The role of outputs and outcomes in purchaser accountability: reflecting on New Zealand experiences.
Recent reforms in a number of countries' health systems have led to the separation of funder, purchaser and provider roles and the strengthening of funders' and purchasers' positions relative to providers. One of the aims of such reforms is to improve accountability. This paper reports on experiences in New Zealand where, in addition to improving the accountability of providers, purchaser accountability has also been a key policy issue. Attempts have been made in New Zealand to develop a funder-purchaser accountability framework based on a mix of outcomes, outputs and inputs. This paper discusses the roles that each might play in contracts and accountability relationships between funders and purchasers. The paper concludes that holding purchasers accountable for outcomes is likely to prove difficult and controversial, because of problems of attribution and because New Zealand funders in recent years have played an important role in determining the priority outputs and inputs which must be purchased. The paper suggests that accountability is more appropriate at the output and process level, in addition to holding purchasers accountable for the ways in which they make decisions and undertake contracting roles. Holding purchasers accountable for purchasing outputs and processes, however, requires greater commitment on the part of the funder to setting priorities more clearly; specifying the range and level of outputs to be purchased and the terms of access to those services; and funding services to this level. The international attention currently being paid to the development of practice guidelines and priority criteria also suggests that holding purchasers accountable for a form of inputs may become an increasingly common practice in future. From 1 July 1998, New Zealand will introduce a priority criteria system for determining access to elective surgery; accountability is thus becoming focused on inputs in the form of patient characteristics. This approach will greatly assist in promoting accountability.
Cumming
J
J
Health Services Research Centre, Institute of Policy Studies, Victoria University of Wellington, New Zealand.
Scott
C D
CD
D003284:Contract Services / Q000191:economics*; D005376:Financial Management / Q000592:standards*; D005380:Financing, Government; D018166:Health Care Reform; D009520:New Zealand; D019984:Quality Indicators, Health Care; D012941:Social Responsibility; D013222:State Medicine / Q000191:economics / Q000458:organization & administration* / Q000592:standards; D016896:Treatment Outcome