting case study research for business andmanagement students. Thousand Oaks, CA: Sage.

Ludwig, T., & Houmanfar, R. (2010). Understanding Complexity in Organizations.Behavioral Systems (1st ed.). Routledge & CRC Press.https://www.routledge.com/Understanding-Complexity-in-Organizations-Behavioral-Systems/Ludwig-Houmanfar/p/book/9780415633949

MedTech Europe. (2020). COVID-19 Procurement Actions. Retrieved 06 02, 2021, fromhttps://www.medtecheurope.org/resource-library/covid-19-procurement-actions/

Merkur, S., Anell, A., & Häger Glenngård, A. (2012, fig.2, p.19). Sweden. Health systemreview. Health Systems in Transition, 15(5), 159.https://www.researchgate.net/publication/265083644_Health_Systems_in_Transition

Moderne transport. (2020). Landet med en million munnbind. Mtlogistikk.no. Retrieved 0519, 2021, fromhttps://www.mtlogistikk.no/bring-helse-sor-ost-korona/landet-med-en-million-munnbind/168376

NORDHELS. (n.d). Sjukvårdens organisation i Sverige. http://www.nordhels.org/. Retrieved04 18, 2021, from http://www.nordhels.org/sv/organisation/sverige/

NTB kommunikasjon. (2020). Smittevernutstyr på vei ut i hele landet. NTB kommunikasjon.Retrieved May 19, 2021, fromhttps://kommunikasjon.ntb.no/pressemelding/smittevernutstyr-pa-vei-ut-i-hele-landet?publisherId=15925840&releaseId=17883034

Reddy, S. K., & Agrawal, R. (2021). Designing case studies from secondary sources – Aconceptual framework. Indian Institute of Technology (IIT) Roorkee.https://mpra.ub.uni-muenchen.de/60423/1/MPRA_paper_60423.pdf

Regeringen. (2020a). Uppdrag att bistå Socialstyrelsen i arbetet med att samordna tillgångentill skyddsutrustning och annat sjukvårdsmaterial till följd av spridningen avcovid-19. Retrieved 05 24, 2021, fromhttps://www.regeringen.se/496702/contentassets/513705b8269d41b9ab1e0ad8e8b4f7c1/uppdrag-att-bista-socialstyrelsen-i-arbetet-med-att-samordna-tillgang-till-skyddsutrustning.pdf

Regeringen. (2020b). Uppdrag att säkerställa ett förfarande för att även icke CE-märktpersonlig skyddsutrustning ska kunna användas. Retrieved 05 24, 2021, fromhttps://www.regeringen.se/496845/contentassets/e20f443fabd5463d9f5a9f655405395f/uppdrag-att-sakerstalla-ett-forfarande-for-att-aven-icke-ce-markt-personlig-skyddsutrustning-ska-kunna-anvandas.pdf

Regeringen. (2020c). Uppdrag om att på nationell nivå säkra tillgången på skyddsutrustningoch fördela skyddsutrustning och annat material till följd av spridningen av covid-19.Retrieved 05 24, 2021, fromhttps://www.regeringen.se/494a34/contentassets/5c41833214fe4e568e5fd62b65eb8681/uppdrag-om-att-pa-nationell-niva-sakra-tillgangen-pa-skyddsutrustning.pdf

Regeringen.no. (2019). Hovedprinsipper i beredskapsarbeidet. Regeringen.no. Retrieved 0425, 2021, from

40

https://www.regjeringen.no/no/dokumentarkiv/Regjeringen-Bondevik-II/ld/Nyheter-og-pressemeldinger/2003/styret_for_verdiskapingsprogrammet/id233999/

Regeringskansliet. (2014). Den svenska förvaltningsmodellen. Retrieved 05 24, 2021, fromhttps://www.regeringen.se/lattlast-information-om-regeringen-och-regeringskansliet/den-svenska-samhallsmodellen/den-svenska-forvaltningsmodellen---tre-nivaer/

Regeringskansliet. (2020). Hemställan om nationella beslut för att säkra varuförsörjning isjukvården. Retrieved 05 24, 2021, fromhttps://www.regeringen.se/regeringens-politik/regeringens-arbete-med-coronapandemin/om-halsovard-sjukvard-och-aldreomsorg-med-anledning-av-covid-19/fragor-och-svar-om-den-tillfalliga-pandemilagen/

Region Stockholm, Region Skåne, & Västra Götalandsregionen. (2020). Hemställan omnationella beslut för att säkra varuförsörjning i sjukvården.

