Helge Ramsdal:
From hierarchical steering to dialogic governance?
An analysis of four welfare state reforms in Norway
helge.ramsdal@hiof.no
Published in:
Barroso, J. and L.M. Carvalho (eds.): Knowledge and Regulatory Processes in
Health and Education Policies. EDUCA, Lisbon 2012. (Ch. 3, pp. 89 – 131).
Introduction
As a relatively rich, small and homogeneous Nordic welfare state, Norway has a long
tradition of initiating extensive welfare reforms in education, employment and health and
social services. One typical feature often overlooked in the international discussion about the
Nordic welfare states, and especially Norway, is that the provision of welfare services is
largely left to relatively autonomous local councils. The local authorities that provide the bulk
of welfare services have an important place in the administrative system as so-called
"generalist" local authorities, meaning that they are responsible for schools, technical services
and not least the health and social services that accommodate all phases of life "from cradle to
grave" (except hospitals). The Norwegian system has been described as a "local welfare"
model, where the central authorities rely on the local authorities' implementation of state
policies in various areas of social policy. There are now about 430 local authorities in the
country. A major challenge for government policy is that these vary greatly in population,
size and geographical features, from relatively large urban authorities to those in rural and
peripheral areas. This is obviously a considerable challenge in the design and implementation
of welfare reforms, both because of the sector-specific requirements for the extent and quality
of services and the need to find a balance between state control and local discretion in the
implementation of reforms.
1
In recent years, different governments have initiated extensive actions and reforms in health
care and social welfare. These initiatives coincide with changes in the relationship between
local and state government, related to the intention to phase out micro-management,
hierarchical control and unnecessary bureaucracy. This appears to be a paradoxical situation,
since the traditional view has been that successful implementation of welfare reform requires
strong governmental measures to achieve the desired results.
But this paradox may be
approached from widely differing perspectives. Some researchers in welfare state
development see local authorities primarily as instruments to carry out clearly pre-defined
goals, while others consider their freedom to adapt actions and services to local conditions as
the most important factor. This is a classic problem in social research. However, we
sometimes experience a schism between those who have a local political perspective,
emphasising the intrinsic value of local democracy and local government institutions, and
those with a welfare policy perspective, concerned with the consequences of the reforms in
sectoral policy. We are therefore in need of analytical measures to transcend these
perspectives in order to study the reforms without putting on either of these two cloaks.
I shall discuss four welfare state reforms, all related to the health and social care sector. These
reforms were launched at different times from the mid-1970s to the present day. My purpose
is to present the instruments that characterised the implementation of the initiatives, in light of
the perspectives outlined above. This will be done on the basis of the design of the reform, i.e.
the sum of governmental steering instruments formally employed. In other words, I do not
discuss how these instruments work in practice at the meeting point between government
intentions and local adaptations. The overriding question in my discussion is rather whether
there have been any changes in the reform design in the roughly 35 years of reform initiatives.
My hypothesis is that the changes in the use of steering instruments reflect a transition from
"steering" to "public action", or from "government" to "governance".
Theoretical approaches
This paper focuses upon regulatory instruments that illuminate the process of regulation in
health and welfare reforms. Drawing on Salamon's definition of policy instruments, we
define a regulatory instrument as a “mechanism, object, tool or process which defines,
specifies or structures the work of information gathering, planning, coordination,
2
implementation, accounting or evaluation in a given domain of public action” (Salamon 2002:
29). Such instruments are intended to bring actors to think or do something they might not
otherwise do. The general idea is that present-day governance systems have changed. The
discussion takes two points of departure: Firstly, it maintains that the Western world has seen
a shift from “traditional” to “new” regulation the last decades (Salomon 2002, Hood and
Margetts 2007). Secondly, that “new” regulation to a larger extent is informed by knowledgebased regulation tools. These approaches implicate that these new regulatory tools are more
complex and ambiguous, referred to as “soft regulation”, often taking hybrid forms according
to the principles, actors, functions and procedures they combine (Pons, X. and van Zanten, A.
2007).
“Traditional” and “new” regulation.
Salamon (2002) claims that governments must change for two reasons in particular: to
become more effective with new specific skills and new ways to legitimate their action.
According to these arguments, knowledge plays a central role in that double process. The
development of “knowledge based instruments” is thus strongly linked to both changes in
regulation processes in general (the development of governance, of post-bureaucratic modes
of regulation and of multi-level political systems), and to new forms of knowledge circulation
among different actors involved in the policy process (researchers, experts, think-tanks, policy
bodies, professionals, clients). These tendencies are claimed to reflect an even broader
movement toward cognitive and reflective societies where knowledge is at the core of social
action. Here, new actors, new knowledges and new institutional arrangements are adding to
the traditional ones, often taking hybrid forms according to the principles, actors, functions
and procedures they combine. New modes of regulation are emerging from diverse sources at
different levels and in different sectors - both governmental and non-governmental. In the
same way, the different 'knowledges' to be appropriated and the conditions of their use
become more diverse as well. At the same time, and to the extent that these new modes of
regulation emphasize the autonomy of actors and organizations and the relevance of
negotiation and persuasion, they reinforce the key role of knowledge in the legitimation of the
policy making process (knowledge-based decision-making) (KnowandPol O3: regulation:
specification:1 2009).
3
Modern societies are highly regulated and it is regulated by different means than traditional
(welfare) society. It is possible to talk about a shift from state regulations by the use of norms,
laws and planning system to an increasing use of indirect, informal and at distance regulations
including use of international standards, reform-based evaluations, knowledge-based
programs etc. We refer here to the shift from traditional government based on laws etc. to
more flexible governance where additional new regulation forms, more informal and
voluntary, expand. In this view governance includes government (Power 1999, Fernler and
Helgesson, 2006), and thus “new” governance is not abandoning hierarchy, but rather blend
into new ways of governing “in the shadow of hierarchy” (Vabo 2010). Following Day and
Klein (1990) this is considered as a shift from “welfare state to regulatory state”.
Here, we will discuss these ideas of a transition from “hierarchical steering” to “new
regulation” in relation to reform designs. We take as a starting point these ideas as a
hypothesis, and that these developments must be studied based upon an operationalization of
“traditional” and “new” reform designs in order to illuminate whether, and to which extent,
these developments are taking place within the context of the Norwegian welfare state. The
reforms we study are as we see it, typical of their time, though not “representative” in other
ways than being regarded generally as important developments of health and welfare policies
at the level of local government.
Reform analysis
The term "reform" is ambiguous and often unclear. There seems to be a consensus that reform
work is intended to "improve" a policy field. Brunsson and Olsen (1993) stress that reform
implies "deliberate changes in organisational forms, structures and working methods", while
Sandvin (1996) argues that organisational changes can only be called "reform" in the case of
changes in the basic ideology behind them. Many political initiatives can be described as
"reforms", precisely because the term itself may generate political support for the initiative.
We often find that reforms have an explicit "positive" or "negative" connotation, highlighting
the fact that certain professional perspectives and practices agree or disagree with the
political objectives in the field. But in many cases, reforms will be intended to regulate,
reinforce or downplay certain professional understandings and practices without this being
explicitly formulated.
4
In order to study how the various driving forces behind the reforms are manifested, one can
start by considering the political authorities' choice of instruments. I shall primarily
concentrate on "reform design", i.e. how the formal structure of the reforms is organised
through the use of various steering instruments (Olsen 1983). In line with the approach of
Rothstein (1986), we will understand the political/administrative/professional structure of the
reform as a result of rational choices of instruments within the cognitive frameworks of the
reform designers. There are of course other ways to interpret design, e.g. as a symbolic
activity where one primarily perceives reform work as an activity to create legitimacy
(Brunsson and Olsen op.cit.). For political authorities, reform design will imply both
"efficiency considerations", i.e. how to create real changes in practice, and symbolic
considerations, i.e. how to create political support both in the relevant field and in general
terms.
