Best of the best: an investigation of policy enactment for key drivers of digitalization

Abstract

Purpose

This paper aims to explore whether the key drivers identified in digitalization policies are being prioritized by practitioners in health and social care and to what degree the goals of the policies are being enacted.

Design/methodology/approach

The investigation comprised two stages. First, the key drivers of digitalization in the national policies were identified. Second, a survey was disseminated to practitioners within health and social care, asking them to indicate their stance on each key driver (using Likert scales).

Findings

The findings of this paper are twofold. First, they demonstrate that practitioners more readily enact the key drivers centered around their everyday operations, such as improving services and care and increasing efficiency. Second, it shows that key drivers of a more rhetorical nature, such as “becoming the best,” do not yield benefits for practitioners.

Practical implications

This paper shows that for policies to have an effect in practice and to contribute to change, they should be rooted in key drivers centered around practitioners’ everyday operations, promoting specificity over abstraction.

Originality/value

While previous studies have involved policy analysis, few studies investigate the enactment of policies, how they are implemented and whether they contribute to changes in practice.

Citation

Heidlund, M. (2024), "Best of the best: an investigation of policy enactment for key drivers of digitalization", Transforming Government: People, Process and Policy, Vol. 18 No. 1, pp. 1-12. https://doi.org/10.1108/TG-06-2023-0082

1. Introduction

Digitalization is widely regarded as a transformative phenomenon, affecting businesses and wider society (Brennen and Kreiss, 2016). The welfare and health-care sectors, grappling with the challenges posed by an aging population and a diminishing workforce, have increasingly turned to digitalization in response (Heidlund and Sundberg, 2021; Frennert, 2018; Frennert and Östlund, 2018). In this context, the welfare sector has experienced the influence of new public management ideals, prioritizing market-led values (Hasselblad and Sundberg, 2020). This market-oriented approach has also been observed in e-government policies, as highlighted by Cordella and Iannacci (2010). Frennert (2018) argues that digitalization in the welfare sector should align with the core values of caregiving. Mansell (2010) has previously raised questions regarding the foundations and motivations of widespread digitalization, emphasizing the need to consider core values. It is crucial to avoid excessive focus on market ideals, as this may undermine important principles of patient empowerment and active participation in health care (Russo et al., 2019). The COVID-19 pandemic has further accelerated organizations’ efforts to develop their use of digital technologies in health care, as noted by Maki et al. (2022). Moreover, they emphasize the importance of identifying the factors that influence health-care systems and understanding the perceptions of current processes, as these elements significantly impact the digital transformation process (Maki et al., 2022).

Different policies incorporate different solutions and values. For example, a solution outlined in one of the policies in this study is e-Health (see policy #9 “Vision e-Health 2025”), where the goal is that “In 2025, Sweden will be [the] best in the world at using the opportunities offered by digitisation and eHealth to make it easier for people to achieve good and equal health and welfare, and to develop and strengthen their own resources for increased independence and participation in the life of society” (p. 8). This is not just a priority in Sweden but also at the EU level (European Commission, 2023). Furthermore, values such as independence can be found in policies on digitalization and aging in multiple countries (Marshall et al., 2022).

Policies play a crucial role in governing changes in practice, described by Ball (1993, p. 12) as “textual interventions in practice.” Consequently, it is essential to study the content and enactment of these policies. The welfare and health-care sectors face numerous challenges, and digitalization is often seen as a potential solution – or even, in some cases, the sole solution (Sundberg, 2019a). As Marshall et al. (2022, p. 3) put it, the authors’ intentions are “to highlight the rhetorical power of policy documents in constructing problems of aging populations and in promoting technologies as contributing to solutions.” Thus, it is not only important to highlight the construction of problems and the promotion of technological solutions through policy, but it is also imperative to gain an understanding of how policies are translated and enacted into action in practice.

This paper examines the key drivers outlined in the digitalization policies developed in the Swedish Government context, responding to calls for more research into the enactment of digitalization policies (Heidlund and Sundberg, 2021, 2023). Against this backdrop, this paper asks whether the key drivers cited in the digitalization policies are being prioritized by practitioners in health and social care and to what degree the goals proposed in the policies are being enacted. To accomplish this, a survey was conducted of Swedish municipalities and private health-care actors.

