The current dissertation argues that ideas from service research should be given a more prominent position in improving healthcare that is capable of managing current and future challenges. The integration and combination of intangible resources, such as knowledge and skills, constitute the service in this thesis; thus, service is conceived as a verb. A central notion in such conceptualization is value co-creation, implying that healthcare providers may only offer potential value, which is realized as real value by people in their broader lifeworlds. Consequently, the healthcare provider is often only one of many actors in the individual’s value-creation process – in which resources from a multiplicity of actors are integrated and combined. One challenge that is particularly addressed in this thesis is unsatisfying inhabitant/patient perceptions concerning how healthcare is executed. More specifically, this refers to interpersonal aspects, including interaction between inhabitant/patient and provider, access to adequate information, and prerequisites to actively participate in one’s own care. Another challenge addressed herein is disparities between groups in society. A mainstream service management perspective is deemed relevant in targeting the first challenge, with foci on the inhabitant’s/patient’s active role rather than the internal affairs of the organization; interaction rather than results; and providing a holistic view rather than treating healthcare in isolation. In order to face the second challenge of disparities between groups, I argue that it is necessary to explicitly integrate the social context, which is claimed to have been neglected in traditional service research. Such context includes not only a diversity of actors, but also societal structures that influence – and are influenced by – the healthcare meeting and thus the individual’s prerequisites to actively participate in her or his care. By adopting a moderate social constructionist position – which contrasts to the individualism characterized by mainstream service research – the focus of the thesis moves from singular to plural, from individual to groups in society. On one hand, in such a position, categorization of individuals into groups is not uncomplicated. On the other hand, healthcare improvements are enabled on a collective level. The constructionist position also permeates conceptions of knowledge: rather than an absolute “truth,” knowledge is about different perspectives. An extension of this reasoning is that healthcare needs to manage multiple perspectives to achieve improvement. Consequently, the purpose of this thesis is not to proclaim a service management perspective as a universal solution, but rather to enhance its position among a diversity of mutually complementing perspectives. The empirical material draws from three studies, discussed in five papers. The first study sought to increase knowledge of three groups’ perceptions on parenthood in a child health service context. The second study mainly addressed the reasons why men and women reported complaints in healthcare. The third study addressed how healthcare providers and community representatives could contribute to increased participation in a screening program in an area with a large number of foreign-born inhabitants. Cumulatively, the studies illuminate the potential of a service management perspective to improve healthcare, not least being the focus on the inhabitant’s/patient’s perceptions, but also their active role and the inclusion of actors in the individual’s broader lifeworld such as family members and the local community. In line with a service management perspective, the interactional aspects are argued to be important enablers for individuals to participate in healthcare. However, by integrating the social context, it is also revealed that interaction may also constitute a constrainer of possibilities for individuals or groups to be participative. A service perspective integrating social context also offers possibilities, not least by enriching the emerging field of improvement science. Through lifeworld-situated perceptions, in which groups’ perceptions beyond healthcare are identified, healthcare may be improved to better address group members’ needs given their broader life situations. Representative co-creation implies that a collective’s unique knowledge and skills are used productively in order to improve healthcare that manages diversified needs and expectations.

This article theorizes equality and inclusion in coproduction, from the perspective of public administrators. Coproduction may occur across the policy cycle and at the individual, group, and collective levels, and for reasons of both instrumentality (such as improved efficiency) and normativity (such as democracy). Participation of the disadvantaged in various modes of coproduction is essential if the solidarity principle (stipulating prioritization of those in greatest need) is to be taken seriously. However, their access may be hindered due to external exclusion (not having a place) and internal exclusion (not having a say). Whether inclusion of the disadvantaged is argued for in terms of sameness or difference, different reasons are addressed: justice (for the former) as well as additional perspectives and resources (for the latter). Policymakers and practitioners need to recognize that strategies of equality are likely to differ at various levels and modes of coproduction.

