Dimensions of Accountability: Voices from New Zealand Primary Health Organisations
Cooperative activity necessitates participants acknowledging joint goals, often delegating resources, consequent performance, tailored accountability reporting and feedback (Levaggi, 1995). Thus, accountability is a process reflecting the interdependence of social relationships (Roberts, 1991). Such interdependence is evident in publicly funded health care systems where governments contract with autonomous providers, as occurs in the New Zealand primary health care system. Primary health care (as patients' first point of contact with the health system) was reformed significantly with the launch of the Primary Health Care Strategy [(Minister of Health, 2001) effective from May, 2002]. Increased government funding became available to Primary Health Organisations (PHOs), new entities that were to act as intermediaries between the government on the one hand, and primary health care practitioners on the other. PHOs became responsible for designing and contracting for the delivery of primary health programmes so as to improve their communities' health (Minister of Health, 2001). Consequent upon increased public funding distributed through these organisations, the government requires all PHOs to be 'fully and openly accountable' for all public funds they receive. O'Dwyer and Unerman (2006) term this 'holistic' accountability. Further, PHOs must be private not-for-profit organisations, reducing the likelihood that public funds will be diverted to shareholder dividends paid out by profit-oriented providers (Minister of Health, 2001). Despite the promise of accountability, the challenges of meeting the expectations of multiple stakeholders and choosing effective accountability mechanisms potentially mitigate against PHOs discharging accountability adequately. Accordingly, this research is an interpretive study into the understanding of PHOs and their stakeholders of 'to whom', 'for what', 'why' and 'how' accountability is discharged and how these challenges are mana ged. Four PHOs consented to be included as case studies during the 2006 and 2007 financial years. This ethnographic research collected financial and non-financial data, observed community meetings, interviewed key stakeholders and integrated research participants' feedback to reflect on current theory. It was found that stakeholders expect PHOs to prioritise either community or their funding and service providers, giving rise to possible conflicting demands. PHOs appear to manage this conflict internally, although the manner in which they do so evokes particular external images. Some District Health Boards (DHBs), as PHOs' funders, seek to manage PHOs' prioritisation by positing themselves as the arbiters of community needs. Further, while the Primary Health Care Strategy appears to require accountability to counter-balance control of PHOs with enhancing trust in DHB/PHO relationships, in this research it was found that PHOs subjected to strong funder control experience reduced autonomy and, by extension, fewer opportunities to learn. A further finding of this research was that 'mapping' the observations of stakeholders' expectations and the operation of control and/or trust against each other enables the identification of deficits in the process of holistic accountability. Accordingly, suggestions for mechanisms that will enable PHOs to balance multiple stakeholders and discharge holistic accountability are derived.