As several authors have pointed at, the way different steering instruments are blended in order
to create the “reform design”, taking contextual factors within the individual country into
consideration, is the main issue of political analysis within the tradition of the “instrumentchoice” perspective to which this study of Norwegian reform designs belong (Peters 2002,
Eliadis, Hill and Howlett 2005, Hood and Margetts 2007, Lascoumes and Le Gales 2007).
The fundamental question in reform design is the force of the power employed in the
implementation of the reform by the reform designers, i.e. the state authorities. From what
has been said before, this power will most strongly manifest itself with the development of a
top-down strategy. Here one attempts in different ways to ensure that local implementers
establish or modify actions and services in line with the policy goals of the reform. At the
other end of the scale, a reform could take account of local conditions and seek primarily to
create a basis for locally-generated learning processes, so that the goals and intentions slowly
but surely manifest themselves in the field.
This way of describing the extremes implies that reforms can be "hierarchical" (highly
integrated) or "dialogic" (loosely connected). The degree of integration selected in the design
of a particular reform will initially be dependent not only on the general administrative policy
frameworks in which one operates (e.g. the degree of decentralisation or centralisation of
management policies), but also on specific professionally substantive characteristics of the
individual reform, for example, knowledge of potential causes and effects as a basis for
5
implementing specific measures. The more secure the knowledge base and the more
centralised the management policy, the more integrated we can expect the reform design to
be. And vice versa: the less substantive the knowledge base or the cause-effect relationship,
and the more decentralised the policy is, the more the reform design will tend towards loosely
connected structures.
What parameters are involved in reform design? Studies of reforms in the Scandinavian
countries (Dahl Jacobsen 1976, Rothstein 1986) indicate that the following factors determine
the design:
-
the extent to which the goals of the reform work are clear and operational
-
how far these goals are prescribed by legislation on the implementation of actions and
services, and how precisely formulated these requirements are
-
the structure of the funding and support measures which are established
-
whether the knowledge of causes and effects is perceived as unambiguous or not
-
whether there are specific professions representing this knowledge both locally and
centrally in the field
-
whether local (political-administrative) implementation bodies are set up to safeguard
the intentions of the reform
What will determine the impact of the reform on the basis of this approach will partly be the
degree of integration between the various steering instruments and partly the
operationalisation of the individual instruments. A reform design characterised by close links
means that the reform objectives are unambiguous and explicitly formulated and that there is
consistency in the choice of instruments. A further assumption is "political clout" behind the
instruments. The fact that each instrument is operationalised implies in turn that the goals for
the extent and quality of actions and services are clearly defined, that the reform is rooted in
law, that the funding is targeted, and that there are certain professions defined as professional
6
carriers of the reform process, together with local decision-making bodies. As a basis for the
discussion of the trend towards more "dialogic" reform design these days, we can thus
develop two "typical ideal" varieties: one rooted in "hierarchical" management thinking, and
one that lays the foundation for a more "horizontal"/dialogic design of the reform:
Naturally, every reform will consist of instruments that vary according to the particular policy
area the government seeks to influence. In practice, the instruments selected will be a mix
determined by the context, but under the influence of the steering regime the policy represents
and related to the time of implementation. However, we can present the extreme forms as
follows:
«Hierarchical design»
«Dialogic design»
Clearly defined operational goals
ambiguous and non-operational goals
Clearly defined target group
No clearly defined target group
based on legislation
based on circulars, memos, etc.
earmarked funding
funding through block grants
vertical management structures
horizontal management structures
Unambiguous knowledge of cause-effect
uncertain knowledge base
profession maintains knowledge
no profession or many professions
state requirements for local implementation
no local implementation agency specified
agencies
by the state
Here we shall use this outline as a basis for our further discussion of various reform designs.
7
Reform design in various stages of the development of the welfare state:
horizontality and verticality in reform design
As indicated above, generally reforms are implemented in local contexts, but designed
centrally. This implies that the design must attempt to compromise between functional and
hierarchical organisation on the one hand, and local identity and horizontality on the other.
Classical analyses focus on the dilemma in the management system between these two
considerations: on the one hand the need to create consistent, professional solutions regardless
of where people live, and on the other hand, the desire to safeguard the local aspect, i.e. the
overall organisation of people's life circumstances that mainly (although perhaps to a
decreasing degree) takes place within local contexts - for our purposes primarily related to the
local authority as a management body (Strand 1978, Dente and Kjellberg 1998). The
relationship between these two considerations has varied over time. However, the general
trends of their relative mix play an important role in setting the agenda for the design of
concrete and specific reforms. There is however also interaction in this design process: We
can on the one hand imagine straight-line rationality, which first hammers out management
policy principles on how to weight the different considerations, and then applies these
principles to specific reform design. On the other hand we can also imagine a reform design
first developed on the basis of the substantive welfare policy considerations required by the
specific reform work, followed by a modification of the general management principles, or a
reform designed as an exception to usual government policy.
The general view of management policy development in the post-war period is that the
emphasis has shifted between the functional-hierarchical axis and the spatial-horizontal axis.
The post-war construction phase of the welfare state saw the dominance of substantive
welfare policy considerations at the expense of local administration. Slagstad (1998) describes
this as a "reform-technocratic" approach. There was agreement between political goals and
ambitions on the one hand, and professional forms of understanding of how to develop
various fields of social policy on the other hand. Knut Dahl Jacobsen (1965) for his part
describes this phase as a "detraction phase", meaning that professional views and
administrative units had considerable influence. Parliament passed mostly framework
legislation, while the specific reform design was left to professional and administrative
sections of the management system. One aspect of this was the emergence of a national
8
standardisation policy, where local authorities were primarily perceived as implementers of
state policy (Offerdal 1978). This reform design process meant that, within the broadly
defined national policy objectives, specific mechanisms were developed to overcome local
variations in the implementation. In the health and social care sector this was reflected in the
so-called "Evang system" (Nordby 1989). This system was characterised by a strong leader of
the Directorate of Health, and rooted in medical professional logic. Medical professional
sector structures were established across the horizontal-geographical identities of the local
authorities. In this period, the reform design was typified by the following features: clearly
defined target groups, special legislation for actions and services for these groups, official
memos specifying minimum standards for actions and services, earmarked financing,
requirements for specific professions and for the establishment of specific politicaladministrative structures in local government.
It can be argued that this reform-technocratic approach dominated until the adoption of a new
Local Health Services Act in 1984. Through precursors and preparatory work prior to the Act,
the emphasis in reform design was increasingly placed on the horizontal spatial dimension.
The revision of the Local Government Act in 1992 can be seen to represent a new turning
point in terms of the premises for reform work: the Local Government Act continued the basic
ideas of local democracy emphasised by the Local Health Services Act, but did so by
introducing a new relationship between central and local government. This new relationship is
described by Kjellberg (1991) as the concept of "the new local authority", emphasising that
the state government sets goals and frameworks for local services, while the local authority is
given a considerable degree of freedom to decide its own priorities and how to implement
measures to achieve goals. The relationship between state and local authorities is claimed to
be more of a "partnership model" than a hierarchical model, in so far as the process of goal
formulation and implementation requires a continuous and balanced dialogue between the
authorities at various administrative levels.
The question we ask here is how far what we can call the transition to a new steering regime
is reflected in changes in central reform design from "hierarchical" to "dialogic". The starting
point is a comparison of four health and social policy reforms. The first was changes in
preventive health care through the development of public health centres in the mid-1970s.
These were aimed at preventing somatic, mental and socio-medical problems among children
9
in the local community. The second reform was for mentally handicapped people, designed
in the late 1980s and implemented in the early 1990s. This reform entailed a radical
deinstitutionalisation; all institutions were closed, and instead programmes and services were
established in the community related to the goal of normalisation of life circumstances for this
group. The third reform is linked to the development of a "psychiatry reform" - the
"Escalation Plan" from 1998 to 2008. This reform involved the strengthening and
restructuring of programmes and services for people with mental disorders, where a key
principle was the goal of "openness and comprehensiveness", where local services were to
have priority. The fourth reform is the so-called "Coordination Reform", designed during
2007-2009, and to be implemented from 2012. The first three reforms have previously been
the subject of extensive research and evaluation, which will form the basis for my discussion
of reform design. Building upon this, I will discuss the design of the Coordination Reform.