The structure of this paper is as follows. Section 2 provides an overview of previous research and situates the paper within relevant literature strands. Section 3 describes the materials and methods, including the survey design, sample selection and analysis. Section 4 presents the results, starting with the key drivers identified and followed by the survey findings. Section 5 presents the discussion, while Section 6 offers the conclusion, including the contributions and limitations of the study.

2. Previous research

This research is situated within three literature strands relevant to policy studies: namely, welfare, digital government and the role of digital technologies in health and welfare. The first strand provides a theoretical foundation for understanding the broader context of policy formulation and implementation in the welfare sector. The second strand pertains to digital government policy analysis and enactment. This body of literature explores the specific domain of digitalization policies within the government sector, examining the processes and challenges associated with their development and implementation. The third strand concerns the role of digital technologies in health and welfare. It investigates the impact of digital technologies on health-care and welfare services, including the potential benefits, challenges and implications for stakeholders. By drawing on these three literature strands, this research aims to enhance understanding of the enactment of digitalization policies in the Swedish Government context, particularly in the welfare sector and the realm of digital technologies in health care and welfare Table 1.

Ball (1993) posits that policies are inherently complex, and authors have limited control over the interpretation of their texts, despite any attempts to influence this. Policies function as textual interventions into practice, but it can be difficult to predict how texts will be acted upon – and in some cases, they are not acted upon at all. Ball (1993, p. 12) states that “Policies do not normally tell you what to do; they create circumstances in which the range of options available in deciding what to do are narrowed or changed.” Consequently, key drivers such as the aspiration to “become the best in the world” are particularly intriguing from an enactment perspective. Notably, this notion of being the best has been subject to research in the education domain (Fransson et al., 2018; Ljungqvist and Sonesson, 2022). Technology and ICT have long been on the agenda with regard to both education (Fransson et al., 2018) and health and social care.

One approach to examining options for action is through policy enactment, which entails the interpretation and translation of policies by various stakeholders (Nyhlén and Gidlund, 2019). Policies are typically formulated at a strategic level, with the aim of guiding development in a specific direction. However, among the actors involved, one group of practitioners is responsible for implementing or applying these policies in their everyday doing (Nyhlén and Gidlund, 2019). Ball et al. (2011, p. 631) characterizes the process of transforming abstract policy ideals into actionable steps as “things to do in ‘real’ situations.” Additionally, Watt et al. (2005) observe that policy enactment alone may not be sufficient to bring about tangible changes in practice. Cordella and Iannacci (2010) emphasize that e-government literature primarily draws on models from the private sector, where technology is viewed as an enabler, without adequately considering the complex context of the public sector.

On a practical level, the utilization of digitalization and digital technologies has long been recognized as crucial in the realm of health and social care for enhancing services and improving overall efficiency. Efficiency is regarded as a potential facilitator, beneficial for addressing the future challenges associated with demographic changes (Heidlund and Sundberg, 2021; Frennert, 2018; Frennert and Östlund, 2018). However, not all digital technologies are expected to yield benefits for health and welfare, as some may find their fundamental principles compromised during the implementation process (Frennert, 2018). Consequently, it is important to explore the key drivers that practitioners deem significant for their day-to-day operations and to examine which drivers may become “lost in translation” (as described by Nyhlén and Gidlund).

3. Materials and methods

The methodology used in this paper comprises two components. First, the key drivers of digitalization derived from the national policies are outlined. Second, the enactment of these key drivers was investigated through a survey administered to practitioners in health and social care. In this section, Subsection 3.1 provides an overview of the survey’s design and operationalization, and Subsection 3.2 details the sample, the response rate and the analysis of the empirical data.

3.1 Survey design and operationalization of key drivers

The objective of this paper is to investigate whether health and social care practitioners prioritize the key drivers outlined in digitalization policies and to what extent the goals proposed in these policies are being enacted. To achieve this objective, a survey was developed, consisting of nine key drivers (see Subsection 4.1) derived from national policies and supported by previous research on digitalization, the public sector and welfare. The survey respondents were asked to indicate whether they worked in the private or public sector and then instructed to rank the nine key drivers, as represented by the statements presented in Table 2.

The statements presented to the respondents were rated on a six-point Likert scale, ranging from “I do not agree” to “I fully agree.” The inclusion of a six-degree scale was chosen to restrict the number of options, as previous research has indicated that when more degrees on the Likert scale are introduced, less alternatives are being selected by the respondent (Matell and Jacoby, 1972). In addition, an even number of points eliminates the neutral or “escape” option, compelling participants to take a definitive stance. The respondents were also asked to indicate which of the aforementioned key drivers they were currently working with in a professional capacity. Multiple key drivers could be selected in this section.

