( )Critical Perspectives on Accounting 1999 10, 223]246Article No. cpac.1998.0274Available online at http://www.idealibrary.com on

FROM WELFARE STATE TO THE CIVIL SOCIETY:THE CONSTITUTIVE USE OF ACCOUNTING IN

THE REFORM OF THE NZ PUBLIC SECTOR

STEWART LAWRENCE

Department of Accounting, School of Management Studies, Universityof Waikato, Private Bag 3105, Hamilton, New Zealand

The legitimacy of the use of accounting depends on democratic adjudi-cation of reasons for and protests against particular forms of accountingpractice. This paper examines new accounting procedures invoked in theattempt to reconstitute New Zealand society from a welfare state to amarket driven economy and to reconstitute public servants, includinghealth professionals, as accountable managers responsible for economicperformance of their entities. Questions are raised}Can the changes berationally justified? How were various interests apparent in the adoptionof or resistance to accounting practices? Was use of steering mediaregulative or constitutive? If government policies are not amenable tological justification, and government actions appear to contravene normsof society, questions about its legitimacy and accountability have to beraised.

1999 Academic PressQ

Introduction

‘‘How can we explain the continued appeal of collectivism?’’ asks the author(of a book published by the New Zealand Business Roundtable Green,

)1996, p. 31 . Five rationales for collectivism are described and rebutted.The book provides the underlying rationale for the move ‘‘ from welfarestate to civil society’’. It justifies what many New Zealanders considerthe harshness of government policies}benefit cuts, market rentals forstate house tenants, charges for education and health services, andremoval of government assistance from voluntary associations such asPlunket Society and Women’s Refuge. Carrying the argument to itslogical conclusion the author advocates the complete removal of thestate from education and health through the privatisation of universities,polytechnics and teacher colleges, and hospitals. For over a decade,

Received 27 April 1998; accepted 15 May 1998

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such thinking has affected government policy and nowhere has the statebeen under attack more vigorously than in New Zealand.

The purpose of this paper is to review the way the public sector hasbeen re-conceptualised through a market-based economic and accountinglogic. In so doing, attention is focused on new accounting proceduresinvoked in the attempt to reconstitute public servants, including healthprofessionals, as accountable managers responsible for economic perfor-

(mance of their entities Treasury, 1987; NZ Society of Accountants,)1989 . The intention is to foster debate about the new accountabilities.

Questions are raised. What were the underlying normative assumptionsof accounting technologies that were so widely implemented? Were theyregulative or constitutive of public service?; do they have legitimacy?}which in a Habermasian sense is dependent on democratic adjudication

(of reasons for and protests against forms of accounting practice Arring-) (ton & Puxty, 1991 . In the spirit of Broadbent & Laughlin’s Laughlin &

)Broadbent, 1994; Broadbent & Laughlin, 1997 calls for evaluation ofpublic sector reforms, this paper attempts to critically discuss the claims,concerns and issues that have arisen out of the reforms to the healthsector. ‘‘Beyond accountability: an evaluation model’’ was the title of

( )Laughlin and Broadbent’s 1994 paper. We need to go beyond andoutside conventional boundaries of accounting and accountability; that is,if these terms are used in a narrow sense in which accounting isseparated from wider social and political issues.

In this paper, accounting is treated as part and parcel of the ideologi-cal changes affecting New Zealand society. This paper aims to illustrateand critique the changes introduced using the specific example of healthservice provision, especially hospitals where new costing, budgeting andinvestment procedures have been introduced. Accounting technologieswere invoked as the transformations were introduced in the name ofefficiency and effectiveness. Accounting was a necessary ally in a newway of ordering relationships, based on economic contracting ratherthan ‘‘collectivism’’. The argument of this paper is that the public sector‘‘reforms’’ and their associated accounting changes were not introducedto solve specific problems, but to express ideological commitment.

The critical theory of Habermas is called upon to enable a critique ofthe business mentality introduced to the health sector; and to provide atheoretical explanation of the nature of the reforms in the public sector

( )and in the workings of once democratic institutions. Habermas intro-duced the term legitimation crisis to capture the problem facing Westerncapitalist society. His contention is that the instrumental reasoning asso-ciated with capitalism has penetrated ever deeper into everyday experi-ence. Political and cultural life have been colonised by instrumental

( )techniques such as accounting and distorted communications, so thatcategories of truth and beauty have been replaced by the instrumentalknowledge of technoscience. This argument will be examined in thecontext of the health sector in New Zealand.