This reform appears to be the most important in the health and social care sector at present.i
The public health centre reform
It is in itself significant that the reform to be discussed here is delineated by the institution
(health centre) and not by its mission to promote preventive health care among children. The
basis for the activities of the public health centre was established by voluntary (women's)
organisations before the Second World War, and was until 1974 largely the responsibility of
NGOs. One important factor is that these health centres had strong local roots, in that the
driving force in their work was usually local branches of the Norwegian Women's Public
Health Association. Through a process that started in 1968 with the work of the Steen
Committee on public health services, which led to the Act on Health Centres and Healthcare
for Children, etc. of 16 June 1972, implemented from 1974, the county councils were given
responsibility for the clinics in the local authorities. The Act on Local Health Services
transferred this responsibility to the local authorities in 1984.
The operations of the health centre can safely be considered as part of the health
modernisation project within the framework of the Evang system. This was specifically
manifested as follows: the implementation of legislation was highly centralised, with detailed
requirements for the operations of the centres. The "Handbook for Health Centres" from the
Directorate of Health gave an overview of the medical goals and ambitions in steering the
10
activities of the centres at that time. Together with the Directorate's "Professional Guidelines
for Public Health Centre Operations of 15 May 1974", there were now detailed directions on
how to organise the work locally. Three key elements should be mentioned here. Firstly, there
was earmarked funding for the operation of the health centres. Secondly, this funding was
linked to the appointment of specially qualified nurses as the professionals in charge of the
centres. Finally, there was a scientifically based technology based on nationally standardised
health cards which would form the basis for health information about children. Jakupstova
and Aarseth (1997) point out that "the Directorate of Health guidelines ... had elements of
strong steering, which could almost be seen as excessive steering against the historical
background" (p.33), mentioning in particular that the Directorate could ultimately close down
a health centre if it was not run correctly.
The nurses represented the most important knowledge base for reform. Specialisation after
basic nursing education gave these public health nurses a strong professional foundation for
their work. This originated from their status as a medical profession, closely linked to the
domain of doctors. In many ways, they acted as an "extended arm" of doctors, especially in
matters of preventive mental health. At the same time they had a high degree of autonomy,
since the health centres were to have a qualified public health nurse as the administrative
leader.
Jakupstova and Aarseth's analysis of public health centres in four local authorities in northwestern Norway shows how the professional basis for the activities has been relatively stable
since the 1974 reform. This is partly reflected by the fact that the reforms in local health and
social services in the 1980s and 1990s only influenced the public health centres to a limited
extent. The most striking factor is perhaps that, despite the emphasis on local preventive
health care in several parliamentary reports at that time, the public health centres were barely
given a mention. And despite an increasing emphasis on local coordination of health and
social services, health centre operations generally retained their original form, including the
public health nurses’ role as administrative leaders.
The main finding of the analysis concerns the stability and consistency of the work in the
health centres. The four local authorities studied show differences with respect to size and a
number of other background variables. Yet the health centre activities are based on the same
11
model, have the same medical professional basis and the same type of technology. It is mostly
the "monitoring model" established within the framework of the Evang system in the early
1970s which predominates. Here the public health nurse is being monitored by the state,
which expects parents of young children to have complete faith in her as a precondition for
her establishing contact with all such parents in the local authority area. The nurses’
professional autonomy is emphasised, while doctors connected to the centres are described as
peripheral part-time participants. Furthermore, and perhaps most interestingly from our point
of view, health centres have "loose ties to their environment", i.e. public health nurses in their
work primarily perceive themselves as representatives of the national preventive health care
strategy which evolved in connection with the government takeover of health centres, and
they have little interaction or coordination of their activities with the local community in
general.
The HVPU reform for mentally retarded.
The basis for this reform was first and foremost political and professional criticism of the
institutions for the mentally disabled. Many prominent participants in the social debate, in
alliance with relatives of these patients, were strongly critical of the functioning of the
centralised institutions administered by the county councils. This criticism was repeated, and
given more authority, by the so-called Lossius Commission, which presented two
recommendations in 1982 and 1984 ("Lossius I and II"). The Lossius Commission argued that
local programmes and services for the mentally handicapped had to be established before the
closure of the institutions. In practice it turned out that the political environment led to a
forced closure in advance of the recommended time frame. This must be seen against the
background of the general criticism of the institutions. Sandvin (ibid.) argues, however, that
there were two underlying premises behind the political fervour: firstly that the most
important client group, NFPU (the Norwegian Association for the Mentally Reaterded), was
strongly insisting on reform, and secondly the fact that there were no professions within the
institutional or administrative system which could launch a scientific defence against
institutional closure. It was, he claims, an alliance between social and political elite groups
and NFPU which, along with strong supporters in the Ministry of Social Affairs, formed the
main basis for the design of the reform.
12
In terms of our design parameters, we find the following characteristics of the HVPU reform:
It was formally based on closure legislation, since Parliamentary Report No. 49 (1987-88)
implied the closure of the institutional apparatus, but contained little in concrete terms about
what should be established at local level to replace this kind of care (Sandvin 1992). Four
circulars from the Ministry of Social Affairs carved out the principles for the transfer of
funding to local authorities, the requirements for the actions and services for clients
transferred from institutional to local care and the general principles for these actions and
services. The financial framework for the transfer of funding from central to local government
was initially based on the existing framework for institutional care, but was later increased
beyond that limit by about NOK 1 billion to a total of about NOK 4.3 billion in 1993. Later,
the funding was further increased. Grants to local authorities were on the basis of individual
clients.i During the first years after the reform was launched, adjustments were made both in
the framework of the total annual funding and in the basis of calculation for the individual
client. The most important point in our context, however, is that as early as the second year of
the reform period (1992) it was decided that the funding was to form part of block grants to
the local authorities. The evaluation of the reform shows that the local authorities considered
the funding for the implementation to be inadequate.
The planning system and ideological influence were the most important state steering
mechanisms regarding the content of the reform. According to Parliamentary Report No. 49
(1987-88), the local authorities were to create an "overall action plan for their measures for
the mentally disabled". This plan should be based on individual action plans for each client.
The plans were to include both those clients transferred to local care from the institutions and
those already under local responsibility. Three aspects of the local authority planning will be
emphasised here. Firstly, it meant a demarcation of the individuals who were the subject of
the local reform work. Although there were several problems related to the registration of
persons, it also meant that the reform was clearly linked to specific actions and services for
named clients. Secondly, the planning was bottom-up, in that it was the client's needs in the
individual action plan that would form the basis for the structure of local council actions and
services in the overall action plan. Thirdly, the individual action plan would then in turn be
linked to the financial plan and plans for health and social care in the council. All in all, this
implied a pressure from below which meant that local authorities bent over backwards to meet
the needs indicated in the plans. The Minister of Social Affairs indeed claimed that it had
13
never happened before that a target group had had their needs as closely scrutinised as under
this reform (Sandvin op.cit: 77). Sandvin also claims that the state guidelines for the planning
work were "both detailed and vague." He states that they were detailed in specifying
relatively closely the content of the plans and planning process, but vague in that the status of
the plans as a steering instrument was changed during the reform process.
The reform for the mentally retarded was generally regarded as an ideologically based reform,
associated with a transition from "special care" to "normalisation". Through an extensive
information campaign, the Ministry of Social Affairs attempted both to create an
understanding of the responsibility of other ministries for the implementation of the reform,
and of course primarily to influence the basis of understanding in local authorities about the
design of actions and services. Normalisation ideology involves a shift from thinking of the
"retarded" as a group to thinking in terms of individualisation. The basis for normalisation is a
person's intrinsic value, and if an individual needs support and help in everyday life, this
should be considered as a supplement to the equality to which all human beings are entitled.
