What Gets Measured in Healthcare Reform Is Fought Over First

When a national healthcare reform promises stronger primary care and more person-centred services, someone eventually has to decide what to count.

Researchers Theresa Larsen, Ewa Wikström, Helle Wijk, Richard Sawatzky and Axel Wolf explored how municipal stakeholders negotiate what should become measurable during the implementation of Close Care, a national Swedish reform aiming to strengthen primary care and develop more person-centred services. Their work, published open access in Health Research Policy and Systems, uses an interpretive descriptive approach grounded in the messy reality of local governance rather than in abstract models of measurement design.

The empirical material came from nine stakeholder workshops involving 191 participants across municipalities in Västra Götaland County. Participants included politicians, managers, civil servants, and healthcare and social care professionals. The workshops examined three things: the indicators already in use, the gaps in available information, and the conditions required for meaningful follow-up of the ongoing reform. The data were analysed using an abductive thematic analysis, moving between the concrete patterns observed in the workshops and broader theoretical ideas about measurement-based governance.

Four closely related empirical patterns emerged from the analysis. First, stakeholders negotiated why, for whom and how measurement should be used, and these negotiations exposed tensions between accountability, quality improvement and learning. An indicator that satisfies an accountability requirement toward regional or national authorities may be poorly suited to supporting local learning, and the workshops showed participants actively wrestling with that mismatch.

Second, conceptual ambiguity about the reform’s governing object made it difficult to determine what should be measured at all. If the thing a reform is meant to change is not clearly defined, any attempt to attach numbers to it inherits that vagueness. The researchers found that this ambiguity was not a minor drafting problem but a structural obstacle to follow-up.

Third, fragmented data infrastructures limited both the availability and the comparability of indicators. Data held by different parts of a decentralised system do not automatically line up, so even well-defined measures can become unusable when the underlying information systems do not speak to each other. Fourth, limited epistemic capacity constrained how available data could be understood and used for governance and improvement. Having numbers is not the same as being able to interpret them in ways that inform decisions.

Through abductive interpretation, the team synthesised these four patterns into a conceptual framework of four conditions shaping the feasibility of measurement-based governance: normative, conceptual, infrastructural and epistemic. In other words, before performance measurement can guide governance, organisations must establish shared agreement on the purpose of measurement, a clear definition of what is being measured, data systems that can supply comparable figures, and the capacity to make sense of the results.

The study’s most provocative claim concerns how tensions between reform ambitions and measurement feasibility should be read. Rather than treating them as implementation failures or as resistance to measurement, the authors argue that such tensions are inherent features of governing complex healthcare systems. A decentralised system in which municipalities, regions and professions each hold part of the picture will naturally produce disagreement about what matters, and that disagreement is not noise to be engineered away but a constitutive part of the governance process.

Performance indicators, the study stresses, are not neutral tools. They shape how reform priorities become visible and governable within reform processes. Choosing an indicator makes some aspects of a reform legible and leaves others in the dark, which means the negotiation over indicators is effectively a negotiation over what the reform is. While previous research has examined the design and effects of performance measurement systems, the authors note that less has been known about how follow-up priorities are negotiated when broad reform ambitions are translated into local governance. This study addresses that gap directly, using the Close Care transition as its empirical setting.

The study is limited to one Swedish county and a workshop-based design, so the patterns it identifies are interpretive rather than statistically generalisable. Even so, its central message is clear: measurement itself is a governance process, and the work of deciding what matters must be done before anything can be made measurable.

Subject of Research: Governance challenges in defining performance measurement priorities during implementation of a Swedish primary care reform

Article Title: Measuring what matters: governance challenges in defining follow-up priorities in complex healthcare systems

Article References: Larsen, T., Wikström, E., Wijk, H., Sawatzky, R., & Wolf, A. (2026). Measuring what matters: governance challenges in defining follow-up priorities in complex healthcare systems. Health Research Policy and Systems. https://doi.org/10.1186/s12961-026-01550-w

Image Credits: AI Generated

DOI: 10.1186/s12961-026-01550-w

Keywords: health policy, performance measurement, healthcare reform, primary care, Sweden, governance, stakeholder workshops, Close Care, data infrastructure, person-centred care, Measuring, matters