Toward an Accountability Framework for Canadian Healthcare

O R I G I N A L

A R T I C L E

Toward an Accountability Framework for Canadian Healthcare

A

Abstract State-funded healthcare systems increasingly recognize accountability as an important public policy issue. This article explores significant aspects of current theory and practice in order to describe an accountability framework for the Canadian health system. Stakeholders include governments, institutions, providers and patients. Their relationships may be framed in constitutional, political, financial, managerial, clinical or ethical terms. The specific processes and instruments to operationalize accountability depend on the terms by which it is framed.

24

ccountability (defined succinctly as an obligation to answer for a responsibility conferred) in the delivery of government programs has become increasingly prominent in recent Canadian public discourse.1 Such discussions often imply that accountability is synonymous with the collection of quantifiable performance indicators, and that similar measures of accountability may be applied to all aspects of public endeavour. In contrast, this article demonstrates that operationalizing accountability is a far more complex process than simple data gathering, and that it demands a flexible approach tailored to individual accountability relationships.2

In this article, we present a broad descriptive synthesis of current theories of accountability and approaches to its implementation in the Canadian healthcare system. We begin by considering why accountability is currently of such interest and suggest an approach to documenting contemporary views and practices. Next, based on a literature review, we offer a functional definition of accountability. We then review current accountability practice to determine who is presently accountable to whom in healthcare, for what, and how such accountability is achieved. We do not imply, however, that theory necessarily corresponds to practice in all jurisdictions. Finally, we conclude with a brief review of obstacles to the elaboration of a comprehensive accountability frame-

Healthcare Management Forum Gestion des soins de santé

by S.E.D. Shortt and J.K. Macdonald

work for the Canadian healthcare system.

Creating a Context Accountability in the exercise of governmental authority is by no means a new concept, its origins having been traced to antiquity;3 nor is its application to healthcare delivery unique to Canada,4 although its structure differs significantly by national jurisdiction.5,6 What is striking, however, is the increasing frequency with which health system accountability is discussed in Canada and the tone of heightened urgency accompanying these discussions. Many factors no doubt explain the recent interest in healthcare accountability. Accountability is a central component of the consumerism that has characterized most forms of consumption in North America for more than three decades. In the case of healthcare in Canada, consumer concern has become all the more articulate in the face of perceived threats to funding the provision of services. The proliferation of access to information legislation has the potential to become a powerful tool in the hands of consumers for holding government answerable for its actions.7 Faced with an apparent erosion of faith in government, politicians are aware of the need for transparency in the decision-making process. Involving consumers in the planning and evaluation aspects of health policy and research is one example of a mechanism intended to enhance public accountability.8

A second commonly identified introduced in 1979 to maintain reason for current concerns about surveillance over the appropriateness accountability is the fear that, over of federal expenditures.18 This was the last three decades, government later abandoned. Most provincial has become sufficiently complex to governments have initiated multiyear outstrip the capacity of traditional business plans against which expenmechanisms of accountability.9 A diture and achievements can be frequently cited example concerns compared annually. the roles and responsibilities of a government minister.10-12 Under the A fourth contributor to the urgency Westminster model of parliamentary noted in discussions of accountability government used in Canada, the concerns the emergence of new minister is accountable for all actions organizational structures in the of all subordinates. Some argue that healthcare sector. The dominant the complexity of contemporary public innovation in Canada has been management renders this obligation devolution of varying degrees of impossible, and that the senior responsibility and authority from departmental bureaucrat, the deputy provincial governments to regional minister, who traditionally answers to health bodies and, to some extent, the minister, must assume a greater municipal governments. Devolution degree of public accountability for relies on the assumption that locally matters other than policy. Another set priorities and locally managed commonly cited example focuses on services would be more cost effective financial management. The 1976 and efficient. By devolving difficult Auditor General’s report, which stated resource allocation decisions to that the federal government was in regional boards, provincial governdanger of losing control of the country’s ments may hope to share responsibility finances, resulted in the Royal in the eyes of the public for the Commission on Financial Management provision19 of care in times of fiscal and Accountability and, eventually, restraint. Devolved organizational enhanced financial accountability structures are still in the process of developing through the c o m p l e x creation of the Of all the relevant factors accountability Office of the generating healthcare mechanisms. Comptroller 13,14 accountability debates, none looms W h i l e , General. structurally, the larger than recent developments A third reason devolved in federal-provincial relations. for interest in organizations accountability are accountable concerns cost control. Faced with solely to their provincial creators, declining revenues and increasing decision authority at the local level public concern about taxes and increases demands for accountability deficits over the last two decades, to constituents served. governments searched for better Of all the relevant factors generating methods of controlling public healthcare accountability debates, expenditure.15 Traditional financial none looms larger than recent audits were increasingly supplemented, developments in federal-provincial during the 1980s, by comprehensive, relations. Creating a state-funded or “value-for-money,” auditing16,17 healthcare system rendered the designed to render departments financing and delivery of care in accountable for the way in which Canada potentially more amenable funds were spent. Similarly at the to accountability mechanisms than federal level, the Policy and Expen- its decentralized, entrepreneurial diture Management System was predecessor.20 However, as federal