Although the public service logic (PSL) has been an important equipoise to the predominant goods-manufacturing logic, there is potential to broaden its scope. An explicit integration of social context may contribute to an enhanced conceptual understanding of the PSL, at the same time addressing a major challenge in healthcare: disparities among population groups. A ‘representative co-production’ approach is suggested. In such an approach, group representatives’ knowledge and skills are used in evaluating, designing, and delivering services with the purpose of supporting other group members’ value co-creation. A case is provided, demonstrating representative co-production in access to preventive health services.

På senare tid har ett bekant begrepp återvänt i modern tappning: samskapande. När varken det offentliga eller marknaden kan lösa samhällsutmaningarna bjuds brukare och medborgare in att planera, designa, utföra och utvärdera tjänster tillsammans med företrädare för offentliga verksamheter. Boken är avsiktligt ifrågasättande och kritisk och vänder sig mot den dominerande synen på samskapande som något ensidigt positivt, där det tas för givet att värde skapas för individ, organisation och samhälle. Oreflekterat utfört kan samskapandet göra mer skada än nytta genom att befästa och förstärka ojämlikhet och utanförskap i samhället, förskjuta ansvar från det offentliga till den enskilde och underminera politikers och tjänstemäns legitimitet. I förlängningen riskerar välfärden att urholkas. Samskapandet har emellertid en viktig roll att spela, men det förutsätter att det sker reflekterat och att offentliga verksamheter särskilt involverar representanter från förfördelade grupper vid samskapandet av vår gemensamma välfärd.

It is increasingly argued that public management should build on a service logic instead of the prevailing manufacturing logic of New Public Management (NPM). Drawing from three cases in Swedish public healthcare, key features of a service logic such as value creation, co-production, and collaboration are prominent in formal documents and everyday talk. However, the 67 interviews in this study reveal that the service logic ideal is practically unreachable in a context impregnated by NPM. Instead, we suggest that street-level bureaucrats often need to address service logic expectations (public values, relationship-building, etc.) using an NPM logic (measurements, control, etc.). 

Drawing from collaborative public management, this article seeks to contribute to public service logic by focusing on what precedes the public service user’s realization of value: the value proposition. A new care model for elderly people with multiple chronic diseases shows that coordinators with an inter-organizational mission, vertical and horizontal supporting structures, trust established through relationships, and recognition of service systems’ embeddedness in social systems are pivotal for the ability of public service organizations to develop coordinated value propositions. The contribution to policy and practice is an increased understanding of a coherent, rather than fragmented, welfare system for users/citizens.

Co-production between public administrators and citizens has attracted renewed interest in recent years. Co-production is predominantly perceived as something desirable and is claimed to improve service efficiency and outcome and user satisfaction, at the same time as addressing democratic ideals. Drawing from interviews with public administrators and patients in a Swedish healthcare context, this paper seeks to nuance the often overly positive notion of co-production by understanding these micro-level practices as being embedded in a macro-level societal context. Theorizing the empirical material based on three features of contemporary society –individualization, marketization, and de-politicization –we argue that co-production risks placing a burden and responsibility on individual users and creating a (welfare)market in which better-off people are recruited and benefitted. In this sense, co-production may consolidate or reinforce inequalities. Through de-politicization, political issues may appear as value-free; however, as long as market-logics prevail, the welfare system and practices of co-production will, in some respects, be impotent to address crucial societal issues. Co-production as a collective practice targeting democratic standards is called for, rather than an efficiency focus, preferably by taking the recruitment of those in the greatest need seriously –scaffolded by a revitalized public service ethos of public administrators and their organizations.

There is consensus that complex problems of contemporary society call for public service collaborations. So-called public service logic (PSL) focuses on joint value creation among a multiplicity of actors in service ecosystems. Despite recognizing various actors, this logic is essentially user-centric, with the service user being the one realizing the value. Consequently, single and collaborating organizations cannot deliver value, only potential value, or so-called value propositions. The elusive public service logic takes a network value configuration for granted and as a starting point. Drawing from two cases in Swedish healthcare, this paper argues that two other value configurations (chain and shop) are also relevant for understanding the development of value propositions – and that these may be related to both intra- and inter-organizational processes. Theoretically, we conclude that just like public service logic, other collaborative public management theories need to recognize the importance of a multiplicity of value configurations and that these are often related to both intra- and inter-organizational processes. We conclude that managers should not adopt the latest network trends without first reflecting on the relevance of existing internal processes.

