Implementing cancer patient pathways in Scandinavia how structuring might affect the acceptance of a politically imposed reform

Through political decisions all three Scandinavian countries implemented national reforms in cancer care introducing cancer patient pathways. Though resistance from the professional community is common to top-down initiatives, we recognized positive receptions of this reform in all three countries and professionals immediately contributed in implementing the core measures. The implementation of a similar reform in three countries with a similar health care system created a unique opportunity to look for shared characteristics. Combining analytical framework of institutional theory and research on policy implementation, we identified common patterns of structuring of the initial implementation: The hierarchical processes were combined with supplementary structures located both within and outside the formal management hierarchy. Some had a permanent character while others were more project-like or even resembled social movements. These hybrid structures made it possible for actors from high up in the hierarchy to communicate directly to actors at the operational hospital level. Across the cases, we also identified structural components acting together with the traditional command-control; negotiation, consensus and counseling. However, variations in the presence of these did not seem to have significant impact on processes causing decisions and acceptance. These variations may, however, influence the long-term practice and outcome of cancer-care pathway-reform. Knowledge from our study should be considered when orchestrating future health care reforms and especially top-down politically initiated reforms.