[

]

funding for healthcare continued to erode into the 1990s, concerns were raised that provinces would no longer be accountable to Ottawa for maintaining the national standards stipulated by the Canada Health Act. The 1999 Social Union Framework Agreement, broadly focused on jurisdictional issues and transfers for health, education, and social services, was accompanied by a health accord designed both to arrest the decline in the proportion of federal funding for healthcare and to abort the potential for drift from the principles of the Canada Health Act. Endorsed by all but one province, the key to the success of the Social Union Framework Agreement was seen to lie in the accountability mechanisms it articulated.21 Signatories pledged to: • monitor and measure outcomes of their social programs and report regularly to their constituents on the performance of these programs; • share information and best practices to support the development of outcome measures, and to work with other governments to develop, over time, comparable indicators to measure progress on agreed objectives; and • publicly recognize and explain the respective roles and contributions of governments. While the Agreement was largely a declaration of shared principals, it was a harbinger of subsequent events. Following a First Ministers’ Meeting in September of 2000, the federal government announced a significant infusion of funding for healthcare, and both the federal and provincial ministers pledged support for the objective of “being accountable to Canadians for health services.”22(p.4) This was to be operationalized by regularly reporting on performance measures concerning health status, health outcomes and quality of

Healthcare Management Forum Gestion des soins de santé

25

service. Although this conception of accountability was rather limited and hampered by fears of jurisdictional intrusion, its articulation was the most overt national statement of the importance of accountability in healthcare yet to appear in Canada. From this brief review, it is clear that accountability has arrived on the contemporary healthcare agenda as a result of diverse trends in federalprovincial relations, government complexity, cost control initiatives, health system reorganization and consumerism. To evolve from an agenda item to an operational reality will require an understanding of the tools and processes of accountability, which, in turn, requires a method of exploring these issues.

A Method To Assess Current Accountability Theory and Practice Initial insight into contemporary Canadian thinking about accountability in healthcare may be gained from published literature. A search of 26 electronic indexes, using the search terms accountability, governance, stewardship, government, Canada and health, produced 52 citations of relevance. It is a relatively scant body of literature, suggesting that Canadian scholars, to date, have largely ignored the issue of accountability in healthcare. The quality of the publications is highly variable, ranging from exhortational pieces in professional magazines, through well-argued essays by senior public servants, to a few detailed academic studies. The literature tends to focus disproportionately on a narrow range of topics, prominent among which are the role of the federal auditor general; accountability of deputy ministers; the relationship of accountability to healthcare reform; and descriptions of tools of accountability such as report cards. A second and more fruitful source of insight into not only theory, but also current practices, is government documents. A number of provinces,

26

including Alberta, British Columbia, Manitoba, Nova Scotia, and Saskatchewan,23-27 have published health system accountability frameworks. Most of the remaining provinces have documents that address specific aspects of accountability, such as business plans and financial reporting requirements. Although varying considerably by jurisdiction, from such documents emerge the broad outlines of an accountability structure for Canadian healthcare. Since published documents often serve political ends, it is essential to distinguish between rhetoric and reality using information provided by representatives of key stakeholders. Evidence was gathered from all 10 provinces and the federal government through structured interviews with 15 senior government officials identified by their respective deputy ministers, 12 spokespersons for hospitals and regional health authorities, and 10 representatives of physician licensing bodies. The provincial interviews were designed to explore a wide range of specific accountability issues including the following: • the comprehensiveness of a provincial health ministry’s responsibility for health-related legislation; • the extent of the provincial auditor’s mandate; • the steps through which departmental programs are approved by the government and the legislature; • the existence of structured accountability processes for the provincial government in general and health ministries in particular; • the extent to which accountability is influenced by the recent reform processes, especially regionalization; • the methods by which departments define their internal accountabilities in relation to changing external systems and