The decentralisation of Swedish healthcare closer to citizens has been slow. Drawing from empirical material of the reform prior and amidst the COVID-19 pandemic, this paper argues that the pandemic has disrupted the healthcare ecosystem. Consequently, citizen-centred collaborations have accelerated integration of resources (such as knowledge and skills) across organisational, hierarchical and professional borders. However, collaborations have been delimited to traditional healthcare providers, neglecting the resources of citizens and other actors to be used to improve service delivery. The pandemic has revealed strengths and weaknesses with the prevailing healthcare ecosystem that post-COVID-19 public management must address, both theoretically and practically. Theoretically, the paper contributes to the development of a public service logic, addressing both strengths and difficulties with the logic in turbulent times. Practically, the empirical descriptions contribute to improved understanding of public service delivery reform and how it is impacted during the pandemic.

Citizens may seek to co-create value during interactions with the provider (co-production), by contributing with improvements of existing services (co-design), or by inventing new services impacting the overall service system (co-innovation). Three empirical cases from Sweden and the UK suggest that disvalue is as likely an outcome as value creation, and that both outcomes need to be recognized at three levels: for the individual citizens themselves, their peer groups, and the broader society. The article contributes to the literature by questioning the assumption that value is inevitably created by theorizing and providing empirical cases that recognize disvalue to be an equally likely outcome in attempts to create value.

The prevailing inequities within the Swedish healthcare system constitute a major challenge, not the least in cancer care. An international comparison shows that outcomes for Swedish cancer care score highly. Even so, the process of how care is delivered to its customers has been questioned, with particular emphasis on disregarded groups of the population. Using the notion of value co-creation, the process of service delivery is highlighted. Moreover, the collaborative and relational elements are considered crucial in service interactions, giving the customer an active role in engaging in various activities to co-create value with service providers and others. However, value co-creation has not been thoroughly investigated in a healthcare context. This thesis addresses the current situation for segments of healthcare customers and explicitly aims to increase equity in healthcare. To achieve this goal, barriers that groups of healthcare customers face during the service delivery process are illuminated, as are the various activities in which they engage to co-create value. The thesis also explores the kinship among various domains; particularly the theories of quality management, value co-creation, and social construction, as well as the methodology of action research. The empirical material draws from two studies that took place in the Western Region of Sweden. The first study explored how a participatory action research approach may contribute to raising awareness about preventive health services, thus increasing the number of participants in a cervical cancer screening program among foreign-born women. The second study investigated complaints of cancer patients and their relatives by focusing on the interpersonal aspects of service delivery and by applying a gender lens. The results underline the importance of how healthcare services are provided, particularly the collaborative, interactional, and relational aspects that enable customers’ value co-creation processes. Incorporating social construction theory into value co-creation offers a collective dimension; the unique knowledge and skills of customer segments should be used more productively, thus enabling healthcare providers to offer more tailored value propositions that better meet the needs and expectations of particular groups. In line with value co-creation ideas, policy makers and practitioners must realize that a need exists to move beyond the two-party sphere of provider–patient by including other actors from the customer’s network, such as family members and civil society. By adopting an action research approach and tools from quality management, disparities may be revealed and quality may be improved to contribute to increased equity in healthcare.

Coordination across healthcare system levels is a global imperative to ensure efficient resource utilization and provide high-quality care. The substantial body of research on coordination in healthcare mainly concerns coordination across professional and organizational domains. Consequently, there is a dearth of empirical research aimed at delineating the determinants of coordination across healthcare system levels. This paper describes and analyses the barriers and enablers of healthcare coordination across national, regional, and local system levels in a populous Swedish region. Individual interviews and focus group discussions, encompassing a total of 63 individuals, were conducted with managers, administrators, and politicians. The findings of the paper underscore that the barriers identified were most often of a structural or institutional character, whereas the enablers of the studied cross-level coordination were mostly relational. Therefore, we propose that future research should aim to further delineate the prerequisites for personal relationships to emerge, as well as how they may act as enablers of coordination across healthcare system levels.