Sandvin claims however that "it may seem a paradox that this reform, with such strong
ideological motivation, was made to depend on relatively autonomous implementation, when
it was well-known that the local authorities had scarcely been involved in the debate" (op.cit:
73). The link between the overriding ideological principle of normalisation and the
ideological basis for the design of local actions and services involved the dilemma between
"the old care paradigm" ("special care"), and "the new", which however emerged as
something radically different and unknown for many at local level.
There are two important points for our further discussion:
Firstly, the needs analysis and design of action plans and interventions were usually left to
dedicated personnel familiar with the mentally handicapped, who in most cases had
previously worked with them under the old system. This was important for the professionalideological alignment of the reform, in that their experiences and ways of thinking from the
institution-based system often followed them into the local authority plans. Secondly,
"normalisation" as a care principle was not sufficiently operationalised. The concept was
partly perceived as a socio-political basis for the reform process, and here the closure of
"special care" institutions and the development of local initiatives and services were in
14
themselves an expression of normalisation. On the other hand, internationally and
increasingly in Norway, normalisation was regarded as a relatively precise scientificideological concept, rooted in the work of Nirje, Michelsen and Wolfensberger
(Wolfensberger 1993, Kristiansen 1994, Solum 1991, Stangvik 1987). Although different
traditions eventually evolved within this field, with divergent methodologies and forms of
analysis, there was nevertheless an established scientific basis for relatively precise
requirements for actions and services to meet accepted normalisation standards.
The
Ministry of Social Affairs initiated a number of projects to assist local authorities in
developing actions and services based on a more precise scientific-ideological concept of
normalisation. Interestingly, after the Ministry had observed the projects for some time, it
concluded that normalisation was not primarily to be regarded as a scientific-professional
concept, but more a pragmatic socio-political care concept, which further encouraged
different local solutions (Ramsdal 1994).
While the reform itself thus expressed the transition to "a new paradigm of care," local
authorities were in practice largely left to themselves regarding the specific content. The
direction was relatively clear: towards "normalised" measures in the form of housing, work
and leisure for those people included in the reform. The design of these measures, however,
was often characterised by the development of "special" communities, with their own staff,
and many of the classical institutional features (such as locked doors, employee movements in
and out of the clients’ flats, and traditional paternalistic behaviour). Work often took the form
of "emergency solutions" such as pseudo-work or underpaid secondary work tasks, and
leisure activities were often given the form of surrogate measures instead of real social
interaction with age peers (special kinds of socialisation, extensive use of personal assistants,
etc.). The basis for a professional strategy to secure the reform at local level was thus left to
the individual local authority. There were no state requirements for specific qualifications or
expertise for the personnel who would implement the intentions of the reform "on the
ground".
Evaluations of the reform show a general agreement that it has been relatively successful
(Romøren 1995, Sandvin 1996). At the same time, it is important to clarify the basis for
evaluation: it seems reasonable to argue that this conclusion is based on goals related to the
"pragmatic" socio-political idea of normalisation. From the perspective of a more stringent
15
academic concept, the success of the reform is seen as more ambiguous: in one respect, it is
considered an "administrative reform", in that responsibility is transferred from the county
council to the local authority, while within this new framework there are clear signs of "reinstitutionalisation". Meanwhile we can distinguish between evaluation criteria related to
(sociologically-based) indicators of life conditions, and those related to (medical and
educational) indicators of mastery. The reform seems to have been more successful on the
former than on the latter. However, there is little doubt that the socio-political normalisation
definition has been considered as the main basis for a general perception that the reform has
been a success.
Mental health care: from the "silent reform" to the ambitious "psychiatry
reform".
Psychiatry has been continuously changing since it was established as a separate branch of
medicine in the 19th century. The development of psychiatry was largely based on
professional input on the desired direction, which in turn led to state initiatives generally
based on the scientific premises presented (Ludvigsen 1997). Psychiatry is characterised by
therapeutic waves and fashions, and has now evolved into different, sometimes contradictory,
perceptions of how mental health care should be organised and practised. It has been
customary to distinguish between three paradigms: medical-reductionist, psychological and
sociological. These have to a certain extent competed for the design of psychiatric services
(Berg 1982). Norwegian psychiatry has sought to integrate the different disciplinary
approaches and their related organisational forms through the official endorsement of the idea
of "eclectic" psychiatry (Action Plan for Psychiatry 1982-88). In practice, the focus has been
on the extent of psychiatric (residential) institutional care and the development of alternatives
either in specialist health services at county level and/or health and social services at local
authority level. Until 1972 there was a marked expansion of psychiatric hospitals and homes
in Norway, but the following years saw a radical dismantling of residential institutions. This
process led to a 20% reduction in mental health beds in the twenty years since the peak in
1972. The number of patients treated, however, does not show the same decline, and the
number of outpatient consultations has risen sharply. This means that psychiatric institutions
are now treating far more patients per bed (Hallandvik 1997). An interesting phenomenon is
that the Norwegian deinstitutionalisation process was more marked than in most Western
16
countries, and almost as extensive as in Italy and the United States, where the corresponding
processes were well-known milestones in the international debate on the development of
psychiatry.
The phasing out of beds in institutions was in various contexts described as "the silent
reform". The reason for this was that the extensive changes taking place in psychiatry at the
time did not receive particular attention either in the national political or the public debate.
The closure of institutional beds in psychiatric care was primarily a gradual process. It mostly
took place on the basis of local decisions, and Norwegian mental health care thus emerged
largely as an unintended result of local decision-making processes. It was particularly the
county planning and resource allocation in the annual budget process which laid the
foundation for the design of services. In many places it was as much a desire to save the
general hospitals from cutbacks as it was a conscious strategy on the closure of institutions
that set the political agenda for this development (Ramsdal 1994). The deinstitutionalisation
process emerged therefore as a result of many local decisions, but still within a general
perception that big institutions were negative. The interesting point here is that the criticism of
the HVPU institutions for the mentally handicapped seemed to become generalised to a
widespread public criticism of all institutions, which in turn laid the conceptual foundation for
the local deinstitutionalisation processes in mental health care (Sandvin and Søder 1998).
Based on my reform perspective, the "silent reform" cannot be called a government reform,
but rather a gradual, "incrementalistic", locally-based development process.
In the early 1990s, the widespread closure of institutional beds led to a backlash, with
increasing criticism of the services offered to psychiatric patients. The main focus was that the
reduction in institutional care had not been replaced by local authority or community services.
The media - and also professionals - increasingly referred to "the next reform" (after the
HVPU reform), which would include mental health services. In the mid-1990s the
government initiated a general review of the psychiatric services in the country, both in terms
of scope and organisation, setting the stage for a major expansion of the services, which was
set out by the Bondevik government in the Escalation Plan for Mental Health 1998-2008.
Parliamentary Report No. 25 (1996-97) "Openness and Comprehensiveness", launched by a
Labour government, includes both a description of the situation and principles for future
17
development. The report states that mental health care was characterised by "failure at all
levels". However, the report did not contain any budgetary framework for the proposed
initiatives. In the parliamentary debate it was assumed that a future action plan would include
this factor. In 1996 the Labour government was replaced by a Liberal government; in spite of
some nuances separating the two governments' perceptions of how this plan was to be
formulated, there was general political agreement on the diagnosis of Norwegian mental
health care and on the main aspects of the plan. The main diagnosis was that the fall of
institutional psychiatry had created a shortage of services, necessitating a considerable
improvement in mental health care. Many of the problems, however, were of an
organisational nature; the support system was too fragmented, with poor coordination and
cooperation between different parts of the system, especially between county and local
councils. In this scenario, the patients were the victims. The report's proposals for solutions to
these problems consisted primarily of three initiatives: an emphasis on the "client
perspective", an increase in the volume of services and a plan for organisational
improvements based on new patterns of coordination and cooperation.