Healthcare Management Forum Gestion des soins de santé

structures; • the nature of relationships between departments of health and professionals; • the use of accreditation and licensing of professionals and organizations as an accountability method; • the mechanisms that departments and their funded organizations use to relate to the public in terms of policy development, planning, priority setting and reporting; and • the means by which each jurisdiction defines the accountability of the public for responsible use of the health system. From the data gathered through the published literature review, government documents and structured interviews with key informants, a nation-wide snapshot was developed of current accountability mechanisms within and between the federal and provincial jurisdictions. Following a synthesis definition of accountability as it is understood in Canadian healthcare, the balance of this article uses the data to describe the key elements of existing theory and practice by answering the question: Who is accountable to whom, for what, and how?

Accountability: A Canadian Definition and a Process While the concept of accountability is essential to democratic political systems, its meaning and application continues to evolve according to historical circumstances. Several concepts are essential to creating a definition of accountability as it is presently understood in Canadian healthcare literature: • In the first instance, accountability means being obliged to answer for something. This differs from being responsible for something, a term indicating an obligation to act.28

• One answers to an authority that assigned the task; however, being accountable to a specific source does not necessarily mean the source exercises control.29,30 • One can only accept the responsibility of answering for assigned tasks for which adequate authority and resources were given.31 • Accountability implies the possibility that action will ensue upon report of inadequate performance. • Accountability occurs within a broader framework of social perceptions of fairness and justice, which the dictates of individual conscience reflect.32,33 Based on these concepts, the following is a synthesis definition of accountability in Canadian healthcare: Set within an implicit ethical context, accountability is the obligation to answer to an authority that conferred a responsibility, by an agent who accepted it, with the resources and delegated authority necessary to achieve it, and with the understanding that inadequate performance will result in intervention. As the final phrase in this definition implies, accountability is not only a theoretical construct describing organizational, ethical and political relationships, but is also part of a dynamic management process. The term used to describe this process is the accountability loop. While there are various depictions of this structure, a generic version of the steps that comprise it is as follows:28 • articulation of the rationale for a proposed action; • definition of specific objectives; • specification of standards against which performance will be measured;

• documentation of outcomes; • comparison of results to standards, so as to establish lessons learned; and • application of lessons to revise as necessary the rationale and objectives. Accountability in healthcare, as captured in the Canadian literature, is both a theoretical construct and an applied management tool.

Who Are the Stakeholders in Canadian Healthcare Accountability? The key stakeholders in Canadian health system accountability may be arranged on a continuum from the public, through institutions and providers, to government. Several points deserve clarification. First it must be acknowledged that these groups lack the integration of a true system, which makes defining lines of accountability difficult. Second, healthcare in Canada is paid for by government, but is provided by private practitioners and institutions owned by local communities or denominational groups. This blend of public and private participation must be captured in health system accountability. Finally, while they have recently gained in importance in areas such as pharmaceutical and rehabilitation coverage, third-party insurers are absent from this list because of their minor role in the single-payer Canadian system.34 The constituent groups and their roles are as follows: • The federal government provides direction to the system through the Canada Health Act and, traditionally, a significant proportion of the funding. • Provincial governments are responsible for system design and monitoring and an increasing share of the cost of service provision.

• In many provinces, regional authorities or equivalents have been given various responsibilities, including identifying local needs and providing services to meet these needs. • An important element of service provision, traditionally accounting for well over 40 percent of health expenditures, are hospitals. In a number of jurisdictions they have been subsumed in regional authorities. Community care organizations are assuming increasing importance, but as yet account for a relatively modest portion of overall expenditure. • Individual providers are the other essential element of healthcare service provision. Many of these individuals, such as nurses or occupational therapists, are predominately based in institutions. A significant proportion of their accountability is framed by their status as employees of the institution. Physicians, however, are largely autonomous practitioners who, for the most part, lack this direct accountability to institutions. In light of this independence, and since expenditures on physicians’ services account for approximately a fifth of provincial health expenditures, physicians will be used as a proxy in this discussion for all health professionals. • The public is the final and most important element in the accountability process. Citizens have at least three roles germane to accountability: as voters, as taxpayers and as healthcare consumers. The precise relationships of the major stakeholders are considered in greater detail later in this article following the discussion of the “what” of current accountability practices. However, we note that the accountability of organizations, institutions and groups is exercised through the

Healthcare Management Forum Gestion des soins de santé

27

people that constitute the entity. It is those people, with their various understandings of, and commitments to, meaningful accountability who will ultimately determine its achievement.

