Insistent individualisation and eroding egalitarianism: Dominant discourses of equality in Swedish healthcare policy.

Abstract

Background: Equality is a core objective that is frequently invoked in Swedish healthcare policy, yet its meaning is rarely examined in depth. This study analyses how equality is articulated in two contemporary healthcare reforms. The aim is to map the extent to which discussions on equality are present and how it is assumed that equality is to be achieved, analyse the meanings of equality that are produced, and discuss and problematise possible implications.

Methods: The study applies discourse theory and conceptual discussions on equality, in the analysis of two major Swedish governmental reform reports: one on highly specialised care (SOU 2015:98) and the other on primary healthcare (SOU 2020:19).

Results: Three meanings of equality were identified, of which the first two are more commonly articulated. Firstly, equality is articulated as sameness and uniformity, particularly in relation to geographical access, coordination across actors and locations, and the standardisation of care through knowledge production and exchange. Secondly, equality is framed as individual agency and patient responsibility, emphasising patients as co-creators of care through mechanisms such as individual care plans and patient contracts. To a lesser extent, equality is also articulated as responsiveness to healthcare needs. The two dominant meanings reflect liberal and individualised notions of equality that prioritise uniform access and the removal of difference, alongside an emphasis on individual responsibility.

Conclusions: The analysis suggests that these dominant articulations marginalise more egalitarian or distributive understandings of equality that would take into account social determinants of health and unequal structural conditions. While equality occupies a central position in Swedish healthcare policy, its meaning is increasingly shaped by liberal values rather than commitments to social justice or redistribution. This has important implications for how healthcare reforms are designed and for the capacity of policy to address healthcare inequalities in practice.