The Escalation Plan sanctioned Parliament’s request for specific measures to strengthen
mental health care. The plan covered the period from 1998 to 2008, and advocated the
spending of an extra NOK 24 billion on mental health services during this period. This
funding should go to improved client-oriented measures, a strengthening of local services
with an emphasis on prevention and early intervention, a restructuring and expansion of adult
mental health care, an investment in local mental health facilities such as "district psychiatric
centres", an expansion of child and adolescent psychiatric services and finally, the
encouragement of education and research in the field. The process would be ensured by
earmarked grants for local authorities for the implementation of the Escalation Plan.i It was
also assumed that there would be politically approved plans for the development of specialist
services at county level. The report stated: "The Ministry will continuously oversee the
Escalation Plan through the goal and performance criteria that will be established as a basis
for funding, and will also monitor the implementation of local and county plans"
(Parliamentary Proposition No. 63, p. 28).
The Escalation Plan for Mental Health was the first comprehensive reform to be carried out
after government policy was changed in line with the idea of "the new local authority". The
18
description of the mental health initiatives cited above reflects the results of the considerations
and choices made as to how strong the implementation measures should be. The choice of
steering instruments shows that the reform took place in a transitional phase, where one partly
used "traditional" hierarchical instruments and partly embraced the new steering principles for
relations between central and local government. The choices thus implied a mixture of
"hierarchical" and "dialogic" instruments. On the one hand, the targets of the escalation were
clear, operationalised, and had considerable political supporti. On the other hand, the target
groups were unclear when the reform was designed, as there was talk in some contexts of
prioritising people with serious mental illness, while in other contexts it was emphasised that
the plan indicated that the measures should be for all those who needed professional help with
mental disorders or problems. During the implementation process it became clear that it was
the comprehensive definition of the target group that would be followed.
With regard to financing and related monitoring and control of the local and specialist
services' use of the earmarked funds, the instruments generally reflected a clear alignment
with strong state and sectoral governance. There were, however, differing views on the use of
earmarked funding in the general context of the transfer of state funds. On the one hand, it
was pointed out that the difficult economic situation in the local authorities could imply cuts
in existing measures in the general health care sector combined with an expansion in
psychiatry with fresh state funding. It was argued that this could lead to a setback for the
positive attitude to the mental health care initiatives found at local level. It was further argued
that as a result of the combination of a generally difficult economic situation and the new
funding for mental health, one might choose to "spread the funds thinly" on short-term
measures - "a little for training, a little for parental guidance, a little for personal assistants, a
little for temporary positions" - which would satisfy the Ministry's reporting requirements, but
would not create the best solutions to improve local mental health care in the longer term. In
this case too, the signals soon became clear: the earmarked funds were to be used in line with
national priorities. Parliament also tightened its grip in connection with the budget, preventing
the possibility of exceptions for local adaptations as the Government had planned.
After an extensive discussion, it was decided that local mental health care planning was to be
integrated into the mainstream planning (Ministry of Health and Social Affairs, Circular 1-4).
Regarding the knowledge base for the reform, i.e. the understanding of cause-effect
19
relationships, an "eclectic" principle is to be applied. This has meant an increase in volume in
all areas of the services, and also the fact that the reform does not imply a further
deinstitutionalisation in the specialist services. But the reform documents were largely
concerned with life conditions, and focused little on diagnoses and therapies. There was also
a heightening of the professional requirements and documentation of results at all levels. The
eclectic principle meant that the problematic scientific basis of psychiatry, where different
paradigms overlap or compete with each other, was taken for granted.
In two respects, however, it is clear that on some important points the new "dialogic" steering
policy has been applied: it was explicitly stated that there would be no requirement for
specific professions to be in charge of local competence-building measures. The combination
of the new management policy and the reform's accent on the eclectic principle meant that the
emphasis of the classical reform strategy on professionalism as a steering instrument was
given an ambiguous and complex form: it was important to raise the general level of
competence through recruitment of well-qualified health and social service personnel, but the
actual education was not specifically mentioned. Together with the general tendency towards
"de-differentiation" in health and social care education, this provided local authorities with a
basis for a relatively free choice of which competencies to use in local mental health care
services.
The second example of the expression of the new management policy was the lack of specific
requirements for the local political and administrative implementing agencies. Since a key
element in the 1992 Local Government Act was the end of state requisites for local political
and administrative organisation, it is not surprising that no specific requirements were laid
down for the organisation of the political-administrative system to be involved with people
with mental disorders. In principle, local authorities are free to choose how services and
actions are to be structured and linked to overall organisational models. The local organisation
of mental health services thus came under the influence of the "reform revolution" in local
authorities, involving experimentation with new organisational and governance models
pervaded by New Public Management ideas..
20
The Coordination Reform – “the Right Treatment – at the Right Place – at
the Right Time”
The Coordination Reform was first launched in the form of a parliamentary report by Health
Minister in 2008-2009; it drew up a tentative but comprehensive framework for how to
achieve better coordination in health service provision. It represents a normative framework
for establishing a process of dialogue to improve the ability of health care providers to
establish a consistent distribution of responsibility, to define common, overarching goals and
to maximise a coordinated and rational provision of services (Parliamentary Report No.
47:13). Technically this invitation to dialogue was directed to the Norwegian Parliament, but
the Parliament’s open deliberation process entailed the involvement of a wide range of
stakeholders. The report itself is also informed by a wide range of stakeholder organisations
and interest groups.
The report emphasises three challenges facing the health care system: fragmented services for
patients, lack of focus on preventative medicine and demographic and epidemiological
changes that will represent a threat to the financial underpinnings of society. As qualified
examples of how to respond to these challenges the report suggests five measures:
-
The clarification and expansion of patients’ rights in the context of better defined
and more comprehensive treatment pathways.
-
Devolution of responsibility to local authorities within the framework of a
comprehensive perspective on health care and social services provision and legally
defined aspects of preventative medicine.
-
The establishment of economic incentives for local authorities to involve
themselves financially with specialist health service providers, including local
authority financial responsibility for patients ready for discharge from the
specialist services.
-
The refinement of specialist service provision by streamlining its interaction with
local authority services and by increasing its specialist focus by implementing
pathway-oriented modes of organisation.
21
-
An increase in the capacity of national health authorities to implement
comprehensive pathway-oriented policies due to insufficient coordination in
current regional and local priorities.
Legal reforms.
According to the report, the effects of using legislation as a reform instrument have not been
documented sufficiently to identify areas in health care provision policies where new or
adjusted legislation will be effective. The report also argues that legislation is an imprecise
instrument that should primarily be used when other measures prove inadequate (ibid).
Nonetheless, the report suggests the creation of legislation aimed at establishing coordinated
support for patients in need of coordinated services. Also, much of the existing legislation
that addresses aspects of shared responsibility should be re-examined for possible
harmonisation with new responsibilities within a pathway-oriented care paradigm. One
important measure in the proposals for changes in the legislation is that the so- called
“profession catalogue” (whereby certain local services should be provided by specific
professional groups) is now formally abandoned.
Economic incentives.
Cost reduction is one of the most central objectives of the reform, but in fact the report does
not emphasise or specify any cost-cutting effects of its economic incentives. Instead it focuses
on the possible effects of such incentives on the division of labour/distribution of
responsibilities between the various actors and the way they can be used to internalise a
comprehensive pathway-oriented view of the organisation of patient care.
The current system is based on a set of financially autonomous administrative units, which
have not been sufficiently encouraged to lift their focus from diagnosis and treatment to
prevention and coping.
The report proposes three broad economic measures:
-
The introduction of local authority co-financing of the specialist health services.
-
Transfer of financial responsibility for inpatients ready for discharge
-
More frequent use of block grants in the specialist services (ibid).
22
Patient pathways/clinical pathways.