To What Does Accountability Apply? The content of accountability relationships in the health system are determined by the entities involved in the relationships and may be characterized as one of six distinct types: constitutional, financial, managerial, clinical, political and ethical. The degree of robustness of these types of accountability may vary. Some accountability relationships are formalized and overtly articulated, as in the case of constitutional relations, while other forms are more implicit as, for example, in democratic theory or ethical norms. It is also worth noting that within several of these types of accountability, notably financial and managerial, the focus is in a state of flux. Traditionally, accountability referred largely to process and inputs, and centred on questions such as the following: Were specific services delivered as stated? Were actions carried out according to the terms of legislation? Was money spent as designated in budgets? Increasingly, however, the emphasis in accountability is on the degree to which intended outcomes were achieved at the population level.

The “to Whom” of Accountability Knowing the significant stakeholders in Canadian health system accountability and the several types of accountability allows the construction of a relationship matrix as shown in table 1. The table should be read across for each of the jurisdictions in the lefthand column so as to identify other entities to whom that level of authority is accountable, as well as the nature of that accountability relationship. Thus, the first accountability relation-

28

ship of the federal government in matters of health is to the provinces and takes the form of honouring constitutional roles and obligations. In the case of provinces, there are two types of accountability relationships with the federal government: first, the obligation to honour their share of constitutionally defined responsibilities and, second, a financial obligation to ensure that federal funds are spent according to the terms on which they are provided. The federal government and the provinces are both accountable to the electorate in matters of health. The shaded boxes in table 1 imply that the jurisdictions listed in the lefthand column are not accountable to themselves. This is not, of course, the case. For example, members of selfgoverning health professions place a significant emphasis on their ethical accountability to the profession itself. At the macro level of resolution in this study, the larger governmental stakeholders are not broken down into internal components such as, at the provincial level, the Minister of Health, the Deputy Minister, the Public Accounts Committee of the Legislature and so on. However, while the fine details of these internal levels of accountability are beyond the scope of this article, the following section provides a brief synopsis.

How Accountability is Operationalized A Common Governmental Context

Since accountability in healthcare is

similar to other areas of public activity in that it is given expression by the structure and usage of government, it is important to appreciate the principal aspects of the Canadian parliamentary system. As in any democracy, the system is founded on the rule of law and the principle that government is held accountable to the public through regular elections. The activities of government are subject to media and other public scrutiny through open proceedings of the legislative branch, periodic published reports, or information obtained under freedom of information legislation. Governments can be held to public account not only by the withdrawal of electoral support, but also by recourse to the judicial system or to special mechanisms such as appeals to ombudsmen or human rights commissions. The governing party is held accountable to the legislature. Constitutional limits on the length of its term in office and the possibility of a vote of non-confidence by the legislature provide methods of achieving accountability. Each cabinet minister heads a government department and reports its activities annually to the legislature. Annual departmental performance and expenditures are scrutinized in a public accounts committee, while requests for future funding are defended before an estimates committee. The legislature also receives an annual auditor’s report covering the financial activities of the government and highlighting problematic practices of some departments.

Table 1: Accountability Relationships and Types Among Key Stakeholders FEDERAL FEDERAL PROV’L

PROV’L

INSTIT’L

PROVIDER

constitutional

PUBLIC political

financial constitutional

political

REGION

financial

INSTIT’L

financial

PROVIDER

financial

PUBLIC

ethical

Healthcare Management Forum Gestion des soins de santé

REGION

managerial financial

managerial clinical

(see text)

clinical ethical

Government departments are accountable to their minister through the deputy minister, who is the senior permanent civil servant. The deputy is generally appointed by the Prime Minister or the Premier and is accountable both to the minister and to the Government. This individual may appear before legislative committees to explain activities and is responsible for implementing the policy direction of the department. Internal department mechanisms for operationalizing accountability to the deputy include internal financial audits, annual business plans and budgets, and monitoring, evaluating and reporting mechanisms. Similar instruments are demanded by departments from entities that derive their mandate from authority delegated by the department. Such arrangements create a generic accountability structure that extends from the local service delivery level through government departments to the legislative branch via the cabinet minister and, ultimately, to the electorate.

