There are intense policy pressures on schools to promote student health and well-being, emphasizing the importance of high-quality provision of School Health Services (SHS) (WHO 2021). Yet, the increasing prevalence of health issues among children and youth, combined with constrained education budgets, have turned SHS into an ever more challenging task.

 In Sweden, SHS is regulated by the Education Act and shall primarily consist of prevention and health promotion.  On the individual student level, besides general health checks, the goal is to create a positive learning situation, to remove obstacles to each student's learning and development. On the group and school unit level SHS shall ensure a good learning environment and good and safe growing up conditions. Access to school doctors, school nurses, psychologists, school social workers and special education teachers is mandatory. SHS work is thus both multi-professional and multi-faceted involving collaboration between SHS professionals, teachers and professionals within health and medical care and social services.

 Municipal school organisers (MO:s) and private school organisers (PO:s) can either provide SHS themselves or outsource SHS to private companies. They may outsource the entire SHS or the medical side of SHS including the formal caregiver responsibility, e.g. that medical assessments, treatments and documentation are conducted correctly and that legal security and confidentiality are considered in line with health care laws. Outsourcing may also involve the contracting of certain SHS services like school doctors and school psychologists. School providers may also buy other SHS services or resources including education, professional supervision, programmes/methods and digital documentation systems.

This paper draws attention to a largely overlooked aspect of the more general market-oriented policy trend prevalent in the Nordic domain (Lundahl, 2016), namely the marketization of SHS. We draw on a research project studying how public as well as private organisers, schools and other stakeholders perceive and navigate this terrain. The aim is to analyze and discuss the strategies and experiences of Swedish MO:s and PO:s in purchasing (or not purchasing) SHS from private companies. We explore the following research questions:

1. What types of SHS services and resources do public and private school organisers buy?
2. Why and on what grounds do school organisers choose to buy – or not buy – SHS services and resources?
3.  What drives commercialisation within the SHS sector and what are the potential implications for SHS in schools?

Conceptually, we draw on literature that highlights how neoliberal globalisation has opened schools to new commercial partners, products and services related to health issues (Macdonald et al., 2020). In this context, we see commercialisation as processes entailing the creation, marketing and sale of education goods and services to schools by private providers (Hogan and Thompson, 2017). In our analysis, we use the notion of projectification (Fred & Godenhjelm, 2023), which encompasses public sector reliance on “temporary organisations” (Sahlin-Andersson & Söderholm 2002) to analyse “outsourcing” and “contracts” (Andersson & Jordahl, 2011; Blomqvist & Winblad 2022; Greve, 2008; Hodgson et al., 2019) of SHS to private companies. We furthermore turn to the notion of brokers (Ozga et al., 2011) to analyse how this development is enabled and governed economically and in terms of content. We also acknowledge attempts to address challenges related to these developments in terms of reversed privatization, re-municipalization, or backsourcing (Berlin et al., 2023; Clifton et al., 2021; Hefetz & Warner, 2004; Jansson et al., 2020). 

We analyse interviews with 65 representatives from 30 MO:s and 30 PO:s using a ‘maximum variation’ sampling strategy (Patton, 2015). To implement this, we first turned to a grouping of municipalities by the Swedish Association of Local Authorities and Regions. These include a) Large cities and municipalities near large cities, b) Medium-sized towns and municipalities near medium-sized towns and c) Smaller towns/urban areas and rural municipalities (SKR 2024). We selected PO:s with different sizes and modes of operation (limited companies, foundations, economic associations, non-profit associations), hence including both large commercial school chains and small rural village schools. The interviews lasted approximately 60 minutes and included questions on SHS purchases, motives for and experiences of such purchases and views of the consequences of marketisation of SHS in Sweden. All interviews were conducted via telephone/video and were audio-recorded and transcribed using digital software. A first descriptive analysis generated a table containing all school providers with an overview if they were buying different services and resources or not. This analysis provided us with an overall map of purchases and responded to the first research question. A second thematic analysis served to identify patterns and themes in relation to research questions two and three and our theoretical framework (Creswell, 2014). More specifically, the thematic analysis aimed to generate insights about how key actors understand and form strategies and responses towards SHS challenges and private services and resources, by focusing on their justifications, rationales and experiences. Throughout the research process, we adhered to the ethical guidelines set forth by the Swedish Research Council (Vetenskapsrådet, 2024). As a consequence, we have chosen to use fictitious names for all school organisers and informants.

The analysis identified similarities and differences between MO:s and PO:s in purchase patterns and experiences. Many of them rely on external staffing. Purchases of services from school doctors are very common (28/30 PO:s and 20/30 MO:s). School psychologists are purchased to a great extent and almost half of the PO:s buy school nurse services, but only three municipalities. The opposite is the case for coaching for SHS professionals, with municipalities buying it more often. A majority of both groups of organisers are sceptical of contract staffing. It is associated with high costs and perceived lack of continuity and coordination. Outsourcing of the caregiver responsibility to a commercial company is done by one-third of the PO:s but not by any of the MO:s. Especially the smaller PO:s argue that they lack the competence needed to fulfil this complex duty. Interestingly, we have not identified this stance among small municipalities, even if they may also have limited resources. Overall, large PO:s (corporate chains with many schools) resemble large MO:s as both seek to control how much and when they outsource, or even “backsource” SHS. Smaller actors struggle to hire staff to cover their SHS needs and obligations and as a result, they engage in what we label as involuntary outsourcing, i.e. a reactive stance towards outsourcing with “no choice” (Shanks, 2023). In conclusion, SHS appears highly dependent on temporary contributions, for instance in the form of directed state grants where state agencies function as brokers (Levinson et al., 2024). Such projectification affects relationships, perceived needs and market-making opportunities for private SHS service providers. We discuss if and how such tendencies and processes also hold relevance to other European SHS systems, thus situating the findings in a wider European context.

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