An attempt is made to understand the underlying changes in institu-tional and organisational ‘‘structures’’ and accounting technologies. The

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focus of this paper is on institutional rearrangements rather than themicrophysics of the internal transformations in particular sites. The intro-duction of accounting technologies and new accountabilities in a particu-

( )lar site has been reported elsewhere Lawrence et al., 1997 . Researchwas conducted by spending extensive periods of time within a local

( )Crown Health Enterprise CHE . This covered a period from 1993 to 1997and included participant observation as well as formal interviews withsenior managers, accountants and clinical and medical staff as newaccountings were introduced. In this paper, however, emphasis is givento secondary sources, as there is a growing literature both justifyingand critiquing the effects of reforms. Reports from Government and itsagencies are useful sources of arguments for and against new modes ofoperation of health services. A recent report of the Health and Disability

( )Commissioner 1998 took various institutions, especially steering media,to task for focussing on financial stringency rather than patient care.

Background—The Political Context

Ironically, the process of reconstituting the welfare state in New Zealandbegan with the election of a Labour Government in 1984. The Govern-ment began to dismantle the plethora of state controls that had beenintroduced by the previous National Government. The National Govern-

(ment had introduced controls on wages, prices, interest rates including)mortgage rates , imports, and exports. New Zealand was at that time

the most regulated economy of the Western World.The Labour Government declared its policy} to remove government

( )from people’s lives Boston & Dalziel, 1992 . The Government’s ideologi-cal commitment to deregulation began an attack on the welfare stateand a celebration of individualism. The reforming zeal was carried outto an extent that surprised even those most closely involved, includingthe Prime Minister! After three years in office, an election was called in1987 and the Prime Minister, David Lange, was startled by the successthe Labour Party achieved in blue ribbon, conservative strongholds suchas Remuera:

‘‘That election night was a great revelation to me. That was an appre-hension on my part that we had actually abandoned our constituencies.And it set me to think what on earth have we done to come within 400votes of winning the true-blue seat of Remuera... that struck me as anact of treachery to the people we were born to represent’’

[ ( )]D. Lange, Prime Minister, quoted in Russell 1996, p. 143

A government elected to represent the labouring classes could hardlybe expected to remove the protection of the state for its most vulnera-ble citizens; indeed to begin an attack on them. The bewilderment andcontradictions were increasingly evident in public discourse. It was alsoevidenced in correspondence between the Prime Minister and his ap-pointed Ministers. Lange put in writing to his Ministers his opposition to

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his Government’s policy and actions, finally resigning from office in1990. Roger Douglas, Minister of Finance, increasingly identified as themajor architect of the reforms, criticised the Prime Minister for ‘‘wantingto be liked’’! For Douglas and the reforming zealots, temporary hard-ships and suffering were necessary if people were ever to stand ontheir own feet and overturn a culture of dependency.

A former labour supporter and political scientist, Professor Gustaffson,commented on the nature of the Labour Government and the fact thatthey did not produce a manifesto before the 1987 elections:

‘‘They were a very arrogant Government, they were an intolerant Gov-ernment, they were a dogmatic Government, they were a hypocriticalGovernment. David was quite open: you don’t tell people what you’regoing to do before an election because they won’t let you do it. To meit struck at the very nature of democracy.’’

[ ( )]Gustaffson quoted in Russell 1996, p. 133

The results of the economic reforms have been celebrated and oftenlauded by international economic agencies as a model to be followed

( )by other countries Richardson, 1995 . The New Zealand Government hassurpluses predicted to rise to between $5 and $6 billion dollars over thenext few years. These surpluses, together with sales of state assetsincluding telecommunications, railways, coal, electricity and forests, havegenerated sufficient funds to eliminate Government overseas borrowings.The interest on these borrowings had taken 30 cents in every dollar of

( )tax revenue in 1984 Boston & Dalziel, 1992 . Yet critics point to aspectsof the reforms which receive little publicity. There has been a change in

(income and wealth distribution favouring the rich Waldegrave et al.,)1995 . The whole of the economic gain has gone to the top decile,

while the bottom two deciles have had their incomes reduced. A recentstudy by Waldegrave, Stephens and Frater, found that 20% of NewZealanders, and possibly one in three children, were living in poverty.Real wages have declined since 1993 and are predicted to continue to

( )decline at least until 1998 Lepper & Simons, 1994 . Profits have risen inabsolute terms and as a proportion of national income. This is despitethe fact that average productivity of capital has declined, while labourproductivity rose. As reported

‘‘It appears that owners of capital have been able to secure for them-selves the rises in labour productivity that have occurred’’