Specific Accountability Processes and Instruments Within this common governmental structure, numerous mechanisms are available for achieving accountability. They may be divided into processes, such as reporting or auditing, which are usually captured in legislation or regulation; and instruments, including performance indicators or value-formoney audit techniques, which are often embodied in policy or regulations.

Political activity: Citizens hold government accountable through the electoral process. Governments increasingly articulate platforms and follow up with report cards on progress several years into their mandate. Televising and publicizing the legislature’s proceedings allows citizens to assess governmental activities. Constitutional practice: The key constitutional instrument is the doctrine of ministerial responsibility under which ministers are accountable to the legislature for the policies and operation of their departments. By tradition, the deputy minister of a department is obliged to appear before the legislative committee dealing with public accounts to explain the department’s record, though not to defend government policy.12,38 Provision of information: Information increases the transparency of government, rendering it accountable to those to whom the information is provided. The publication of annual reports that describe performance, measure it against predetermined benchmarks and evaluate it in light of a strategic plan, are of growing importance.39,40 The existence of effective access to information legislation is also essential in providing the knowledge that is necessary to judge government performance.

The following list captures the processes of most relevance to the healthcare system and the instruments by which they are commonly operationalized.

Delegated activity: The legislative branch may delegate its responsibility to oversee a particular aspect of government to an independent review board, such as the Royal Canadian Mounted Police Public Complaints Committee or the Security Intelligence Review Committee.29,9,41,42 As well, legislatures delegate regulatory and review functions to selfgoverning professions.

Citizen involvement: This process may be implemented in several ways including consultations8 or more direct involvement through boards of regional health authorities35 or hospitals.36,37

Review functions: Routine audits of government spending by the Auditor General15-17 and program evaluation direction from the Office of the Comptroller General14 are critical internal accountability instruments.

Management practices: Management instruments relevant to accountability include the development of performance indicators and their articulation in report cards or balanced score cards;43 benchmarking and guidelines to promote activity likely to assist in reaching such standards; and quality assessment and assurance systems, the results of which are widely disseminated. Legal contracts: A variety of legal contracts are deployed by government to ensure accountability, including performance-based personal service agreements with senior public servants and institutional managers;44 purchase/ service agreements with both individual and institutional healthcare providers; performance contracts designed to allow managers of public enterprises greater autonomy without sacrificing accountability;45 and partnership agreements.46 Legislation: Laws for which a ministry of health is responsible may have accountability provisions built into them. For example, legislation establishing provincial health insurance agencies confers surveillance and audit authority by which providers may be held accountable for any infraction of billing procedure. Accreditation and credentialing: Some governments view accreditation as a form of accountability in that an external source attests to the quality of an institution’s activities. Similarly, the licensing of professionals is deemed overt evidence that an objective standard, designed to enhance quality of service provision, has been imposed on entry into the profession. Complaints procedures: If other mechanisms fail to hold government or individuals accountable, a complaint may be placed before an ombudsman, the complaints committee of a professional body, client representatives in institutions, or the courts. Ethics: Beyond legal enforcement of accountability lies ethics, a com-

Healthcare Management Forum Gestion des soins de santé

29

Table 2: Accountability Instruments Associated with Accountability Processes

pendium of shared beliefs about equity and justice. It is difficult to legislate or adjudicate matters involving ethics until their breech or absence become a matter of illegality. Attempts to legislate such matters as they apply to health include breech-of-trust laws, conflictof-interest regulations, whistle-blower legislation and Good Samaritan laws. The forgoing list of processes and instruments, which is summarized in table 2, includes the principal mechanisms relevant to healthcare that are used in Canadian jurisdictions. When matched to significant stakeholders, they will allow the creation of a theoretical framework of health system accountability.

A Canadian Healthcare Accountability Framework In an accountability framework, stakeholder identity largely determines the type of relationship, which in turn predicts mechanisms. Table 1 describes the participants in accountability relationships and categorizes these relationships as one of six types. Table 2 lists the processes and the associated instruments used to operationalize the concept of accountability. Table 3 links the preceding two tables by showing the relationship between the type of accountability relationship and the mechanisms used to express it. Taken in concert, then, these tables elaborate a framework for accountability relationships in the Canadian healthcare system by describing who is accountable to whom, for what, and how.

