Understanding accountability in an ever-changing New Zealand health system

The purpose of this research was to understand how the constant adoption of reforms affected accountability understanding and its practices in the New Zealand public health system. This study adopted a qualitative methodology and took a critical hermeneutics approach in order to explore the reasons for, and formats of, public health reform, and the experience of health policy implementers in dealing with reforms, policy changes, and accountability. To develop new insights about accountability and its practices, this study reviewed a range of policy documents and relevant publications, and interviewed senior health managers who were experienced in dealing with reforms. The research evidence is presented in line with Ricoeur’s stages of understanding; these are: preunderstanding, understanding, and finally, comprehensive understanding. The preunderstanding was developed from study of secondary sources, while the understanding was achieved through interviews. A comprehensive understanding results from both review of and reflection on preunderstanding and understanding. The findings are that reform can be described as a ‘means without ends’ because it was continually implemented in a political loop, in which, demand and supply for change were determined by the government’s political interests. Postreform accountability was full of frustrations because of its complexity in practice. Surprisingly, despite that fact, the health managers still believe that accountability per se is essential. This study proposes that postreform accountability can be understood as two sides of the same coin: accountability means being accountable, in a normative sense, and not being able to be accountable, in practice. The adoption of constant reforms has increased the level of organisational complexity. This has affected the notion of accountability and its practices because accountability rests in the organisational structures. This study suggests that accountability cannot be detached from its normative and mechanism perspectives. No matter how much the policy has changed or will change in the future, the possibility of policy implementers facing similar challenges and the same feelings is high because reform produces two identical outcomes for accountability: i.e., hopes and frustrations. The study contributes in three ways to an understanding of accountability in the context of reform. First, it offers valuable insights into the ongoing developments in the public health system and the issues of accountability. Second, it contributes to the wider understanding of the effects reform have on the notion of accountability and its practices. Third, it advances understanding relating to recent discussions on postreform accountability