Recentralizing healthcare through evidence-based guidelines – striving for national equity in Sweden

BACKGROUND The Swedish government has increasingly begun to rely on so called informative governance when regulating healthcare. The question this article sets out to answer is: considered to be "the backbone" of the Swedish state's strategy for informative governance in healthcare, what kind of regulatory arrangement is the evidence-based National Guidelines? Together with national medical registries and an extensive system of quality and efficiency indicators, the National Guidelines constitutes Sweden's quality management system. METHODS A framework for evaluating and comparing regulatory arrangements was used. It asks for instance: what is the purpose of the regulation and are regulation methods oriented towards deterrence or compliance? RESULTS The Swedish National Guidelines is a regulatory arrangement intended to govern the prioritizations of all decision makers - politicians and administrators in the self-governing county councils as well as healthcare professionals - through a compliance model backed up by top-down benchmarking and built-in mechanisms for monitoring. It is thus an instrument for the central state to steer local political authorities. The purpose is to achieve equitable and cost-effective healthcare. CONCLUSIONS This article suggests that the use of evidence-based guidelines in Swedish healthcare should be seen in the light of Sweden's constitutional setting, with several autonomous levels of political authority negotiating the scope for their decision-making power. As decision-making capacity is relocated to the central government - from the democratically elected county councils responsible for financing and provision of healthcare - the Swedish National Guidelines is part of an ongoing process of healthcare recentralization in Sweden, reducing the scope for local decision-making. This represents a new aspect of evidence-based medicine (EBM) and clinical practice guidelines (CPGs).