Ongoing Issues in Canadian Health System Accountability Articulating a comprehensive accountability paradigm for the entire healthcare system in Canada presents a number of theoretical and organizational challenges, significant among which are the following:

30

Process

Instruments

Citizen involvement

consultations board service

Political activity

elections legislature transparency

Constitutional practice

ministerial responsibility public accounts committee

Provision of information

business and strategic plans annual reports access to information

Delegated activity

independent review boards self-governing professions

Review functions

Auditor General and provincial auditors Comptroller General

Managerial functions

program evaluation guideline development report cards performance indicators quality assessment and assurance

Legal contracts

personal service contracts purchase service agreements performance agreements partnerships

Accreditation and credentialing

regional and facility accreditation professional licensing

Complaints procedures

ombudsman patient representatives professional disciplinary committees litigation

Ethical judgments

implicit social standards individual conscience laws

• Conceptual clarity about the nature of accountability is lacking. The processes and instruments by which accountability is operationalized are often confused with accountability itself. The use of health data to inform performance indicators, for example, is only one aspect of the accountability loop, and is certainly not synonymous with accountability. Rather, accountability is best seen not as any one type of activity, but as an integral aspect of an organizational culture for which there are many different expressions. • In addition, the purpose of accountability in government is not clear. It is often expressed

Healthcare Management Forum Gestion des soins de santé

as little more than a control mechanism for provinces to deal with regional authorities or as a response to financial constraints, rather than as an integral feature of a democratic political system. • Separate but occasionally overlapping jurisdictions for health tend to diffuse responsibility. The federal government elaborates the broad principles by which healthcare is to be provided for Canadians, but priority selection and planning services are a provincial responsibility. Although both the federal and provincial governments have taxing authority and regional authorities do not,

Table 3: Accountability Processes Appropriate to Accountability Types ACCOUNTABILITY TYPES:

FINANCIAL

CONSTITUTIONAL

POLITICAL

MANAGERIAL

CLINICAL

ETHICAL

x

Citizen involvement Political activity Constitutional practice

x

Provision of information

x

x

x

x

x x

x

x x

Delegated activity Review functions

x

x

Managerial functions

x

x

Legal contracts

x

x

Legislation

x

x

x

x

x

x

x

Complaints procedures

x

x

Ethics

x

x

the latter organizations plan and deliver services. At the regional level, there is added confusion over whether accountability is entirely to the province or is accompanied by an accountability to the population served. • The precise domains to which accountability should be applied in healthcare delivery is unclear. For example, are those charged with the responsibility of providing healthcare accountable only for the process of service delivery, or must they also be held accountable for outcomes? If outcomes are important, are data available? Are there evidencebased benchmarks for service provision against which the performance may be measured? To what extent can the formal healthcare system be shown to

The seven points listed above, while by no means exhaustive, capture the principal difficulties encountered in creating an effective framework of accountability for the Canadian healthcare system.

Conclusion

x

Accreditation and credentialing

x

x

evolving international trade obligations. The very real possibility exists that, in the future, Canadian authorities will be held accountable for the way in which the health system is organized and financed by trade tribunals charged with the surveillance of adherence to the provisions of agreements such as the General Agreement on Trade in Services.47

have caused specific outcomes at a population level? • Most current provincial accountability frameworks acknowledge a failure to incorporate adequately all stakeholders in the health system. (This usually applies to the public and to independent care providers.) • While jurisdictions may articulate frameworks for accountability, how effective these instruments are remains unknown. If data are poor, performance indicators inappropriate and reporting desultory, or if reported activity is unrelated to strategic planning, the gap between accountability rhetoric and reality will be substantial. • Finally, discussions of accountability to date have accorded no attention to the potential impact of Canada’s

The study described in this article reached the following conclusions on the structure of accountability in Canadian healthcare: • The state of accountability in the healthcare system is a work in progress that is rapidly evolving with the growing acceptance of accountability by those who exercise authority, an expanding number of mechanisms through which accountability can be achieved, and increased expectations on the part of the public. • Effective accountability cannot be confined to healthcare; it must be one aspect of an overall accountability framework within a jurisdiction. • While not a necessary precondition, jurisdictions with regionalized health systems are more likely to have articulated detailed accountability frameworks. • The essential groups in a health accountability framework are the public, the federal government, provincial governments, regional authorities, institutions and providers.