3.2 Sample, response rate and analysis

The survey was distributed to public and private actors in health and social care. A total of 290 municipalities in Sweden were contacted via e-mail and asked to forward the survey to the managers of their health and social care operations. To match this sample of public organizations, the survey was also sent to 290 private actors in the Swedish health and social care sector, selected from the Business Retriever database.

The survey yielded a total of 176 responses, with 147 from public organizations and 29 from private organizations. The overall response rate was 30%, including 50% for the public sector and 10% for the private sector. The survey was distributed in March 2020, coinciding with the first confirmed cases of COVID-19 in Sweden. Therefore, a reason for the low number of responses could be that practitioners were occupied with preparing pandemic procedures and treating COVID-19 patients, with the survey naturally becoming a low priority.

The key drivers in the national policies were identified by a thorough examination of the policies to determine the “reasons why” digitalization and associated technologies were being used in the sector. These key drivers were then cross-referenced with findings from previous research. The analysis of the empirical material involved the use of descriptive statistics (i.e. means and standard deviation). The various key drivers were sorted based on their mean values, providing a ranking of the drivers from highest to lowest mean. Due to the numerical disparity in responses between the public (n = 147) and private (n = 29) groups, no comparison could be made.

4. Results

The key drivers derived from the national policies can be found in Subsection 4.1 (a comprehensive list of complementary policies is included in the Appendix). Subsection 4.2 outlines the results of the survey, which ranks the key drivers based on input from practitioners.

4.1 Key drivers

Nine key drivers were identified; these drivers are stated in Swedish policy documents and in the existing literature. The deliberate inclusion of multiple policies – as opposed to a single policy – aligns with the assertion by Ball (1993) that various policies can coexist and mutually influence one another’s enactments:

• Demographic challenge: The demographic challenge is arising from the wave of retirements from the workforce, resulting in an increased demand for care as this aging population requires additional support. Moreover, the retirement of this older generation is creating job vacancies that remain unfilled by younger individuals. Consequently, fewer health-care workers are available to attend to a larger number of citizens. Digitalization and automation have been proposed as potential solutions to this issue. Recognition of the demographic challenge is evident in multiple policies (e.g. #1, #2, #3) as a driver of the digitalization of health and social care and has been explored in previous literature (Frennert and Östlund, 2018; Heidlund and Sundberg, 2021).

• Exporting welfare solutions: One key driver is the export of welfare solutions. This is particularly controversial in a country such as Sweden, where the government has historically shouldered the responsibility for health and welfare. However, with the increasing demand for health-care services, private actors have been entering the sector since the 1990s. Sweden possesses a wealth of knowledge regarding welfare, and when this is coupled with advances in AI, it could pave the way for service exports. This argument finds support in two specific policies (#1, #4).

• Decreased tax revenue: One key driver is the decreased tax revenue, which is partly a consequence of the demographic challenge. As the older generation retires, the tax revenue available to finance the welfare sector and other government-funded operations is declining. This argument is evident in two policies (#1, #3) and has been discussed in previous literature (Edebalk, 2010).

• Provide better care and service: Another driver is the desire for quality improvement, with digitalization enhancing the provision of care and services. This objective is highlighted in policy #5 and has been explored in the literature, particularly in relation to patient empowerment (Russo et al., 2019) and service delivery through automated decision-making (Ranerup and Henriksen, 2019). The focus here is on leveraging digital technologies to improve the quality and effectiveness of health-care delivery.

• Increased accessibility: Digitalization could increase the accessibility of services and assistance for individuals. Automated decision-making processes, such as the one implemented in Trelleborg (Ranerup and Henriksen, 2019), can play a significant role in this regard. Such advancements are addressed in various policies (#2, #3, #5, #6), reflecting a recognition of the potential benefits of digitalization in expanding access to services and support for a broader population.

• Efficiency: Efficiency is a crucial concept in the context of technology and automation, where the aim is to generate greater output with the same input – or to achieve the same output with reduced input. Efficiency gains become a particularly important driver in light of the demographic challenge, where fewer health-care employees will need to cater to a larger population. This argument is supported by a number of policies (#2, #3, #7) and has been discussed by Ranerup and Henriksen (2019) as well as Maki et al. (2022). It underscores the significance of leveraging technology to improve efficiency in health-care delivery and resource allocation.