Regjeringen. (2018). Nasjonal Helseberedskapsplan. Helse - og omsorgsdepartementet.Retrieved 05 16, 2021, fromhttps://www.regjeringen.no/globalassets/departementene/hod/fellesdok/planer/helseberedskapsplan_010118.pdf

Regjeringen. (2019). Hovedprinsipper i beredskapsarbeidet. Regnjeringen.no. Retrieved 0510, 2021, fromhttps://www.regjeringen.no/no/tema/samfunnssikkerhet-og-beredskap/innsikt/hovedprinsipper-i-beredskapsarbeidet/id2339996/

Regjeringen. (2020a). Delegert myndighet i forbindelse med koronavirus-utbruddet.Regjeringen.no. Retrieved 05 16, 2021, fromhttps://www.regjeringen.no/no/aktuelt/delegert-myndighet/id2692686/

Regjeringen. (2020b). Slik er spesialisthelsetjenesten bygd opp. Regjeringen.no. Retrieved 0518, 2021, fromhttps://www.regjeringen.no/no/tema/helse-og-omsorg/sykehus/innsikt/nokkeltall-og-fakta---ny/slik--er-spesialisthelsetjenesten-bygd-o/id528748/

Regjeringen. (2020c). Vedtar hjemmel for å sikre tilgang til nødvendige legemidler og utstyr.Regjeringen.no. Retrieved 05 16, 2021, fromhttps://www.regjeringen.no/no/aktuelt/vedtar-hjemmel-for-a-sikre-tilgang-til-nodvendige-legemidler-og-utstyr/id2691898/

Regjeringen. (2021). Kommunale helse- og omsorgstjenester. Regjeringen.no. Retrieved 0420, 2021, fromhttps://www.regjeringen.no/no/tema/helse-og-omsorg/helse--og-omsorgstjenester-i-kommunene/id10903/

Robinson, M. (2007). Does Decentralisation Improve Equity and Efficiency in Public ServiceDelivery Provision? Institute of Development Studies, 38(1), 7-17.https://core.ac.uk/download/pdf/286043983.pdf

Sjukhusläkaren. (2014). Blir det bättre med statlig sjukvård? Sjukhusläkaren. Retrieved 05 2,2021, from https://www.sjukhuslakaren.se/blir-det-battre-med-statlig-sjukvard/

SKR. (2020). Pandemin och hälso- och sjukvården. Sveriges Kommuner och Regioner.Retrieved 04 23, 2021, fromhttps://www.icuregswe.org/globalassets/artiklar/pandemin_och_halso_och-sjukvarden.pdf

SKR. (2021a). Covid-19 och det nya coronaviruset. Sveriges Kommuner och Regioner.Retrieved 04 25, 2021, fromhttps://skr.se/skr/covid19ochdetnyacoronaviruset.31764.html

SKR. (2021b). Därför är självstyrelse bra. Sveriges kommuner och regioner. Retrieved 0524, 2021, from

41

https://skr.se/skr/demokratiledningstyrning/politiskstyrningfortroendevalda/kommunaltsjalvstyresastyrskommunenochregionen/darforarsjalvstyrelsebra.1567.html

SKR. (2021c). Så styrs regionerna. Sveriges Kommuner och Regioner. Retrieved 04 18,2021, fromhttps://skr.se/skr/demokratiledningstyrning/politiskstyrningfortroendevalda/kommunaltsjalvstyresastyrskommunenochregionen/sastyrsregionerna.1790.html