(quote from Integrated Economic Services Report in)Waikato Times, 29 December 1994

It is unusual for an economic forecasting unit such as IntegratedEconomic Services to mention social repercussions of such inequalitiesand injustices. Yet the report warns that such differences will inevitablylead to social disharmony. Reflecting on his period in office, David

( )Lange is reported Russell, 1996, p. 247 as saying the reforms hadbeen a ‘‘ tragedy’’ for anyone disabled, of limited ability or without

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resources of their own. Despite such outcomes, the Business Roundtablehave had published a book celebrating the move to a more libertarian

( )society Green, op. cit. .The ideological zeal of the reformers was uncaring of those who

dared to resist. As a spokesperson in the health industry observed afterthe ‘‘resignation’’ of one of several senior managers:

‘‘Opposing the health reforms seems a dangerous career choice’’( )National Director Nurses Organisation, NZPA, 29 July, 1995 .

The Health Sector—Context of Study

In the health sector, change was abrupt and resulted in social divisionsand clashes, particularly between medical and business accountabilities.The abrupt changes resonate with other aspects of life in New Zealandsociety, and may be theorised as a part of the dynamism of moderninstitutions. As one manager said when asked about the history of theWaikato Health:

‘‘What history? This organisation has no history}everything is new’’( )Executive Administrator, Waikato Health

This was a reference to what happened in July 1993. Under theHealth Services and Disability Act of that year, public hospitals weretransformed into commercial enterprises called Crown Health Enterprises( )CHEs with unspecified social responsibilities. Their statutory requirementis to operate as ‘‘successful and efficient businesses’’. This represents adramatic redefinition of the role and function of hospitals in NewZealand, and of accountability relationships within them.

A schism has developed in the medical fraternity. Clinicians in publichospitals have been encouraged to adopt new managerial practices andbusiness language. Some have resisted strongly, but others more recep-tive to managerial philosophies have reconceptualised patients as clientsor customers; as sources of revenue. The aim of a hospital was con-ceived in business terms as achieving high levels of satisfaction whileincreasing throughput and productivity. This approach, consistent withgovernment thinking, was considered necessary in order to eliminateinefficiencies, and to ensure business survival and growth. For thesecommercially-oriented people, sophisticated accounting and informationsystems introduced to track patient costs and to report costs by diag-

( )nostic related groups DRG were viewed as essential for managingclinical budgets.

There is another group, some of whom have formed the Coalition forPublic Health. They are resistant to new managerial practices and ac-counting systems. They claim to have devoted themselves to publicservice. Their tradition is not to treat patients as some ‘‘product’’ whose

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cost must be kept below its revenue generation, but as worthy recipi-ents of the best technically available treatment irrespective of cost.Those wishing to reconceptualise the public sector have characterisedthem as spendthrifts who think there are no bounds to the public pursein the pursuit of their highly expensive and technical medical practices.

The Government has favoured supporters of its business-likemarket-based approach. It seems that it is ideological commitment, notperformance, that is rewarded. For example, Government appointed CEOs

( )of Crown Health Enterprises CHEs who have been faithful to the causewere rewarded with bonus payments of up to $30,000, despite the fact

(that their ‘‘businesses’’ have made substantial losses New Zealand)Herald, 1996 . In a business sense the new CHEs have been abject

failures. Such rewards cannot be justified in terms of economic andaccounting rationality. In these cases the government pragmatically ap-pealed to ‘‘private interests’’ rewarding loyalty not success, disregardingits own rhetoric about of business-like approaches, and what Arrington

( )and Puxty 1991, p. 59 refer to as ‘‘objective’’ or ‘‘generalizable’’ inter-ests. When government policies cannot be explained rationally, andgovernment actions appear to contravene norms of society, questionsabout its intentions will be raised.

Accounting, Accountability and the Reform Process

In the New Zealand health sector there has been a long tradition based( )on the provision of service according to need Boston & Dalziel, 1992 .

According to this tradition, there was to be no discrimination in accessto or type of treatment received between rich and poor. The historicalroots of this commitment lay in the Social Security Act 1938. The SocialSecurity Act provided ‘‘ free’’ hospital health care for every New Zealan-der. It was to be paid for from local taxes, abolishing the need forprivate hospital care. For over fifty years, free access according to needremained the basic premise for secondary and tertiary health care inNZ.

For any clinicians brought up in this tradition, money, costs andprofits were of secondary importance in healthcare delivery and playedlittle part in making sense of what was the purpose and meaning ofdaily activity in hospitals. In these historical circumstances, there waslittle demand for accountants. Accountability was internal and professio-nal. Information systems reflected clinical needs and not those of exter-nal parties.