• Becoming the best in the world: The aim of becoming a global leader in digitalization is commonly referenced in discussions on digitalization and AI. This key driver is recognized in two policies (#8, #9). Similar aspirations have been explored in other domains, including education, as highlighted by Fransson et al. (2018) and Ljungqvist and Sonesson (2022). The goal is to position oneself as a frontrunner in digitalization efforts, leveraging technological advances to gain a competitive edge and drive innovation in various sectors.

• Urbanization: Urbanization poses a challenge for the staffing of welfare services in rural areas, as it can leave an insufficient number of individuals available to fill the roles. Consequently, it is becoming necessary to automate and digitize certain aspects of these services. This argument is supported by one policy (#10) and has been explored elsewhere by Dubois and Sielker (2022). This underscores the potential of technology and digital solutions to address the workforce shortage in rural areas and to ensure the provision of essential welfare services.

• Attracting other competencies: As previous studies have revealed, there has been a decline in the number of younger individuals entering the health-care professions. The digitalization of health-care services creates a demand for individuals with technical expertise (#11). The importance of competence is discussed by Gjellebæk et al. (2020), who highlight that managers often lack competence in the use of digital technologies. The authors emphasize the importance of managers having the competence required to effectively implement e-health initiatives. Thus, there is a need for a diverse range of competencies, including technical expertise, to drive successful digitalization efforts in the health-care sector.

4.2 Results from the survey

Table 3 displays the means and standard deviations for each key driver, sorted from the highest to the lowest mean, thereby providing a ranking of the drivers. As noted earlier, the majority of the responses were from the public sector, accounting for approximately 85% of the sample.

The provision of higher-quality care and services is the highest-ranked driver and can be considered the core operation of the public sector. Increased accessibility also ranks highly and can be viewed as an extension of the former, as it involves providing care and services to vulnerable groups. Finally, efficiency is the third-ranked key driver, often linked with digital technologies and emphasized as a focus of digital government.

Four interrelated key drivers follow: the demographic challenge, decreased tax revenue, the attraction of new competencies and urbanization. The demographic challenge has been triggered by the retirement of the baby boomer generation, leaving job vacancies unfilled and increasing the demand for welfare services. This directly affects two key drivers: decreased revenue (due to a smaller workforce paying taxes) and the need to attract new talent to fill the vacant positions. Urbanization further complicates workforce distribution and welfare service provision.

The last two key drivers in the ranking are the aspiration to become “the best in the world” and the notion of exporting welfare solutions. The goal of becoming a world leader in digitalization is derived from an overarching narrative set by the Swedish Government for e-health (Government Offices of Sweden and Swedish Association of Local Authorities and Regions, 2016). However, the survey findings reveal that this narrative is not considered helpful or a priority by practitioners in the welfare and care sectors. Moreover, this notion of striving to become the best has been previously critiqued in domains such as education (Ljungqvist and Sonesson, 2022). Ranked last is the concept of exporting welfare solutions, which is mentioned in policies but does not translate into practical benefits for practitioners’ operations. Figure 1 illustrates the current focus areas of the respondents, and these align with the findings presented in Table 1. Notably, 90% of the respondents are engaged in efforts to enhance efficiency through digitalization. This emphasizes the widespread prioritization of efforts to leverage digital technologies to drive efficiency gains.

5. Discussion

This paper examined whether practitioners in health and social care were prioritizing the key drivers outlined in digitalization policies and assessed the extent to which the goals proposed in these policies are being enacted. To achieve this, a survey was conducted of 290 municipalities and 290 private organizations operating in the health and social care sectors. The survey gathered insights into the practitioners’ perspectives and practices in relation to digitalization.

The results indicate that the highest-ranked drivers of digitalization are efficiency, service and accessibility. This aligns with previous research on the relationship between digital technologies and service and efficiency values (Sundberg, 2019b; Ranerup and Henriksen, 2019), as well as with the majority of statements found in municipal digitalization strategies (Heidlund and Sundberg, 2023). Cordella and Iannacci (2010) note the limited nature of the efficiency notions in e-government, showing that these often revolve around “best practices” and do not consider current limitations. The results show that not only have the benefits associated with digitalization been enacted but also challenges such as demographic changes and decreased tax revenue have been observed. This goal of using technology to “change the status quo” has been included in automation policies (Heidlund and Sundberg, 2021) and health-care contexts (Östlund, 2017). The alignment between the focus of the practitioners’ current work and their ranking of the key drivers provides further evidence of enacted priorities in digitalization efforts.