Customers are vital to any organization and system, and must therefore be considered when seeking to improve. However, how to improve with regard to the customer, is not clear, and the knowledge is spread over several research fields, making it difficult for researchers and practitioners to comprehend. The purpose of this literature review is to show how customer-related improvements are described in the literature and how the research is performed. 666 articles were screened, resulting in 99 coded and analysed articles. The study concludes that there is a lack of understanding when it comes to the process of how to improve and that both practitioners and academics should focus more on the system level. It is also seen that by involving the customer in the improvement process, the improvement is more likely to succeed. The article concludes that there is a need for future research which are conceptual, longitudinal, and are addressing actual improvements, not just potential. From the practitioners’ point of view, the article is proposing an increased focus on customer-related improvements which address aspects concerning people, such as employee competence and work environment, and reward systems, rather than strategy and processes to improve the potential benefits.

Using six focus groups with frontline employees within the Swedish sick-leave service, this article explores the co-creation/destruction of value. The article both adheres to and questions the public service logic by utilizing an empirical case in which frontline staff represents not one, but multiple, public service organizations. Moreover, as value creation/destruction is not restricted to one beneficiary, and several beneficiaries can be tied to one single service, the research builds upon this notion and distinguishes between four levels of value creation/destruction.

Purpose – This article aims to examine how users’ involvement in value co-creation influences thedevelopment and orchestration of well-being ecosystems to help tackle complex societal challenges. Thisresearch contributes to the public management literature and answers recent calls to investigate novel publicservice governances by discussing users’ involvement and value co-creation for novel well-being solutions.

Design/methodology/approach – The authors empirically explore this phenomenon through a case studyof a complex ecosystem addressing increased well-being, focussing on the formative evaluation stage of alongitudinal evaluation of Sweden’s first support centre for people affected by cancer. Following an abductivereasoning and action research approach, the authors critically discuss the potential of user involvement for thedevelopment of well-being ecosystems and outline preconditions for the success of such approaches.

Findings – The empirical results indicate that resource reconfiguration of multi-actor collaborations provides aplatform for value co-creation, innovative health services and availability of resources. Common themes include the needfor multi-actor collaborations to reconfigure heterogeneous resources; actors’ adaptive change capabilities; the role ofgovernance mechanisms to align the diverse well-being ecosystem components, and the engagement of essential actors.

Research limitations/implications – Although using a longitudinal case study approach has revealedstimulating insights, additional data collection, multiple cases and quantitative studies are prompted. Also, theauthors focus on one country but the characteristics of users’ involvement for value co-creation in innovativewell-being ecosystems might vary between countries.

Practical implications – The findings of this study demonstrate the value of cancer-affected individuals,with “lived experiences”, acting as sources for social innovation, and drivers of well-being ecosystemdevelopment. The findings also suggest that participating actors in the ecosystem should utilise widerknowledge and experience to tackle complex societal challenges associated with well-being

Objective: Kraftens Hus is the first support centre in Sweden designed by and for people affected by cancer, including patients, family, friends, staff members and local community representatives (collectively ‘stakeholders’). The purpose of this study was to explore the meaning, role and experiences of Kraftens Hus stakeholders using a patient and public involved methodology.

Methods: To understand and map the experiences of visitors to Kraftens Hus, we applied concept mapping (CM), a mixed methods approach where data are collected and analysed in four structured steps designed to capture the diverse perspectives of multiple stakeholders. Qualitative interviews with relevant stakeholders supplemented the CM findings.

Results: The final concept map contained six clusters of ideas. Within the clusters, there was a recurring theme that cancer-affected people value accessible and long-term psychosocial support (PSS). The intended emotional, social and practical needs identified in a previous design process seem to have been addressed and appreciated by Kraftens Hus visitors.

Conclusion: Kraftens Hus is an example of a new patient-led social innovation based on a life-event perspective and integration of resources from different sectors in society. By focusing on life, not the disease, the care continuum expands, and long-term PSS is provided alongside cancer treatment. The evaluation confirms that PSS should focus on health and well-being in the broadest sense.