Government and business people raised questions in the 1980s aboutthe efficacy and fairness of this approach. Questions were raised aboutequity of treatment in a service that was free of charge and thereforenot subject to the allocative mechanisms of a price system. There wasno information about the costs of individual patient treatment. Therewas no way of knowing which patients were receiving treatment at theexpense of others, possibly not admitted to hospitals because of scarcity

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of resources. While it was recognised that allocative decisions werebeing made on the basis of clinical rationales, to most observers, theallocative mechanisms were obscure and there was no attempt to mea-sure efficiency or effectiveness of procedures. Outside consultants hiredby the Government could always find examples of waste and lack ofconcern for ‘‘efficient’’ resource utilisation. One of their advisers, AlanGibbs, author of a Government initiated report entitled ‘‘Unshackling the

( )Hospitals’’ Gibbs et al., 1988 , was quoted saying.

‘‘We pour money into our hospital system, without asking what iscoming out the other end... There’s massive amounts of inefficiency; thatmeans that most doctors could do at least twice as much work in theprivate sector’’

[ ( )]Alan Gibbs, quoted in Ray 1988, p. 39

Gibbs was one of the influential people enrolled by Government whenthe whole of the public sector came under scrutiny during the term ofthe Fourth Labour Government elected in 1984. The health sector wasnot immune to Government’s attempts to allow market forces ratherthan bureaucrats to allocate resources. In this mode of reasoning the

( )Government initiated the Financial Management Reform FMR , which( )was to transform NZ institutions and society Ball, 1992 .

In relation to health, there was a dramatic change in institutionalarrangements. Prior to the reforms, there were locally elected AreaHealth Boards which were responsible for health care provision withintheir defined geographical boundaries. Area Health Boards were replacedby two types of institution creating a split between the purchasing andproviding of health services; 23 CHEs were established as providers and

( )four Regional Health Authorities RHAs were responsible for the pur-chase of appropriate health services for their respective populations. TheGovernment allocated funds to the RHAs on a population based formula.

The CHEs were required by statute to operate, not as caring institu-tions, but as ‘‘successful businesses’’, selling their ‘‘products’’ and ser-vices in a competitive market place. Boards of Directors and ChiefExecutives were appointed to effect the necessary changes. Preferencefor such appointments was for people who had been successful in theprivate sector in order to inject a new type of manager in the healthsector. This reflects a belief in the superiority of private sector disci-plines, where accounting is well established, consistent with the rise of

( )the New Right political authority Morgan & Willmott, 1993 .( )The reason for the adoption or rejection of information and account-

ing systems is socio-political, not technical. Technically, it had beenpossible for many years to introduce sophisticated financial accountingand costing systems to hospitals. But the systems of accountability, and

(the structures of signification, legitimation and domination Giddens,)1984 have to be worked upon before accounting systems become a

( )part of routinised procedures Lawrence et al., 1997 .The change to structures of meaning and signification introduced to

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hospitals in July 1993 was profound. The income for any surgical ormedical unit was no longer a budgetary allocation but rather a functionof output achieved} the number and type of patients treated, times theestablished ‘‘price’’ by the RHA. There was a need to secure contractswith the purchasing authority. A different sort of statistic and accountingwas necessary under such conditions. Whether it makes sense to treat apatient or a group of patients may now revolve around the issues ofresources used and payments received. A competing interpretive schemeof signification became apparent.

Monitoring Procedures and Emerging Problems

( )The Crown Company Monitoring and Advisory Unit CCMAU was formedas a unit within Treasury. CCMAU was to act on behalf of the Crown

( )to monitor, among other things, the 23 Crown Health Enterprises CHEsset up in 1993 as providers of public health and hospital services. Thepaucity of information and lack of commercial management processes inthe newly formed CHEs was a concern for CCMAU. The CHEs were tobe run as businesses and were required to earn a return on assetsemployed. Performance monitoring involved initially a wide range ofperformance indicators covering quality, human resources, operationaland financial matters. These indicators were developed with the claimthat they would be

‘‘a primary driver in making the CHEs more customer focused, qualitydriven and efficient’’

( )Department of the Prime Minister and Cabinet, 1993, p. 2

Measuring quality and human resources was controversial and littleagreement could be reached on appropriate comparable indicators. Overtime the monitoring focused more on operational efficiency and financialperformance. In keeping with international trends CCMAU encouragedmore intensive use of resources by reductions in length of hospital stayand increasing the proportion of surgery performed on a day-stay basis.The performance indicators on which attention was directed in CCMAU

( )reports were as follows Lawson, 1997 :

1. net profit after tax;2. return on equity;3. equity/ total assets ratio;4. average length of stay;5. day surgery percentage; and6. customer satisfaction.