Cordella and Iannacci (2010, p. 53) highlight e-government policies as carriers of goals that ultimately affect design: “By following this train of thought, we endeavour to show how e-government policies shape the choice and design of ICT projects so that technologies become carriers of the e-government policies’ goals and aims.” Thus, e-government policies not only carry ideas of – and ambitions for – what digitalization could be in practice, but they could also affect the design and practitioners’ expectations. This observation is intriguing because, as noted by Ball (1993), policies are textual interventions put into practice. However, the findings of this study suggest that policies can go beyond textual interventions and begin to shape certain developments. This aligns with the assertion of Nyhlén and Gidlund (2022) that policy documents affect reality and influence actions.

However, it appears that enacting values related to core operations (e.g. services) and addressing practical challenges is a more straightforward process than “becoming the best in the world.” Abstract rhetoric of this nature may have strategic or political implications, but it lacks practical enactment and fails to drive the meaningful change intended by the policy. Previous critiques have highlighted such ambiguities; and if these statements are enforced, it could lead to an “un-resilient digital modernity” (Nyhlén and Gidlund, 2022, p. 339). The notion of “becoming the best” with regard to digitalization initiatives, as previously observed, does not contribute value to practice and might be considered “lost in translation” (Nyhlén and Gidlund, 2019) or “lost in digitalization” (Frennert, 2018) when being enacted. Figure 1 further supports this, as it shows that few respondents are currently engaged in working with these grand narratives. It is important to heed the warning of Cordella and Iannacci (2010) that the long-term impacts of e-government reforms. In short, efforts to “become the best in the world” should be made cautiously, as they can have enduring effects on the design of the digital technologies that will outlive the initial vision and policy themselves.

6. Conclusion

The paper makes a dual contribution. First, it reveals that practitioners in health and social care prioritize the key drivers aligned with their daily operations. Second, it demonstrates that they do not seek to act on the rhetoric of “becoming the best” or to export welfare solutions, as these concepts lack a clear connection to their daily operations.

Rather, this paper demonstrates that practitioners are more inclined to enact the key drivers that concern their core operations of providing improved, increased and more efficient services. It also highlights practitioners’ awareness of societal changes and challenges, such as the growing elderly population and lack of funding. Practitioners are seeking to enhance service provision while optimizing resource utilization, and digital technologies are seen as potential tools to achieve this.

Furthermore, this paper adds to the existing critique of the dominant narrative in Swedish digitalization, which emphasizes the goal of becoming a world leader. While this narrative may have strategic and political significance, it is failing to drive change and lacks proper enactment. Again, this reinforces the argument of Ball (1993) that policies are textual interventions into practice that may not contribute to change or be enacted properly. Additionally, the paper underscores the warning of Cordella and Iannacci (2010) regarding the influence of policies on the design of digital technologies. It highlights the long-term impact of policy visions and ambitions on technology design, indicating that ideas can shape design processes long after the policies themselves have been archived.

Having various implications for practice, this paper highlights the need for policies that align with the core operations of practitioners. The use of rhetoric and ambiguous statements can pose challenges for putting policy into practice, as this leaves room for varied interpretations and translations. Consequently, in accordance with prior research, this paper emphasizes the importance of prioritizing specificity over abstraction in the process of policymaking.

6.1 Limitations and suggestions for future research

Due to the limited response rate from the private sector, the findings for the private sector – and on the differences between the public and private sectors – cannot be generalized, nor can a comparison be made between the two groups. However, the 50% response rate for the public sector permits important generalizability. It is also important to acknowledge that the key drivers examined in this paper represent only a subset of the potential drivers of digitalization, and as health-care contexts vary between countries, the drivers may need to be adapted to national contexts. Additionally, as highlighted by Heidlund and Sundberg (2023), policies should prioritize specificity rather than abstraction. In this study, some of the key drivers identified are abstract, and a more interpretive study would be necessary to gain a deeper understanding of how service and efficiency are enacted in practical terms.