Healthcare Management Forum Gestion des soins de santé

31

• The type of accountability will vary according to the character of the groups involved in a specific relationship. The principal types in the healthcare system are political, constitutional, financial, managerial, clinical and ethical. • The processes that operationalize accountability are specific to the type of accountability relationship. • Similarly, the instruments used to document accountability are specific to the processes deployed. This article has outlined significant aspects of a framework for accountability theory and practice in Canadian healthcare. How should health system accountability move beyond its present state? Systems of accountability reflect and are constrained by the political culture and circumstance in which they are found. In Canada, accountability in healthcare has evolved within a parliamentary democracy, a federal constitutional structure and a system of state-funded healthcare. The recent interest in accountability has been fueled by a desire to enhance and preserve this uniquely structured healthcare system. However, many questions as to how this might best be accomplished remain unanswered. Should accountability be designated a priority over other healthcare issues? Should a prescribed national framework of accountability be mandated and, if so, is there a risk of discouraging innovation, risk and creativity? Should ever more finely tuned processes and instruments be developed to ensure accountability? The challenge for decision-makers is to move beyond theory to robust practice in a manner that enhances, but does not inhibit, the recognized accomplishments and unique character of the Canadian healthcare system.

32

Acknowledgments Research for this article was undertaken as part of a project on accountability for Health Canada. We are indebted to Jim Lavery, Christian Keresztes and Vicki Kristman, who provided valuable research assistance and critical commentary for the project.

References and Notes 1. Auditor General. Reflections on a decade of serving Parliament. Ottawa: Government of Canada; 2001.

27. Saskatchewan Department of Health. A framework of accountability. Regina: the Department; 1995. 28. McCandless H, Wright D. Enhancing public accountability. Optimum, The Journal of Public Sector Management 1993;23:110–118. 29. Beaulne JP. The RCMP Public Complaints Commission. Optimum, The Journal of Public Sector Management 1993;24:58–96. 30. Stenning PC. Some reflections on accountability in the Ministry of the Solicitor General of Canada. Optimum, The Journal of Public Sector Management 1992;23:41–57.

2. Flood CM. International healthcare reform, a legal, economic and political analysis. New York: Routledge; 2000.

31. Kernaghan KL. The accountable public servant. In: Kernaghan KL. The responsible civil servant. Montreal: The Institute for Research on Public Policy and the Institute of Public Administration of Canada; 1990. p. 157–181.

3. Day P, Klein R. Accountabilities, five public services. New York: Tavistock; 1987.

32. Mitchell JR. Accountability. Optimum, The Journal of Public Sector Management 1992;23:2–16.

4. Relman AS. Assessment and accountability, the third revolution in healthcare. New England Journal of Medicine 1988;319:1220–22.

33. Sawyer DM, Williams JR. Core and comprehensive healthcare services: 3. Ethical issues. Canadian Medical Association Journal 1995;152:1409–1411.

5. Daniels N, Sabin J. The ethics of accountability reform in managed care reform. Health Affairs 1998;17:50–64.

34. Canadian Institute for Health Information. The evolution of public and private healthcare spending in Canada, 1960 to 1997. Ottawa: the Institute; 1999.

6. Emanuel EJ, Emanuel LL. Preserving community in healthcare. Journal of Health Politics, Policy and Law 1997;22:147–184. 7. Grace J. Accountability and independent review. Optimum, The Journal of Public Sector Management 1993;24:80–85. 8. Parboosingh J, Stachenko S, Inhaber S. A model of consumer participation: the Canadian Breast Cancer Institute. Canadian Journal on Aging 1997;16:177–186. 9. Finn TD. Independent review agencies and accountability: snapping at the heels of government? Optimum, The Journal of Public Sector Management 1993;24:9–22. 10. Aucoin P. Securing accountability. In: Aucoin P. The new public management in Canada: a comparative perspective. Montreal: Institute for Research on Public Policy; 1995. p. 217–242. 11. Carmen RD. Accountability of senior public servants to Parliament and its committees. Canadian Public Administration 1984;27:542–55. 12. Osbaldeston GF. Keeping deputy ministers accountable. Toronto: McGraw-Hill Ryerson; 1989. 13. Bens CK. Comprehensive auditing: a management approach for improving accountability. Government Finance Review 1991 Mar:9–12.

