As the public sector and specifically the health sector, undergo reform
throughout the Western world in order to find systems that work better and cost less, the
phenomenon of accountability is of increasing concern to policy-makers. Although the
public administration concept of accountability is ancient, and has been debated and
described in the languages of many diverse disciplines, little academic work is available
on its meaning or application to the Canadian Health System. Without a clearer
understanding of the concept, the basis for improving accountability in the Canadian
Health System will remain unknown.
This dissertation seeks to clarify the concept of health system accountability and
elucidate the issues related to improving accountability in the system. This is
accomplished through a concept analysis methodology using two qualitative data
collection strategies: a structured review of Canadian literature on accountability from
the domains of health policy/administration, professional and popular literature sources;
and an interview process whereby 24 health system leaders from five Canadian
provinces were interviewed.
The findings reveal that the concept of accountability, in its current explicit,
performance-based form, is relatively new to Canadian health system policy
discussions, its use only beginning in the 1980’s. Prior to this, accountability was
implicit in the delegation of health matters to self-regulating professions. The concept
evolved from public administration theory and continues to evolve as a health concept.
An attempt is made to disentangle the concept of health system accountability from its
many related concepts and references. The defining attributes of accountability are: a
performance assessment according to standards/goals; an obligation to render an
account; and an answerability to the community served. Antecedents or pre-requisites to
accountability include a renewed culture, strategic direction, citizen engagement,
information management, performance measurement and reporting. Consequences of
accountability are: a sustainable health system, increased public confidence, improved
health outcomes and quality services, added bureaucracy and uncertainty. Although
there is a majority view on the defining attributes, there are several conceptions of
accountability: as a theoretical or ethical construct; as gesture; as a formal system or set
of practices; as an on-going political process; and as desired outcomes or results.
Likewise several normative modes or models exist: the historical professional model,
the emerging managerial model and the potential citizen participation model. These are
all encompassed within the broader political framework. Also, accountability is a
multi-level construct: personal, organizational and political.
There are several policy issues related to accountability and democratic
governments in today’s modem societies. Within the health sector, the key issues
identified, by health system leader research participants, as problematic to improving
accountability included: a lack of direction and role definition, cultural issues, a lack of
citizen engagement, and a lack of appropriate measurement and information with
which to evaluate organization and system performance. Although the purpose of this
dissertation is not to answer or provide prescriptions to policy issues, several health
policy questions are generated.
I trust that the conceptual analysis presented here will assist to clarify our
language and understanding of accountability as it continues to evolve in health care,
provide a helpful reference point from which to discuss health system policy issues, and
prompt further research in an area that has largely been ignored by Canadian academics.
We need to get clear about our language, (so that), our intelligence is
not bewitched by our language. (Hodgkinson, 1996, p.144) / Graduate
| Identifer | oai:union.ndltd.org:uvic.ca/oai:dspace.library.uvic.ca:1828/10214 |
| Date | 01 November 2018 |
| Creators | Penney, Betty Christine |
| Contributors | Cutt, James |
| Source Sets | University of Victoria |
| Language | English, English |
| Detected Language | English |
| Type | Thesis |
| Format | application/pdf |
| Rights | Available to the World Wide Web |
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