The concept of patient pathways is a cornerstone of the reform. The primary purpose of
perceiving treatment in terms of patient pathways is to clarify the role of the patient and to
integrate the patient in decision-making processes, both on an individual level and, on a more
aggregated level, in the development and refinement of such pathways. On an individual
level patient involvement in treatment pathways is meant to facilitate coordination between
institutions so that a comprehensive treatment programme can be developed when necessary.
There is already an instrument in place, Individual Plans, that serves this purpose on an
individual level, and clinical pathways are therefore seen primarily as a systemic tool.
On a systemic level patient pathways are viewed as the common denominator that constitutes
the standard for modelling the interaction between actors and for the orientation of financial
incentives. Furthermore, it is important to nurture organisational cultures that are based on a
common understanding of the role of each profession and organisational unit as elements of
patient pathways (p. 48). The development and evaluation of specific pathways should be
inclusive processes where a wide range of stakeholders are invited to participate.
Dialogues.
The development of the Reform is meant to be a deliberative and inclusive process. The
introduction to the report states:
“It is in the nature of the Coordination Reform that actors in the various positions
must come together to determine measures that provide improved patient pathways
and more rational socioeconomic solutions” (Op.cit: 19).
In the preparation of the report the government arranged dialogue meetings with and among a
wide range of actors and stakeholders – patient organisations, unions and employers, regional
health authorities, private service providers, representatives of the Sámi people, immigrant
organisations and various national advisory councils. Furthermore, an expert panel was
appointed to advise the health minister in his work and to arrange public discussion gatherings
in two local communities.
The emphasis on dialogue is equally strong in the further process, according to the report. The
framework for these further dialogues is not specified, but the report suggests a focus on three
challenges:
23
-
Balancing the various specific sources of professional specialist knowledge with
the broader ambitions of the Reform.
-
Establishing a dialogue that can strengthen the interface between the voluntary
sector and the public health care sector.
-
Establishing a dialogue aimed at improving and adapting the interface between
private sector health care providers and the structures of public health care
provision.
Local processes.
The Reform is intended to strengthen the role of local authorities. The starting point is legally
binding responsibilities in two areas: co-financing of the specialist health services and
responsibility for preventative medicine. These new responsibilities entail a requirement for
local authority service providers and political authorities to ensure cooperation with the
specialist services and the procurement of a wide variety of other services. The report
suggests that in the new framework local authorities will continue to have wide-ranging
autonomy in policy formulation.
The role of private health care providers, however, is
specifically stated in the report as being beyond the scope of the Reform itself, and it does not
suggest any changes to current regulations and practices. It does, however, acknowledge the
need expressed by private service providers for establishing a framework that can provide
contractual predictability and compatible entry points for the private sector.
Despite its ambitious and comprehensive nature, the Coordination Reform is characterised by
a surprising number of uncertainties and ambiguities, in relation to what has been common in
reform strategies in Norway. This is reflected both in its knowledge base, where the reform
documents base much of the argumentation on anecdotal accounts of both coordination
problems and best practices, and in its financial calculations, which are sometimes completely
lacking. One of the key arguments in the (part of) the reform concerning the savings involved
in patients ready for discharge being more quickly transferred to local authority care is based
on allegations that hospital stays are considerably more expensive than local services for these
patients - but no financial calculations are presented to confirm this. These challenges in the
reform design must be viewed in light of the fact that the reform is described as a "directional
reform," and that the various steering instruments used appear to address some, but far from
all, of the development processes which the reform is intended to generate at local level. In
24
practice this has meant that the local authorities themselves have had to clarify the nature of
the binding agreements to be made with specialist services, and have also had to find out
themselves how to develop preventive health care and the kind of local expertise needed when
patients are discharged earlier from hospitals. It also had to be established what form the
cooperation with private actors would take and whether to set up community hospitals and if
so, how to organise them. In addition, it is up to individual local authorities to initiate interauthority cooperation, which is important for small authorities without the necessary
resources and expertise to implement the reform objectives. Although in a few selected areas
there are relatively tangible requirements, still the main feature of the reform is that the local
authorities have to anticipate the future organisation of the services.
Discussion: a comparative review
The choice of the four welfare and health reforms reviewed here was based on the following
reasoning: the public health centre reform of the 1970s was linked to the establishment of the
welfare state, as a stage in the development of the "Evang system". Here an unambiguous
hierarchical reform design was to be expected. The HVPU reform for the mentally
handicapped from the late 1980s to the early 1990s can be considered a transitional phase,
with a strong emphasis on central fiscal management and with an ambiguous reform design.
The psychiatry reform from the late 1990s is connected to the hypothesis of a new
relationship between central and local government, based on the 1992 Local Government Act.
Here the idea of the "new local authority", implying a goal-oriented, dialogic relationship
between state and local government, could be expected to form the basis of the reform design.
This trend towards a dialogic reform design is expected to be confirmed and reinforced in the
current Coordination Reform.
In the introduction it was argued that it is the way various governmental steering instruments
are designed and their interrelationship which determine the character of the reform design.
The first step in the analysis is a characterisation of the steering instruments used in the four
reforms. The table below presents a comparison of these instruments:
25
Table 3. Comparison of reform designs
Health Centre
HVPU
Psych.
Coordination
Legislation
yes
yes
no
yes
Clearly defined goals
yes
yes
no
no
Ideological basis
yes
yes
no
no
yes
no
no
no
required
yes
no
no
no
Earmarked funding
yes
yes
yes
no
yes
no
no
no
yes
yes
no
no
yes
yes
yes
no
mentation agencies
yes
no
no
no
Planning required
no
yes
yes
no
Scientific-professional
basis
Prof. compentence
Local design of actions
and services required
Unambiguous
knowledge base
Vertical management structures
Local polit/admin imple-
This table shows primarily the contrast between reform design under the "Evang system" and
the more complex considerations which typify particularly the last two reforms. In line with
general expectations for an Evang type of reform design, the health centre reform shows how
the scientific-professional, vertical aspects dominate the design. Thus the health centre reform
26
represents a basis for contrast with the three more recent reforms. In these reforms the design
is characterised to a greater extent by the dilemma between verticality and horizontality in the
steering system. The HVPU reform was in many ways the birth-child of a politicaladministrative transitional period in which simultaneous work on the new Local Government
Act appears to have influenced the design of some key aspects, especially the fact that after
only two years the earmarked funds were integrated into the block grants to the local
authorities. Compared with the health centre reform, we still have the impression of another
"habitus": in the administrative sense, it is a "negatively" formulated reform, coupled to the
"new scientific-professional paradigm" of normalisation. As pointed out by several authors,
normalisation
is
to
be
considered
as
a
"de-differentiated"
perspective,
where
professionalization, specialisation and "special care" are negative for the design of
interventions and services. For the local authorities this meant that they had to provide the
HVPU reform with its scientific-professional content. The main reason why the local design
of actions and services in the reform was so strongly based on traditional forms of care was
that the local expertise in the field was limited to traditional forms of understanding rather
than any particular influence by the state. The state could give advice but could in practice
not sanction local authorities that did not implement "normalised" actions and services.
However the design is strikingly isomorphic, clearly due to the local authorities recruiting
similar expertise and learning from each other.i
The final two reforms we have considered were initiated after the adoption of the new
management policy. To what extent then can ideas related to the "new local authority" be
found in the design of the psychiatry and coordination reforms? Here we presented a
hypothesis that the idea of the new local authority, linked to the development of a state-local
government relationship influenced by a "partnership model" would result in a loosely
connected reform design. This hypothesis however was not confirmed. By contrast the reform
demonstrates an ambiguous relationship between verticality and horizontality. On the one
hand, the local authorities have a relatively free hand in the scientific-professional profile of
the design of actions and services. This is expressed by the "open", negatively formulated
objective that there is to be "no development of special care". In practice this leaves important
questions about the design of actions and services, and the competence structure in local
psychiatry, to the individual local authority. These points confirm the dialogic relationship
between state and local government. On the other hand, the guidelines emanating from the
27
state authorities, particularly the financing and control systems which were established, are
clearly in conflict with the dialogic partnership model. This particularly applies to the design
of control systems related to the use of earmarked funding. Here the Ministry went further in
rejecting local use of funds than mental health advisors had recommended it to do. It even
happened that some of the mental health funding was held back because the requirements
were not met for the use of the corresponding earmarked funds in another reform designed in
parallel, the so-called initiative for the elderly. In the design of the planning system state
government has long wavered between demands for a separate local mental health plan and
expectations of an integrated plan for the entirety of local authority health and social services.