The role played in the monitoring of CHEs changed as a result of itsanalysis of the performance indicators and financial results. The poorerthe indicator results and the poorer the performance against budget, the

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more intrusive CCMAU became in the CHEs management. CCMAU listedfive levels of monitoring, becoming more intensive as the number gotbigger. Tier 5 was the most intensive specifying that CCMAU couldappoint a new Board of Directors and CEO to manage the CHE. Thisright was exercised in the case of one CHE in 1996. Tier 4 meant aCCMAU appointed monitor would join the Board. All capital expenditurehad to be approved by the monitor, all borrowing from the privatesector was suspended and the organisation worked to an approved

( )business plan a ‘‘work out’’ . Ten CHEs were in this category by 1996.At the other end, Tier 1 meant the CHE was operating profitably andCCMAU received only the minimum regular performance indicators andreports.

An example of a ‘‘work out’’ plan was reviewed in a report by the( )Health and Disability Commissioner on Canterbury Health Ltd 1998 . The

Commissioner was critical of the CCMAU’s unreasonable pressure placedon the Canterbury CHE which in her view precipitated a chain of eventswhich caused danger to patients in the hospitals managed by the CHE.

‘‘CCMAU placed Canterbury Health under severe pressure to improve itsfinancial performance according to a plan that CCMAU acknowledgedwas a high risk, but did not consider or monitor the effect its imple-mentation had on the hospital’s delivery of service... The drive forefficiency within an unrealistic time-frame, with minimal patient focusand without appropriate purchaser support, contributed to under-resourc-ing of Canterbury Health and a breakdown in the relationships betweenclinicians and management’’

( )Canterbury Health Ltd, 1998, pp. 52/53

The Commissioner’s reference to a breakdown in relationships at Can-terbury Health related to the Christchurch Hospital’s Medical Staff Asso-ciation report to senior management entitled ‘‘Patients are Dying’’. Thisreport was the culmination of attempts by clinical staff to have concernsabout safety brought to the attention of, and rectified by, managementat Canterbury Health. The latter reacted by saying it was clinicians’‘‘mischief-making’’. It was the release of such reports by‘‘mischief-makers’’ to the Ministry of Health which prompted theCommissioner’s investigation and report in 1998.

The Commissioner reported CCMAU’s reaction to her criticism of itslack of regard for patient welfare. CCMAU claimed it was responsible for

(‘‘overall, and not specifically clinical, performance’’ Canterbury Health)Ltd, 1998, p. 52 .

The purchasing authority, Southern Regional Health Authority, was alsocriticised by the Commissioner for paying too little heed to patientwelfare.

‘‘The Southern Regional Health Authority did not pay sufficient revenueeither in terms of the price paid or the volume purchased, to enableCanterbury Health to provide appropriate services in the short or mediumterm... SRHA took an aggressive approach to negotiations and did notappear to take into consideration the effect of this approach on the

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standards of care provided to the public if Canterbury Health was notable to negotiate appropriate funding for the required volumes.’’

( )Canterbury Health Ltd, 1998, p. 48

The result in the Commissioner’s view was that a shortage of re-sources, especially in the Emergency Department, was becoming danger-ous. The purchasing authority retorted that the Commissioner misunder-stood the respective roles of organisations, such as the purchaser, whoseduty was to ensure compliance to standards in the purchasing contractand not to monitor in detail individual patient safety.

There is apparently a lack of integration in the overall concern forpatient safety. The only people directly involved, the clinicians, are notallowed to speak out publicly, and their efforts to bring their concernsto the attention of management were labelled mischief-making.

Those who speak are usually leaving the service. Dennis Pickup criti-cised the Northern RHA after he resigned as CEO of New Zealand’slargest CHE in Auckland. He claimed the RHA had failed miserably in itsoverall responsibility to assess the health needs of the region and thenmeet them through appropriate provision of services. In its first twoyears North Health had sat on millions of dollars of cash and operatingsurpluses while the people of Auckland suffered. He admitted to havingwept about correspondence concerning people on hospital waiting listshe could do nothing about and referred to his time as CEO as ‘‘souldestroying’’.