SKR. (2021d). Swedish Association of Local Authorities and Regions. Sveriges Kommuneroch Regioner. Retrieved 04 18, 2021, fromhttps://skr.se/skr/tjanster/englishpages.411.html

SML. (2019a). Helsetjenesten. Store Medisinske Leksikon. Retrieved 04 20, 2021, fromhttps://sml.snl.no/helsetjenesten

SML. (2019b). Helsevesenet. Store Medisinske Leksikon. Retrieved 04 20, 2021, fromhttps://sml.snl.no/helsevesenet

SML. (2019c). Kommunehelsetjenesten. Store Medisinske Leksikon. Retrieved 04 20, 2021,from https://sml.snl.no/kommunehelsetjenesten

SNL. (2021). Statsforvalter. Store Norske Leksikon. Retrieved 04 20, 2021, fromhttps://snl.no/statsforvalter

Socialstyrelsen. (2019). About the Swedish healthcare system.https://www.socialstyrelsen.se/. Retrieved 04 18, 2021, fromhttps://www.socialstyrelsen.se/en/about-us/healthcare-for-visitors-to-sweden/about-the-swedish-healthcare-system/

Socialstyrelsen. (2020a). Lägesrapporter, samordning och övriga uppdrag med anledning avcovid-19. Socialstyrelsen. Retrieved 05 22, 2021, fromhttps://www.socialstyrelsen.se/coronavirus-covid-19/socialstyrelsens-roll-och-uppdrag/

Socialstyrelsen. (2020b). Socialstyrelsens plan inför eventuella nya utbrott av covid-19.https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/ovrigt/2020-9-6886.pdf

SR. (2020a). Facket: Regionen bryter mot lagen. Sveriges radio. Retrieved 05 24, 2021, fromhttps://sverigesradio.se/artikel/7326890

SR. (2020b). Kommunerna har olika stora lager av skyddsutrustning. Sveriges radio.Retrieved 05 24, 2021, from https://sverigesradio.se/artikel/7529983

SR. (2020c). Socialstyrelsen: ”Ingen prioritering som kommer från oss”. Sveriges radio.Retrieved 05 24, 2021, from https://sverigesradio.se/artikel/7498668

SR. (2020d). Viruset kan leda till materialbrist i vården. Sveriges radio. Retrieved 05 24,2021, from https://sverigesradio.se/artikel/7408590

Statsforvalteren. (2021). Health, care and social services. Statsforvalteren.no. Retrieved 0420, 2021, fromhttps://www.statsforvalteren.no/en/portal/Health-care-and-social-services/

Statskontoret. (2020). Förvaltningsmodellen under coronapandemin. 1-71.https://www.statskontoret.se/publicerat/publikationer/2020/forvaltningsmodellen-under-coronapandemin/

SvD. (2020). Ordrar på vårdutrustning når "extrema" nivåer. Svenska Dagbladet. Retrieved06 02, 2021, from https://www.svd.se/ordrar-pa-vardutrustning-nar-extrema-nivaer

Sveriges läkarförbund. (2021). Swedish healthcare system. https://slf.se/. Retrieved 04 18,2021, from https://slf.se/in-english/swedish-health-care-system/

svt Nyheter. (2020a). Arbetsförmedlingen: Ny typ av kris vi inte sett i modern tid. svt.se.Retrieved 05 24, 2021, fromhttps://www.svt.se/nyheter/inrikes/ny-typ-av-kris-vi-inte-sett-i-modern-tid

42

svt Nyheter. (2020b). Kritiken: Byråkrati gör att Sverige går miste om sjukvårdsmateriel.Retrieved 05 24, 2021, fromhttps://www.svt.se/nyheter/ekonomi/kritiken-byrakrati-gor-att-sverige-gar-miste-om-sjukvardsmateriel

