Shifting accountabilities: Patient-citizen voices and contested governance in public-private hybrid healthcare
Bibliographic record
Abstract
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. Public-PrivateFormal collaboration between public agencies and private enterprises Partnership in providing a public asset or service.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.027 | 0.033 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.002 | 0.002 |
| Science and technology studies | 0.030 | 0.066 |
| Scholarly communication | 0.022 | 0.013 |
| Open science | 0.003 | 0.021 |
| Research integrity | 0.005 | 0.009 |
| Insufficient payload (model declined to judge) | 0.004 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".