The government, embarrassed by ever-lengthening waiting lists, issueda directive that waiting lists were to be scrapped and replaced by abooking system. Only people who could be given a date for surgeryand guaranteed treatment within six months would enter the bookingsystem. Those who had no chance of treatment within that periodwould not be recorded officially and would therefore drop off thewaiting lists. This was bad news for the 19,225 patients who hadalready been two years on the list. To win a place on the bookingsystem one had to be scored above a set level on a newly introducedpoints system. The level meant that only seriously ill people wouldqualify. This meant an end to routine and elective surgery in publichospitals. The CHEs had to send letters to thousands of people explain-ing they would no longer be on a waiting list. The mangers at the CHEsaw these people as a newly ‘‘disenfranchised’’ segment of the market

( )place interview with Commercial Manager, Waikato CHE, 10/11/1997 .There was wide public support for the views of ‘‘mischief makers’’

among the medics. In 1997, protests at reductions in health servicesbecame widespread. There were street marches in Invercargill, Whangarei,Dunedin, Tauranga, Hamilton and Auckland as well as minor centreswhere hospital services were cut. Hospital services were cut in an effortto avoid financial losses.

There was a mixed reaction in hospitals. Some people in the hospitalswelcomed the new business mentality and the supporting informationsystems.

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‘‘The need for financial workups may irritate some people, but whyshould this organisation be any different? People need to get down tothe reality of the business environment’’

( )General Manager Mental Health, September 1993

Others, including surprisingly a government appointed director, sawreasons for difference:

‘‘Normal commercial business principles don’t necessarily apply} there isa social versus commercial conflict’’

( )Member of CHE Board, December 1993

Commentators outside, and medical staff inside, hospitals noticed anew twist to the meaning of performance and accountability:

‘‘The health reforms mean that implicit indicators of performance devel-oped by the professionals over decades of health care, balanced byexperience and a comprehensive view of patient needs, are being re-placed by a new explicit set, which focuses on profits and peripheralsand away from patient concerns.’’

( )Easton, 1993, p. 64

The emerging business and managerial culture challenged a professio-nal culture. According to Treasury, problems meant that more account-ing and business planning were needed. External accountability wasreplacing internal peer review and CCMAU required more explicit andresource related performance measures.

The Infusion of Accounting Technology into a Local CHE

The need for more and better accounting systems had been emphasisedin report of the Government’s Taskforce called ‘‘Unshackling the Hospi-

( )tals’’ 1988 . The report commented on the paucity of information sys-tems and insisted that the implementation of information systems hadto be a precursor to more business-like practices.

New managers were introduced at Health Waikato from the privatesector who began to transform accounting and information systems inhospitals. Health care accounting systems were claimed to be ‘‘a natio-nal disgrace’’ by one of the managers brought in to effect change inthe local CHE:

‘‘Accounting was somewhat of a backwater in the Area Health Boards.In fact, it was a disgrace, a national disgrace. The Boards would alwaystake on a nurse or a clinician ahead of an accountant. And not paymarket rates.’’

[ ( ) ]Interview April 1995, General Manager Finance GMF , Health Waikato

In his time at the helm the GMF was responsible for the recruitmentof many additional accountants. He was always fond of relating that theold Area Health Board which had an annual budget of over $250 million

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had only one qualified accountant. The growth in accounting expertisewas revealed by the Human Resources Manager who reported in 1995that there were seventy people designated as accountants employed inthe local CHE. This influx of technical accountants accompanied a newdiscourse and new structures of legitimation, signification and domina-

( )tion Lawrence et al., 1997 . People were brought into hospitals from thecommercial sector and these people expressed the new ideology. TheGMF himself came from a shipping company. His thinking is reflected in

( )the following statement Interview, 16 April 1995 :

‘‘In an important sense, running a hospital is no different from ashipping company}both have heavy capital investment, high overheadand critical break-even points. Both are businesses and need to earn areturn on resources employed.’’

The new GMF was a strong believer in the power of market forces toprovide a more efficient and customer-oriented service. He thought com-petition is vital and that all CHEs should be given a target return onassets to achieve. The important thing is not the rate, but the commonrequirement that a return be earned on assets employed. He also sawthe need to have one agency setting out explicit community needs andthen purchasing from the most efficient producers. In this way hereasoned resources will be allocated to the best producers.

Furthermore, the GMF argued that the whole hospital service shouldbe decentralised into many small businesses. These smaller units shouldbe run by people who realise their jobs depend on running successfulbusinesses. The GMF saw his job as:

‘‘arming them, equipping them, with information, with the necessaryaccounting information, to do their jobs.’’

