Contentious countrysides : social movements reworking and resisting public healthcare restructuring in rural Sweden

Sammanfattning: The broader aim of this thesis is to contribute to the understanding of the production and reproduction of spatial inequalities following from the restructuring of the public healthcare system. More specifically, by analyzing the contention around healthcare restructuring related to two cases spanning a longer period in northern Sweden, I aim to investigate the changing conditions for healthcare provision in rural and sparsely populated areas, and I explore the forms of collective action that local people engage in to sustain the access to healthcare, as well as how state authorities’ attitudes towards such collective action have shifted. In the context of larger public healthcare restructuring in contemporary Sweden, where the marketization and privatization of healthcare since the 1990s have impacted the provision of healthcare across the country, rural areas are experiencing deteriorating accessibility to both primary healthcare as well as emergency healthcare. This development is increasingly contentious, and is frequently met with resistance from rural populations as well as various strategies to rework these uneven conditions. The first case concerns the preceding protests as well as the occupation and opening of a citizen cooperative primary care center in Sollefteå, Västernorrland, in response to cutbacks at the local hospital. The second case follows the worker-cum-citizen cooperative primary and occupational healthcare centers in Offerdal, Jämtland. Through these two cases I explore people’s experiences of public healthcare restructuring, their motivations for engaging in contention around it, their experiences of self-organizing cooperative healthcare, as well as their visions and desires for a future healthcare.As shown throughout this thesis, healthcare restructuring is highly contentious and comes in many forms, ranging from protests, demonstrations, and occupations of healthcare facilities to the self-organization of healthcare services through worker and citizen cooperatives. Healthcare restructuring marked by spatial concentration and withdrawal has thus given rise to a number of drawn-out and spectacular collective actions in contemporary Sweden, but responses can also take the form of low-key efforts to maintain healthcare provision. The healthcare authorities’ attitude towards such low-key efforts by not-for-profit healthcare providers has shifted from a favorable approach in the 1990s to emphasizing their role in safeguarding fair market conditions in the healthcare market. This shift has created a more hostile welfare state landscape for not-for-profit healthcare providers in rural areas, which exacerbates the already unfavorable conditions they operate under. Rural populations’ efforts to remedy the withdrawal of public healthcare are thus highly precarious. While reworking uneven healthcare provision, they operate in this increasingly hostile welfare state landscape, which is not adapted to either rural areas or not-for-profit healthcare. In practice, public healthcare restructuring and withdrawal amount to a cutback in healthcare provision for rural populations. This transfers the work of sustaining social reproduction to the private sphere, in this case not-for-profits healthcare providers. The public healthcare restructuring and withdrawal outlined in this thesis thus present an example of a form of ‘rural neoliberalism’, whereby rural populations are dispossessed of welfare services that instead accumulate in urban areas, which both increases and is connected to larger questions around spatial (in)equalities and the restructuring of the public sector in contemporary Sweden. Nevertheless, those engaged in contention around and the self-organization of healthcare nurture visions and desires for a future healthcare system that would take a holistic approach to the patient and make possible a more equitable access to healthcare.