It gradually became clear that local authorities would draw up a separate substance
abuse/mental health plan to be discussed in council board meetings. Mental health advisors
were then asked to adopt a role more as controllers of the development of local mental health
care, and were in many ways linked to the tendency to establish stronger audit systems
whereby state authorities needed to approve plans before the earmarked funds were allotted,
as described above.
By contrast, the Coordination Reform represents in many ways a new reform regime. This is
reflected in its many and complex goals, with a wide variety of target groups and a "holistic"
approach to the development of local authority services. Interaction with the specialist
services is a key element. Since the Coordination Reform is so ambiguous and ambivalent, the
habitus of the reform is aptly described by the political phrase "directional reform". The main
point is that the detailed discussion of the development of services should take place through
dialogue between the actors, while the state government sets a framework for the these local
solutions. This is also reflected in the steering instruments chosen: a mixture of hierarchical
and "traditional" instruments intended to force local choices to be in compliance with state
goals in some areas, and to allow for a wealth of local solutions in many others. The most
concrete example of this is the local authority funding of hospital patients ready for discharge,
where local authorities are given a portion of the funds previously allocated to hospitals. This
transfer scheme implies a variant of the purchaser-provider model, which both gives local
authorities a stronger influence over hospitals, and also lower costs since the refund to
hospitals will be reduced when better and cheaper local services for these patients are
eventually established. The Coordination Reform thus consists of both hierarchical and
dialogic instruments, but as the table shows there is a strong predominance of steering
28
instruments indicating the new regime of state-local government ("dialogic partnership"), the
growth of control and audit systems, and agreements between the various actors in the sector.
For a complete picture of the steering instruments typical of this reform, it must also be
realised that new relationships, where the "dialogue" between the actors is given new
substantial content, influence local decisions at least as strongly as some of the traditional
instruments.
Conclusion
The review presented above was based on the hypothesis that reform design in the health and
social care sector has shifted from "traditional" welfare state reform-technocratic instruments
to an emphasis on dialogic partnership, reduction of hierarchical structures and use of more
complex and ambiguous steering instruments. This hypothesis was based on the
administrative policy principles as especially manifested in the 1992 Local Government Act,
and we therefore wished to examine how far health and social policy reforms were influenced
by these trends from that time onwards. We identified a number of characteristics of
hierarchical reform-technocratic instruments from the post-war development of the
Norwegian welfare state, and sought to show the extent to which these characteristics are still
represented in the reforms of recent years. The developments in administrative policy create a
framework for reform design, together with the change processes taking place in relevant
scientific and professional fields. The ideological guidelines in government policy tend to
suggest an emphasis on "horizontal/dialogic" design, according to our definition. The
conceptualisation of the "new local authority" must be regarded as a hypothesis, as an
administrative policy intention without an independent status in the design of the current
reforms. The psychiatry and coordination reforms indicate that the classic dilemma between
horizontality and verticality in the steering system appear in new guises. On the one hand, the
state is concerned about accountability: local authorities must demonstrate that they are able
to use the funding in ways consistent with the national targets, which implies wide-ranging
control systems. On the other hand, local authorities are given a large degree of freedom in
the organisational and professional aspects. Compared to the unambiguous verticality of
reform design in the era of the "Evang system", the design has thus become more complex
and ambiguous. Some of the elements established in the design are influenced by the New
Public Management ideas of performance management and evaluation, and some by the
peculiarities of the field to be reformed. In summary, one can argue that the ambiguous
29
aspects of the concept of performance management, i.e. local freedom within limits, and the
development of re-bureaucratisation in the form of new control systems, occupy an uncertain
position in the reform design, oscillating between verticality and horizontality. When at the
same time the two reforms adopted after the 1992 Local Government Act operate with
uncertainty, ambiguity and complexity, in terms of objectives, target groups, knowledge base
and in the design of actions and services, the result becomes "doubly ambiguous", both
because of the ambivalence in government policy and in the scientific-professional basis for
the reforms.
There has been a perception that the "dialogic partnership model" has an ideologically weak
basis, being a conceptual model based on developments in state-local government policy
which had a certain significance in the context of the decision-making process leading to the
1992 Local Government Act, but which have since been modified in important aspects
(Ramsdal, Michelsen and Årseth 2002). In some ways state steering today is just as detailoriented as before, but has a veneer of modernity in the newly-established management and
control systems. The Coordination Reform, however, shows that there has now been an
adjustment between general administrative policy and reform design whereby local authorities
are largely left to themselves to find strategies to implement the reform, while it is also
pointed out that the reform itself is not written in stone but rather a development process that
will take many years to implement. Thus we can observe a change in line with the hypothesis
presented above, but also that the new reforms are designed "in the shadow of hierarchy", i.e.
they maintain hierarchical relationships between central and local government; this may be a
necessary characteristic of governmental reform design irrespective of the management
policy. Thus we can observe the creation of management instruments in line with the idea of
a transition from "steering" to "public action". However, we also see forms of rebureaucratisation and re-emerging hierarchy in some of the steering instruments used, and that
the relationship between central and local government is structured in a way one would not
have expected in the wake of the Local Government Act, but one which is consistent with
observations of the development of state-local government relations in other European
countries.
30
References.
Baldersheim, Harald (1998): Kommunal fristilling. Subsidiaritet på norsk i Grønlie, Tore og
Per Selle (red.): Ein stat? Fristillingas fire ansikt. Samlaget, Oslo.
Berman, P. (1980): Thinking about Programmed and Adaptive Implementation; Matching
Strategies to Situations, in Ingram and Mann: Why Policies Succeed or Fail. Sage Yearbooks
in Politics and Public policy, Sage, London.
Berg, O. (1982): Medisinens logikk. Studier i medisinens sosiologi og politikk.
Universitetsforlaget, Oslo.
Brunsson, N og J.P. Olsen (1993): Makten att reformera. Carlsson, Stockholm.
Dahl Jacobsen, Knut (1965): Teknisk Hjelp og Politisk Struktur. Universitetsforlaget, Oslo.
Dahl, Jacobsen, Knut (1976): Institusjonelle betingelser for regional planlegging, University
of Bergen.
Day, P. and R. Klein (1987): Accountabilities – five public services. Tavistock Publications,
London and New York.
Dente, Bruno og Francesco Kjellberg (1998) The Dynamics of Institutional change. Local
Government Reorganization in Western Democracies. London: SAGE Modern Politics
Series Volume 19
Eisenstadt, S.N. (1959): Bureaucracy, Bureaucratization and De-bureaucratization, in
Administrative Science Quarterly, 4.
Eliadis, P., M.M. Hill and M. Howlett (2005) (eds.): Designing Government. From
Instruments to Governance. McGill-Queen’s University Press, Montreal & Kingston –
London - Itacha.
Fernler, K. and Helgesson, C-F. (2006) (eds.): Kloka regler? Kunnskap i regelsamhallet
(Wise Rules? Knowledge in the Rules Society). Studentlitteratur, Lund
Freeman, Richard and Michael Rowe (2011): Introduction, in Rowe, M., M. Lawless, K.
Thompson, L. Davidson (eds.).: Classics of Community Psychiatry. Fifty Years of Public
Mental Health Outside the Hospital. Oxford University Press.
Erichsen, Vibeke (1993):
"State Traditions and Medical Professionalisation: Scandinavian
Experience(s)". In Terry Johnson, Gerry Larkin and Mike Sachs (eds.), Health Professions
and the State in Europe, London: Routledge.