He knew that there had to be a demand for accounting information, ifever it were to be used in decision making. He saw progress as thehealth professionals began to use their accountants and demand infor-mation for their managerial duties.

‘‘They are beginning to realise they need the information to manageresources. They have twigged that the information is necessary to runbusinesses; that survival may depend on understanding the numbers.’’

Initially, seven Divisional Accountants were appointed, and though offi-cially responsible directly to the Divisions, they were also the GMF’sfront-line troops in introducing new accounting technologies. From nowon, to emphasise new decision procedures based on economic andaccounting rather than medical criteria, discounted cash flow calculationshad to accompany any request for capital.

The GMF’s comments reflect a new structure of legitimation whichappeared in 1993 to challenge the medical rationales. A new accounting,based on external financial accountability, was introduced, with the in-

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tention of giving the right to external authorities to hold medical staffto account for their procedures. The health reforms had the intention ofcapping expenditure and reversing relations of who should be account-able to whom. Under the newly introduced business mentality, healthcare was regarded as just another economic commodity. The fundershad a right to expect value for money for each dollar spent on healthcare. It was the duty of health professionals to increase throughput,eliminate waste, and operate more efficiently. The health professionalshad to be more accountable for their use of resources and money.

A newly appointed CEO at Health Waikato, an accountant who hadworked with Treasury officials on a ‘‘workout’’, clearly supported thebusiness mentality. Together with the GMF, he introduced new account-abilities. In a public, open letter he introduced the thinking behind thenew business plan and a new organisational structure. The hospital wasto be broken into 22 clinical units and expressions of interest wereinvited for clinical unit leaders.

‘‘Units will be encouraged to undertake positive strategies to grow theirrevenues and explore new business opportunities’’

( )Waikato CHE, Internal Communication, 1995

Applicants for the new positions of clinical unit leaders would haveaccountability for both clinical and business performance. Short-listedcandidates were to attend a ‘‘one day assessment centre’’ early in 1996,the purpose of which was to establish the most suitable person for therole of unit leader. It was expected that those who strongly supportedthe new managerialist philosophy would apply. Anyone who opposedrunning hospitals as businesses would probably not apply or would notbe considered suitable for the position of unit leader. In Habermasianlanguage this would constitute a colonisation of the lifeworld by theinstrumentalism of business. A new language of business and economicswould then dominate in new structures. In reality, there were insufficientconverts to fill the positions. The natural leaders of certain clinical units,sometimes outspoken critics of the business philosophy, applied unop-posed for the position of clinical unit leader. Some people were pragma-tists willing to work in both public and private sectors, i.e. wanting tomaintain the public service ethic in their public hospital work whiletaking advantage of private practice where their revenue generating andearning potential could be realised. They were allowed to contract intenths of a full-time load in the public service.

( )In preparation for the new structure within the CHE Figure 1 , a greatdeal of effort had been put into developing accounting and reportingprocedures to give profit/ loss statements at the unit level. The revenueswould be the result of contractual arrangements with the Regional

( )Health Authorities RHAs and costs would be available through acasemix accounting system based on DRGs.

It was possible for non-clinical staff to become leaders of clinicalunits. The competencies required were related to negotiating, running

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Figure 1. The creation of small ‘‘businesses’’ within the CHE

and building a team, so that the team would develop a business planand budget covering both clinical and business aspects. One intervieweesuggested that after unit leaders had experience of running such units,they may well see little advantage in staying within the public serviceand may decide to set up private businesses.

( )Initially, there was to be a Waikato Hospital Organising Group WHOGwith representatives from support services and clinical units to coordi-nate the complex new arrangements. This was seen as a temporarydevice until clinical unit leaders were in full control. Support services,both business and clinical, were considered non-core activities and intime could be outsourced, leaving simply twenty-two clinical units whichwould each have contractual arrangement with funders, RHAs.

The 22 units would become profit directed businesses, which mightultimately see no point in belonging to an overarching organisationalstructure. As one manager pointed out, what used to be a hospitalcould be viewed as simply a large facility which individual businessunits might lease. So the hospital would disintegrate.

Questioning the Legitimacy and Productivity of the Reforms

The capitalistic emphasis on running hospitals as successful businessesand the increasing amount of private provision have brought into ques-tion the whole purpose and legitimacy of the health reforms. It raisesquestions about the driving force for the changes introduced. Was thewhole scheme a means of privatising health and absolving government

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from responsibility for the public health? Was it an attempt to subvertthe democratic process in favour of business interests? Questions oflegitimacy and productivity are at the core of Habermas’ communicationtheory.

