Shifting accountabilities: Patient-citizen voices and contested governance in public-private hybrid healthcare

ContextPublic-Private Partnerships (PPPs) are increasingly ubiquitous in Canadian healthcare and across the world.They have seen poor consequences for patient care and failures in democratic accountability.Literature has highlighted fundamental differences in the logics that govern accountability between private and public organizations.Whilst the espoused role of the state in a public system is to advance the welfare of its citizens, private companies are ultimately concerned to increase the wealth of their shareholders.Despite this recognition, little is known about how these apparently contradictory patterns of accountability function at the micro-level of healthcare governance.The experiences of patients and citizens are notably absent from the literature. ObjectivesWithout better understanding the interplay of these apparently contradictory accountability logics, we lack guidance for how to protect democratically-governed, publicly-accessible healthcare.This thesis aims to identify the consequences for accountability in public-private hybrid healthcare, exploring how accountability is enacted on the front lines of healthcare governance.Specifically, it examines the positioning of patient-citizens, seeking to understand how they enact their interests in this context. MethodsThis thesis adopted a critical ethnographic research design to explore enactments of accountability at a Canadian PPP hospital, using a combination of observational activity and interviews.An ethnographic approach involved direct observation of how PPP policy was translated at a micro-level of healthcare governance and, in line with the aims of this thesis, enabled foregrounding the voices and experiences of patient-citizens. ResultsParticular accountability positions and cultures were reflected in the perspectives, agendas and strategies of three central stakeholder groups in the PPP arrangement: private sector representatives, healthcare managers and patient-citizens.The formal PPP contract had a central role in shaping how private sector representatives and healthcare managers enacted governance and accountability.In contrast to the transactional accountability that was inscribed in the technologies of the formal contract, patient-citizens sought to enforce a socially-based accountability that reflected interdependence between individuals and their overarching systems of influence (culture), and their "real-life" embodied contexts. Glossary of key terms AccountabilityAn ongoing accomplishment that denotes the answerability of actors through use of accounts, as well as explanations or justifications of practice.To be 'accountable' for one's activities involves both to explicate the reasons for them and to supply the normative grounds through which they are justified. CultureThe customs, behaviors and norms enacted by a group of people, as well as values and assumptions about social reality that structure and normalize their practices. DemocracyA philosophical ideal, a political strategy, and an instrument of economic well-being.As a system of rule, democracy denotes the organization whereby power is vested in the people and exercised directly or indirectly through a system of representation. EnactmentThe practices, activities and techniques and events that make an object or concept visible, tangible and knowable. Public-PrivateFormal collaboration between public agencies and private enterprises Partnership in providing a public asset or service.

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