Sykehusinnkjøp. (2020). Fordeling av smittevernutstyr. Sykehusinnkjøp. Retrieved 05 18,2021, from https://sykehusinnkjop.no/nyheter/fordeling-av-smittevernutstyr

Thurén, T. (2005). Källkritik (2nd ed.). Stockholm: Liber.Tien, J. M., & Goldschmidt-Clermont, P. J. (2009). HEALTHCARE: A COMPLEX

SERVICE SYSTEM. 257-282. 10.1007/s11518-009-5108-zTommasi, M., & Weinschelbaum, F. (2007). Centralization vs. Decentralization: A

Principal‐Agent Analysis. Journal of Public Economic Theory, 9(2), 369-389.https://doi-org.ezproxy.its.uu.se/10.1111/j.1467-9779.2007.00311.x

Treiblmaier, H. (2018). Optimal levels of (de)centralization for resilient supply chains. TheInternational Journal of Logistics Management, 29(1), 435-455.10.1108/IJLM-01-2017-0013

UIB. (2020). Hvordan ta gode beslutninger når ekspertisen mangler svarene? Universitetet iBergen. Retrieved 04 23, 2021, fromhttps://www.uib.no/svt/135261/hvordan-ta-gode-beslutninger-n%C3%A5r-ekspertisen-mangler-svarene

United States of Labor. (2021). Personal Protective Equipment. Retrieved 05 24, 2021, fromhttps://www.osha.gov/personal-protective-equipment

Upphandlingsmyndigheten. (2020). Utvecklingen på upphandlingsområdet 2020. Retrieved05 24, 2021, fromhttps://www.upphandlingsmyndigheten.se/globalassets/dokument/publikationer/trendens_2020.pdf

Uppsala Kommun. (2020a). Överenskommelse och borgensåtagande för inköp avskyddsutrustning till Sveriges kommuner med anledning av coronaepidemin.Retrieved 05 24, 2021, fromhttps://www.uppsala.se/contentassets/fcf083361d1d48af934ff25c710b63d7/4.-overenskommelse-och-borgensatagande-for-inkop-av-skyddsutrustning-till-sveriges-kommuner.pdf

Uppsala Kommun. (2020b). Storstäderna säkrar skyddsutrustning till hela landets omsorg.Retrieved 05 24, 2021, fromhttps://via.tt.se/pressmeddelande/storstaderna-sakrar-skyddsutrustning-till-hela-landets-omsorg?publisherId=3235517&releaseId=3274999

Vårdgivarguiden. (2019). Hälso- och sjukvårdslagen. Vårdgivarguiden Region Stockholm.Retrieved 05 24, 2021, fromhttps://vardgivarguiden.se/avtal/styrdokument/lagar-och-forordningar/halso--och-sjukvardslagen/

Vargas Bustamante, A. (2010). The tradeoff between centralized and decentralized healthservices: Evidence from rural areas in Mexico. Social Science & Medicine, 71(5),925-934. https://doi.org/10.1016/j.socscimed.2010.05.022

Varuförsörjningen. (2020). Varuförsörjningen och varuförsörjningsnämnden. Retrieved 0524, 2021, from https://varuforsorjningen.se/om-oss/vaar-organisation/

Vetenskapsrådet. (2017). The Swedish healthcare system. https://www.kliniskastudier.se/.Retrieved 04 18, 2021, fromhttps://www.kliniskastudier.se/english/sweden-research-country/swedish-healthcare-system.html

VG. (2020). Norske kommuner må bygge egne beredskapslagre: − De pengene har vi ikke.Retrieved 06 02, 2021, from

43

https://www.vg.no/nyheter/innenriks/i/OQnJqq/norske-kommuner-maa-bygge-egne-beredskapslagre-de-pengene-har-vi-ikke

WHO. (2020). Shortage of personal protective equipment endangering health workersworldwide. World Health Organization. Retrieved 05 24, 2021, fromhttps://www.who.int/news/item/03-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-worldwide

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