From Silos to Flows by Redesigning Regional Care for System-Wide Coordination: A Qualitative Study of Organizational Capabilities and Governance in Sweden

Background Decentralised and market-inspired health system reforms have increased organisational plurality and local autonomy but often intensify fragmentation and complicate system-wide coordination. This study explored how healthcare top leaders in a Swedish regional health system conceptualise governance and stewardship for coordination across organisational boundaries, which mechanisms and capabilities are perceived to enable or constrain coordination, and how leaders assess outcomes and strategies for sustaining integrated care flows. Methods An interpretive qualitative study was conducted in Region Stockholm. Semi-structured interviews were carried out (March–May 2023) with 18 senior actors: eight provider chief executive officers, eight board chairpersons, senior functional directors, and representatives from the purchaser organisation. Transcripts were analysed using directed qualitative content analysis, applying the Context and Capabilities for Integrating Care (CCIC) framework as a deductive coding structure. Perceived outcomes and suggested improvements were coded as additional inductively generated categories. Cross-category analysis generated overarching themes. Results A total of 356 codes were identified. Interviewees described a pluralistic provider environment with limited collaboration and strong siloing. Across the CCIC categories and inductive outcome/improvement categories, four cross-cutting themes were identified: (1) coordination pressures in a pluralistic provider environment; (2) fragmented system architecture and contractual steering; (3) competing governance logics and ambiguous authority; and (4) fragile relational and process infrastructures, where coordination often relied on individual “champions” and informal workarounds. Leaders reported system-level inefficiencies linked to fragmented contracting, misaligned follow-up demands, and incentives that did not support integrated care pathways. Proposed strategies included strengthened system stewardship, trust-based governance, clearer accountability, and organisational arrangements, such as regional flow groups, to enable coherent regional care pathways. Conclusion Senior leaders described coordination as persistently constrained by contractual fragmentation, ambiguous governance, and fragile relational infrastructures in a decentralised purchaser–provider system. Strengthening system stewardship and meta-governance was positioned as central to sustaining integrated care flows while retaining local autonomy.