31
Hallandvik, J.-E.: Helsetjeneste og helsepolitikk. Universitetsforlaget 1997.
Hood, Christopher C. and Helen Z. Margetts (2007): The Tools of Government in the Digital
Age. Palgrave macmillan.
Jákupsstovu, Beinta og Turid Aarseth (1996): Norsk helsestasjonsvirksomhet. Nasjonal
politikk og lokal policyutforming av forebyggende arbeid for barn. Rapport 9603.
Møreforsking, Molde.
Kjellberg, Francesco (1988): Local Government and the Welfare State. I Dente og Kjellberg
(red).: The Dynamics of Institutional Change. Local Government Reorganization in Western
Democracies. SAGE: London.
Kjellberg, Fransesco (1991): Kommunalt selvstyre og nasjonal styring. Mot nye roller for
kommunene? Norsk Statsvitenskapelig Tidsskrift 1: 45-63
Kristiansen, K. (1994): Normalisering og Verdsetting av Sosial Rolle. Kommuneforlaget,
Oslo.
Kooiman, J. (1993):
London
Modern Governance. New Government-Society Interactions. SAGE:
Kjellberg, F. (1988): Local Government and the Welfare State. I Dente og Kjellberg (red).
The Dynamics of Institutional Change. Local Government Reorganization in Western
Democracies. SAGE: London
Kjellberg, F.(1991): Kommunalt selvstyre og nasjonal styring. Mot nye roller for
kommunene? Norsk Statsvitenskapelig Tidsskrift 1: 45-63
Kjellberg, F. (1994): Between autonomy and integration. The revision of the Norwegian
Local Act Government 1987-1992. Institutt for statsvitenskap, UiO. Forskningsnotat 06/94
NOU 1990:13 Forslag til ny lov om kommuner og fylkeskommuner, Kommunaldepartmentet.
Lascoumes, P. and Le Gales, P. (2007): Understanding Public Policy through its instruments
From the nature of instruments to the sociology of public policy instrumentation. Governance
20 (1) 1-21
Lichtwarck, W. og G. Clifford (1996): Samarbeid i barnevernet. Ideologi, endring og konflikt.
Tano, Oslo.
Lubotsky, Bruce, A. Hanson, K.D. Hennesy and J. Petrila (2010): A Public Health Approach
to Mental Health Services, in Lubotsky, Bruce, Kevin D. Hennesy and John Petrila (eds.):
Mental Health services. A Public Health Perspective (third edition): Oxford University Press.
Maravelias, (2003): Post-bureaucracy–control through professional freedom in Journal of
Organizational Change Management Vol: 16 (5) 2003 Page: 547
Mechanic, D. (2008): The Truth about Health Care. Why Reform Is Not Working in
America. Rutgers University Press, New Brunswick, New Jersey and London.
32
Nordby, T. (1989):
Karl Evang - en biografi. Universitetsforlaget: Oslo
Offerdal, A. (1978): Kommunane som iverksetjarar av statleg politikk, i Baldersheim, H., A.
Offerdal, T. Strand (red.): Lokalmakt og sentralstyring, Universitetsforlaget, Oslo.
Parliamentary Report No. 47 2009: The Coordination Reform - the Right Treatment - at the
Right Time (Engl. version), Ministry of Health, Oslo.
Peters B G (2002): The Politics of Tool Choice, in Salamon L.M. (ed.) (2002), The Tools of
Governance. A Guide to the New Governance. Oxford: Oxford University Press.
Pons, X. and van Zanten, A. (2007): Knowledge Circulation, Regulation and Governance.
Literature Review (Part 6), EU.KnowandPol, June 2007.
Power, M (1999) The audit society, Oxford Univ. Press
Ramsdal, H. (1994): »Iverksetting av Normalisering»- Evaluering av Kommunalt
Opplæringprogram om Normalisering, OR 38/94, Stiftelsen Østfoldforskning 1994.
Ramsdal, H. (1996): Kan psykiatrien reformeres innenfra? Høgskolen i Østfold, rapport
1996:3.
Ramsdal, H. and K. Ludvigsen (1998): «Kompetanseutvikling og profesjonsorganisering i
psykiatrien». I Andersen, A.J. og B. Karlsson: Psykiatri i endring - forståelse og perspektiv
på klinisk arbeid. adNotam Gyldendal.
Ramsdal, H., V. Erichsen, S. Michelsen og T. Aarseth (1997): Lokalstyret og velferdstatens
profesjoner. Norsk Statsvitenskapelig Tidsskrift no. 1 2000.
Ramsdal, H., S. Michelsen and T. Aarseth (2002): Profesjonar, stat og lokalstyre. Om
kommunen som iverksettar av statlege velferdsreformer, i Bukve, O. and A. Offerdal: Den
nye kommunen. Kommunal organisering i endring. Samlaget
Romøren, Tor-Inge (red.)(1995): HVPU-reformen i forskningens lys. Ad.Notam Gyldendal,
Oslo.
Rothstein, Bo (1986): Den Socialdemokratiska staten. Reformer och forvaltning inom svensk
arbetsmarknads- og skolpolitik. Arkiv Avhandlingsserie, Lund.
Rothstein, Bo (red.) (1991): Politik som organisation. SNS-forlag, Stockholm.
Salamon, L.M. (ed) (2002): The Tools of Government. A Guide to the New Governance.
Oxford. Oxford University Press.
Sandvin, J.T. (1996): Velferdstatens vendepunkt. En analyse av reformen for mennesker med
psykisk utviklingshemming som uttrykk for brytninger i velferdsstaten. Nordlandforskning,
Bodø.
33
Sandvin, J.T. og M. Søder (1998): Fullt og helt eller stykkevis og delt? En sammenlikning av
HVPU-reformen og nedbyggingen av institusjonsplasser i psykiatrien. Tidskrift for
velferdsforskning nr. 1 1998, Universitetsforlaget, Oslo.
Slagstad, Rune (1998): De nasjonale strateger. Universitetsforlaget, Oslo.
Sosial-og helsedepartementet: St.prp. nr. 63 (1997-98): Om opptrappingsplan for psykisk
helse 1999-2006. Endringer i statsbudsjettet for 1998.
Sosial-og helsedepartementet: Rundskriv 1-14-98: Statsbudsjettet 1998: Styrking av tilbudet i
kommunene til mennesker med alvorlig psykiske lidelser og til forebyggene psykososiale
problemer blant barn og unge.
Sosial- og helsedepartementet: Rundskriv 1-44/97: Forslag til statsbudsjett 1998: Øremerket
tilskudd til styrking av tilbudet til mennesker med alvorlige psykiske lidelser - foreløpig
orientering.
Sosial-og helsedepartementet: Rundskriv 1-4/99: Opptrappingsplan for psykisk helse –
utbygging av kommunale tiltak. Øremerket tilskudd til kommunene 1999.
Solum, L. (1991): Normalisering. Grunnlag og mål for omsorg. ad Notam Forlag, Oslo.
Stangvik, G. (1987): Livskvalitet for funksjonshemmede. Bind 2. U-forlaget, Oslo.
Stortingsmelding nr. 25 (1996-97): Åpenhet og helhet. Om psykiske lidelser og
tjenestetilbudene. Sosial- og helsedepartementet.
Stortinget: Innst. S. Nr. 222. Innstilling fra sosialkomiteen om opptrappingsplan for psykisk
helse 1999-2006.
Strand, Torodd 1978: Standardisering, hjelp og sjølhjelp, I Baldersheim, Offerdal, Strand:
Lokalmakt og sentralstyring, Universitetsforlaget.
Timmermanns, S. & Berg, M. (2003): The Gold Standard: The Challenge of Evidence-Based
Medicine and Standardisation in Health Care. Temple University Press.
Vabo, S (2010): Governance in the shadow of hierarchy. Mimeo, Oslo University College .
Wolfensberger, Wolf (1993) Social Role Valorization. A Proposed New Term for the
Principle of Normalization. Mental Retardation 21 (6).
34