35. Lomas J, Woods J, Veenstra G. Devolving authority for healthcare in Canada’s provinces: 4. Emerging issues and prospects. Canadian Medical Association Journal 1997;156:817–823. 36. Chenoy NC, Carlow DR. Changing perspectives on hospital governance. Healthcare Management Forum 1993;6:4–18. 37. Croll K. Elected or appointed? The case for healthcare trustees. Leadership 1996 Mar-Apr:7–12. 38. Wilson VS. Public administration reform and the “new managerialism”: a comparative assessment of a fundamental challenge confronting Canadian public administration. International Journal of Public Administration 1996;19:1509–1553. 39. Atkinson AA, McCrindell JQ. Strategic performance measurement in government. CMA Magazine 1997 Apr:21–3. 40. Price ES, McAdams LP. Bringing accountability results to government in British Columbia. Public Administration and Development 1996;16:305–315. 41. Gibson FE. Independent review and accountability: conditional release in transition. Optimum, The Journal of Public Sector Management 1993;24:70–79.

14. Rayner M. Evaluation in Canada. Evaluation Practice 1986;7:45–56.

42. Sutherland SL. The evolution of program budget ideas in Canada: does Parliament benefit from estimates reform. Canadian Public Administration 1990;33:133–164.

15. Banks B. On guard for thee, a powerful new lineup of auditors faces off against deep deficits, high taxes and government mismanagement. CA Magazine 1994 Jan/Feb:25–37.

43. Baker GR, Brooks N, Anderson G, Brown A, McKillop I, Murray M, et al. Healthcare performance measurement in Canada: who is doing what? Hospital Quarterly 1998–99;2:22–26.

16. Dubois R. Accountability in Parliament: the role of the Auditor General. Canadian Parliamentary Review 1990;13:28–29.

44. Noble R. Executive performance: the demands of the 1990’s. Healthcare Management Forum 1990;3:16–20.

17. Gingell F. Getting results: accountability reporting can help politicians identify those expenditures that need to be cut. CA Magazine 1995;May:33–34. 18. Charih M. The policy and expenditure management system: lessons from experience. Optimum, The Journal of Public Sector Management 1992;22:50–56. 19. Lomas J. Reluctant rationers: public input to healthcare priorities. Journal of Health Services Research and Policy 1997;2:103–111. 20. Mueller CB. Some effects of health insurance in Canada — from private enterprise toward public accountability. New England Journal of Medicine 1978;298:535–539. 21. Canada. A framework to improve the Social Union for Canadians. Ottawa: 1999. 22. Intergovernmental Conference Secretariat. First Ministers’ meeting communiqué on health News Release 800-038/004. Ottawa, 2001. [available at: http://www.scics.gc.ca/cinfo))/80038004_e.html ] 23. Alberta Department of Health. Achieving accountability in Alberta’s health system. Edmonton: the Department; 1998. 24. British Columbia Ministry of Health and Ministry Responsible for Seniors. Accountability framework for British Columbia health authorities. Victoria: the Ministry; 1998. 25. Manitoba Department of Health. Achieving accountability. Winnipeg: the Department; 1999. 26. Nova Scotia Department of Health. Accountability in Nova Scotia’s health system. Halifax: the Department; 1997.

Healthcare Management Forum Gestion des soins de santé

45. Islam N. Performance contract: conceptualization of the government-public enterprise interface. Optimum, The Journal of Public Sector Management 1993;23:53–59. 46. Rodal A, Mulder N. Partnerships, devolution and powersharing: issues and implications for management. Optimum, The Journal of Public Sector Management 1993;24:27–48. 47. Shortt SE. Alberta’s Bill 11: will trade tribunals set domestic health policy? Canadian Medical Association Journal. 2001;164:798–99.

S.E.D. Shortt, MPA, MD, PhD, is Director, Queen’s Health Policy Research Unit, and Professor, Department of Community Health and Epidemiology, Queen’s University, Kingston, Ontario. J. K. MacDonald, MSW, is Associate Director (Administration), Queen’s Health Policy Research Unit, and Assistant Professor, Department of Community Health and Epidemiology, Queen’s University, Kingston, Ontario.