Future research should also explore the perspectives of policymakers and their understanding of how policy ambitions and visions can be effectively translated into actionable steps. An investigation of policymakers’ perspectives could provide valuable insights into the decision-making processes and strategies for implementing digitalization initiatives in the health-care sector. Thus, an exploration of collaborative approaches and the dynamics between policymakers and practitioners could contribute to bridging the gap between policy intentions and actual implementation on the ground.

Figures

Figure 1.

What the respondents are currently working with

Table 1.

Literature strands

Literature strands	Description	Exemplary papers
Policy studies in welfare	The discipline of education, as an integral part of the welfare sector, has long devoted attention to the study of policies and their enactment. In the context of this paper, which examines health and social care within Scandinavia, a region with comprehensive welfare systems which education is part of, the insights and theoretical frameworks developed in the educational literature strand are especially relevant	Ball (1993), Ball (2011), Fransson et al. (2018), Ljungqvist and Sonesson (2022)
Digital government policy analysis and enactment	Policies are the method primarily used to govern the development of an envisioned digital future, and policies and their enactment have been the subjects of research in the digital government domain	Heidlund and Sundberg (2021, 2023), Nyhlén and Gidlund (2019, 2022), Cordella and Iannacci (2010)
Digital technologies in health and welfare	The use of digital technology in health and welfare has raised questions regarding its alignment with core values and operational aspects. Consequently, in a policy context, it is particularly important to investigate the key drivers prioritized and enacted by practitioners	Frennert (2018), Frennert and Östlund (2018), Hasselblad and Sundberg (2020)

Source: Authors’ own creation

Table 2.

Operationalization of key drivers

Key driver	Statement
Demographic challenge	We want to use digitalization to counteract the effects of the demographic challenge
Export welfare solutions	We want to develop welfare solutions that can lead to service exports for Sweden
Decreased tax revenue	We want to use digitalization to prepare for a future in which there is less tax funding to finance health and social care
Better care and service	We want to offer better care and service
Increase accessibility	We want to use digitalization to be able to offer better accessibility
Efficiency	We want to use digitalization to increase the efficiency of our operations
Become the best in the world	We want to be the best in the world at using the possibilities of digitalization
Urbanization	We want to use digitalization to counteract the effects of urbanization and continue to offer services all over Sweden
Attract other competency	We want to use digitalization to bring new skills and competency into our business

Source: Authors’ own creation

Table 3.

Descriptive statistics both groups (n = 176)

Key driver	Mean	SD
Provide better care and service	5.51	0.778
Increase accessibility	5.48	0.778
Efficiency	5.41	0.884
Demographic challenge	5.10	1.085
Decreased tax revenue	4.63	1.499
Attract new competence	4.06	1.397
Urbanization	4.03	1.623
Become the best in the world	3.61	1.462
Exporting welfare solutions	2.26	1.314

Source: Authors’ own creation

Appendix. Policy documents

#1 Andersson, C., Lindsjö, G., Hagberg, R. (2018). Artificial Intelligence in the Public Sector – How do we realize the potential? Governo.

#2 Inera. (2017). AI and Automation for Primary Care – A report from Inera AB and the preliminary study Digital Healthcare Advice.

#3 Swedish Association of Local Authorities and Regions. (2018). Work Automation: Opportunities and Challenges for Municipalities, County Councils, and Regions.

#4 Vinnova. (2018). Artificial Intelligence in Swedish Business and Society – Analysis of Development and Potential. Vinnova report VR 2018:08.

#5 Swedish Association of Local Authorities and Regions. (2017a). Artificial Intelligence – Opportunities for Welfare.

#6 Swedish Association of Local Authorities and Regions. (2017b). Decisions within 24 Hours!

#7 DIGG. (2020). Promoting the Public Administration’s Ability to Use AI. Interim Report.

#8 Government Offices of Sweden. (2018). National Direction for Artificial Intelligence.

#9 Government Offices of Sweden and Swedish Association of Local Authorities and Regions. (2016). Vision e-Health 2025 – Common Principles for Digitalization in Social Services and Healthcare.

#10 Swedish Municipalities and Regions. (2015). Urbanization – Challenges for Municipalities with Growing and Declining Population.

#11 Swedish Social Services. (2019). Assessment of the Supply and Demand for Licensed Personnel in Healthcare and Dental Care – National Planning Support 2019.