Is There Accountability in Health Care? A Governance Perspective on Systemic Reform Notes for a presentation by Denis Desautels, OC, FCA Centre on governance Centre on governance University of Ottawa April 4, 2003 Institute of Public Administration of Canada Toronto Region

2 Outline of Presentation Recent trends in governance and accountability Recent trends in governance and accountability Health Care: an enormous governance challenge Health Care: an enormous governance challenge The current delivery system The current delivery system Why Canadians want accountability Why Canadians want accountability Gaps and obstacles Gaps and obstacles Avenues for improvement Avenues for improvement Conclusions Conclusions

3 Defining Governance Governance is the framework of practices and structures which govern decision making and implementation in organizations and structures where power and information are shared. This applies to a country, a society or an organization be it private, public or civic. Governance is the framework of practices and structures which govern decision making and implementation in organizations and structures where power and information are shared. This applies to a country, a society or an organization be it private, public or civic.

4 Defining Governance (cont’d) From the more simple to the very complex From the more simple to the very complex A private corporation A private corporation A public company A public company A state-owned corporation A state-owned corporation A hospital A hospital A ministry A ministry A health care system A health care system

5 Evolution of Governance in the Public Sector Factors which encouraged innovation Factors which encouraged innovation Globalization Globalization Technology Technology Horizontal management Horizontal management Factors which imposed innovation Factors which imposed innovation Crisis in public finances Crisis in public finances Political ideology Political ideology

6 Evolution of Governance in the Public Sector (cont’d) General direction (attributes of new systems or models of governance) General direction (attributes of new systems or models of governance) Less hierarchial Less hierarchial More inclusive More inclusive More distributed More distributed More horizontal More horizontal Decentralization and empowerment Decentralization and empowerment

7 Accountability and Governance Good governance is not an end in itself Good governance is not an end in itself Good governance contributes to effective accountability Good governance contributes to effective accountability Effective accountability leads to superior performance, but: Effective accountability leads to superior performance, but: Governance and accountability are becoming more complex Governance and accountability are becoming more complex

8 Impact of this Evolution on Accountability Modularity and need for coherence between accountability and management systems Modularity and need for coherence between accountability and management systems Less hierarchical accountability (more between equals) Less hierarchical accountability (more between equals) Emphasis on results Emphasis on results Shared accountability Shared accountability Can lead to better accountability Can lead to better accountability Need for experimentation and learning Need for experimentation and learning “Soft” accountability “Soft” accountability

9 Governance & Accountability in Health Care The public interest challenge is accountability to Canadians: The public interest challenge is accountability to Canadians: A conceptual challenge A conceptual challenge High public expectation for information on the state of the health care system High public expectation for information on the state of the health care system

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11 Governance & Accountability In Health Care, being accountable to Canadians raises questions: Canadians as stakeholders in society? Canadians as stakeholders in society?>>access/coverage/equity Canadians as users of health care system? Canadians as users of health care system?>>performance Canadians as taxpayers? Canadians as taxpayers?>>spending

12 Do we have Accountability? Gaps and Obstacles 1. Data Gathering 2. Coordination 3. Incentives 4. Legislation 5. Funding and increasing costs 6. Acceptance of open evaluation

13 Avenues for improvement Committing to accountability and transparency Committing to accountability and transparency Building the foundation for accountability Building the foundation for accountability Technology Technology Service integration Service integration Joint oversight Joint oversight

14 Conclusions Resolving F/P/T tensions Resolving F/P/T tensions Providing accountability to the public Providing accountability to the public Meeting the true challenge of creating a continuum of services locally Meeting the true challenge of creating a continuum of services locally