Programme de la conférence

The Public Health Service (ÖGD) has traditionally played a marginal role in Germany’s health care system and is often only loosely embedded within cooperative structures between social administrations and service providers. However, given its legal mandate and broad portfolio of responsibilities, the ÖGD is well positioned to assume a central role in shaping and coordinating health care provision at the municipal level - thereby contributing to the goal of equal living conditions across the country.

The SARS-CoV-2 pandemic highlighted the ÖGD’s critical importance - not only in crisis response but also as a key institution in the broader landscape of public service delivery. This prompts a central question: Have the reforms initiated in the wake of the pandemic laid the groundwork for the institutional modernization of the ÖGD (‘ÖGD Pakt’), enabling it to serve as a cornerstone of a more resilient, future-oriented public administration - one that not only withstands shocks but also ‘bounces forward’ by reconfiguring public health service provision?

To investigate this, we conducted an online survey targeting all 376 local public health agencies, complemented by a series of expert interviews.

The ‘ÖGD-Pakt’-reforms, however, remain vague in many respects regarding which modernization scenario is actually being pursued: an incremental renewal within existing institutional pathways, or a programmatic reorientation aligned with the guiding principle of “Public Health at the local level.” Our analysis of modernization efforts in recent years reveals two key findings. First, there is no coherent modernization strategy across the federal states. The institutional heterogeneity that characterized the landscape prior to the pandemic has persisted in its aftermath. Second, even within individual states, a consistent pattern is lacking when comparing different dimensions of modernization. For example, incremental developments in the area of human resources - such as the continued reliance on exclusively medical leadership - may coexist with more substantial innovations, such as the use of digital tools to facilitate cross-sectoral data exchange. Overall, the modernization process is fragmented and does not follow a unified logic - neither at the national level nor within individual states, and possibly not even within individual local public health offices.

Primary care in the Nordic countries has traditionally been delivered through publicly owned clinics (Sweden) or by private general practitioners operating within national agreements and close integration in public planning (Denmark). However, recent decades have seen the introduction of other ownership forms than public and GP ownership in both countries. Both Sweden and Denmark have experienced a growth in the number of clinics that are owned by profit oriented corporate chains and in some cases backed by private equity. This change in ownership forms has been welcomed as a way to create competition (in Sweden) and to mitigate problems of “primary care deserts” (both Denmark and Sweden), but has also been criticized for potentially negative effects on quality, access, integration and robustness. While the overall development trends are similar in the two countries there are differences in the speed and scope of private ownership growth. We investigate these differences and discuss possible explanations. As primary care plays a critical role for developing coherent responses to demographic changes and increasing chronic care needs, we will pay particular attention to issues of regulation and operational strategies that may impact their role as care managers in an integrated care system.

Why is it relevant to study for-profit ownership in the primary care sector in Scandinavia? There is growing international evidence that for profit actors are targeting the health and elderly care sectors. This is particularly evident in the US (Unruh and Rice 2025) but can be expected to grow in Europe as well. At the same time, there are emerging concerns that the economic and quality results of increasing for-profit ownership are negative (Gupta 2021, Lin et al 2023, Unruh and Rice 2025). It is therefore important to follow the trends closely and to investigate how they impact resilience and traditional values in the systems.

The aims of this paper are thus to:

• Extend the geographical focus area with descriptive analysis of developments in for-profit ownership in primary care in two Scandinavian health care systems.

• Provide a review of emerging evidence about effects of for-profit ownership in the international literature and a discussion of the potential relevance of this evidence for the Scandinavian cases. Are we likely to see similar results, or will the regulatory and institutional framework temper some of the effects experienced internationally?

• Discuss the results in light of systemic resilience and public values in the Nordic region