Decentralization and centralization in the context of a global crisis

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

Abstract

Decentralization 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 1

1.1 Problematization 2

1.2 Purpose and research question 3

1.3 Academic and practical relevance 3

2. Empirical background 5

2.1 National health care service 5

2.1.1 Personal protective equipment (PPE) 5

2.2 Sweden’s decentralized national health care service 5

2.2.1 National level 6

2.2.2 Regional and local level 6

2.2.3 Coordination by a political organization 7

2.3 Norway’s centralized national health care service 7

2.3.1 National level 8

2.3.2 Regional level 9

2.3.3 Local level 9

2.4 Allocation of control in Swedish and Norweigan health care 9

2.5 Principles of responsibilities in a crisis 10

3. Theory 12

3.1 Conceptual frameworks of decentralization and centralization 12 3.2 Theoretical opportunities and challenges related to decentralization 13 3.3 Theoretical opportunities and challenges related to centralization 13

3.4 Empirical evidences 14

4. Method 16

4.1 Qualitative research strategy 16

4.2 Multiple-case study design 16

4.2.1 Selection of cases 16

4.2.2 Situational context 17

4.2.3 Dimension of time 17

4.2.4 Abductive approach 17

4.2.5 Secondary sources 18

4.2.6 Collection of empirical data 18

4.2.7 Overview of chosen research design 19

4.3 Reflections on methodological choices 20

4.3.1 Secondary sources and related limitations 20

5. Empirical findings 22

5.1 Case study of Sweden’s national health care service 22

5.1.1 Critical access of PPE and regions request help from national level 22

5.1.2 Ad-hoc collaborations 23

5.1.3 Confusions regarding share of responsibilities 24

5.1.4 Variations among regions 24

5.2 Case study of Norway’s national health care service 25

5.2.1 Proactive phase 25

5.2.2 Reactive phase 26

5.2.3 Reported stability 27

6. Analysis 28

6.1 The Swedish national health care case 28

6.2 The Norwegian national health care case 30

6.3 The cases in relation to each other 33

7. Conclusions 35

7.1 Sweden 35

7.2 Norway 35

7.3 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. Introduction

One 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

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 Problematization

Whether 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).

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 relevance

The academic relevance of this research is that a widened understanding of the theoretical

associated challenges and opportunities with the concepts of centralization and

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.

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 service

A 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 service

Sweden’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.

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 that include 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 Affairs

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 Welfare

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.

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Swe. Socialdepartementet.

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-government

. 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 Board

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

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 Regions

(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).

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Swe. Sveriges Kommuner och Regioner, SKR.

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Swe. Inköpsnämnden.

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Swe. Varuförsörjningsnämnden.

3

Swe. Kommunalt självstyre.

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 (Merkur et al., 2012, fig.2, p.19).

2.3.1 National level

At a national level, the Ministry of Health and Care Service

controls the budgets, suggest laws to the Parliament and control several agencies, among others the Directorate of Health

and the Institute of Public Health

(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.

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Nor. Helsedirektoratet.

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Nor. Helse- og Omsorgsdepartementet.

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

, 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 Governour

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 care

The 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. Statsforvalter

10

Nor. Sykehusinnkjøp

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 to Norway.

2.5 Principles of responsibilities in a crisis

The 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 responsibility

, parity

and proximity

(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).

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Swe. Närhetsprincipen. / Nor. Nærhetsprinsippet.

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Swe. Likhetsprincipen. / Nor. Likhetsprinsippet.

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Swe. Ansvarsprincipen. / Nor. Ansvarsprinsippet.

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).

3. Theory

Following 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).

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,

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.

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).

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 design

Within 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

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 approach

A 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

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?

- 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 design

The 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.

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 limitations

Secondary 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

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.

5. Empirical findings

The 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 level

The re gions 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 request

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

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Swe. hemställan.

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 boards

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 Authority

on the 7 of April a task to ensure that there are procedures for providing non-CE marked

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

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label for fulfillment of safety requirements (Arbetsmiljöverket, 2012).

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Swe. Arbetsmiljöverket.

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Swe. länsstyrelserna.

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 responsibilities

The 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 regions

In 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

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 phase

According 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).

5.2.2 Reactive phase

On 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

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 stability

The 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).

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

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

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