Control or collaboration? Contrasting accountability relationships in the primary health sector

Purpose - This paper seeks to analyse accountability relationships developed since the introduction of reforms requiring nonprofit primary health organisations (PHOs) to discharge holistic accountability. Design/methodology/approach - Case study data were obtained principally through semi-structured interviews with PHOs and their key stakeholders, observation of formal and informal meetings, and primary and secondary documents. Findings - While government strategy requires these PHOs to discharge holistic accountability, prior hierarchical-based practices linger. A major impediment to securing holistic accountability is the failure of the new strategy to define clearly how the funder and provider should share accountability for improving their community's health. The implementation of holistic accountability was retarded when funders' propensity to control outcomes coincided with providers' lack of enthusiasm for embracing a greater range of stakeholders. The history and structure of individual PHOs was a key indicator of whether they discharged hierarchical or holistic accountability. Research limitations/implications - This case study research is context-specific and may have limited applicability to other PHOs or jurisdictions. However, the study shows that when funders and providers build trust rather than depending on control, holistic accountability relationships can be developed. Practical implications - Despite government intention that primary health care relationships will lead to holistic accountability, this will not occur until funders clearly define responsibilities and trust their service providers. Originality/value - There is a paucity of research into government-sponsored holistic accountability relationships with local nonprofit service providers. This research provides a unique contextual analysis of the perspectives of funders, providers and a wide group of stakeholders and the operationalisation of two different styles of accountability.