The institutions of the health sector will be examined with thesetheoretical concepts in mind so the institutional and administrativechanges in health can be understood set within a model of societal

( )development. Broadbent et al. 1991 have used this approach in explicat-ing changes within the NHS in the UK. Lifeworld and system becomedifferentiated in complex, capitalistic societies. The ‘‘steering media’’ me-diate between the lifeworld and the system. Economic and administra-tive systems are guided by ‘‘steering media’’ which also assume con-crete substance in the form of social institutions. Steering media are themeans through which the lifeworld is objectified in the world.

The health care system in New Zealand may be used as an illustra-tive example of different forms of steering media. A form of concreteinstitutional arrangement, once used in New Zealand, employed demo-cratically elected Area Health Boards to direct the hospital system. Local,democratically elected boards held open meetings and were representa-tive of and accountable to the people in the areas they served. Theywere the means of giving concrete expression to the values and concernsof people with respect to health care provision. They were neverthelesscontroversial and critics felt they were too much subject to local politicalinfluences in their resource allocation decisions.

Local democratic institutions may be resistant to control or manipula-tion by central government. The whole of the Auckland Area HealthBoard was dismissed in 1990 by the Minister of Health, Helen Clark,because they consistently failed to keep expenditure within budgetedamounts. A prominent business person, Harold Titter, was recruited toact in its place.

When the Area Health Boards were abolished, the National Govern-ment was able to exercise more control over the steering media. Ironi-cally, this greater government control was gained by appealing to thepower of ‘‘market forces’’ and competition. The purchaser/provider splitwas a means of enabling government to exercise greater influence overthe steering media of money and power. There was a more complicatedarrangement after Regional Health Boards were replaced by more

( )bureaucratic, government appointed Regional Health Authorities RHAs .RHAs were to purchase from the most cost efficient provider, not

necessarily the local hospitals. It was a form of managed market place,closer to the capitalistic conception of how resources should be directed.CHEs were simply businesses.

Habermas warns, however, that in capitalist societies, systems arealways threatening to instrumentalise the lifeworld. The impact on Can-terbury Health analysed by the NZ Commissioner for Health and Disabil-ity and reported above, is an example of the steering media removingfrom ordinary people the power to decide what kind of health systemthey want. The move to contract for every service had far-reaching

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effects on the New Zealand way of doing things. Contracting seemed tobe constitutive and disruptive rather then regulative of social institutions.Another illustrative example is the Plunket Society, a New Zealandinvention which for nearly 90 years has provided a free ‘‘well-child’’health service. It is a universal service. Every family with a new baby isentitled to it. The experience of Plunket reflects that of many agenciesthat were joint state/voluntary organisations and now must try to runas businesses contracting with RHAs, increasingly perceived as an instru-ment to contain costs.

(Plunket is an institution with overwhelming community support Else,)1996, p. 90 . Women’s health activist Sandra Coney explains the impor-

tance of Plunket services for many first time mothers:

‘‘I had twenty visits with Plunket by the time my son was two. For thefirst three months these were in my home... It was my Plunket nursewho spotted that what I thought was a simple post-feeding ‘milky spill’was actually projectile vomiting, caused by pyloric stenosis, an obstruc-tion in the baby’s stomach’’

[ ( )]Sandra Coney quoted in Else 1996, p. 89

Plunket used to be nationally based and state funded and depended agreat deal on voluntary work. Now it is fragmented and local brancheshave to compete for RHA contracts. With the economic difficulties en-countered by families there are fewer and fewer volunteers. Government

( )funding has been restricted and RHAs buy only so many three homevisits to new mothers. To be able to provide the service means a greatdeal of effort securing contracts.

‘‘We now deal every year with four different RHAs, plus we have had a[ ]contract with the Public Health Commission now disbanded so that’s a

separate round. You spend your entire life tendering and contracting. Butthe central problem is that we don’t believe the RHAs are acting asgenuine purchasers. They say ‘Here’s the amount of money you got lastyear, this is the amount we’ll give you this year’. Nothing about ‘Theseare the services we want and this is what we reckon the costs are, solet’s negotiate a price’... So we say what do you think it should cost?and they have no idea’’

[ ( )]Diane Armstrong, President of Plunket, quoted in Else 1996, p. 93

In a book entitled ‘‘False Economy’’ dealing with the relationship( )between paid and unpaid work, Else 1996, p. 2 writes

‘‘Business leaders and policy makers seem unable to understand thathuman beings live in a complex web of connections. Every time statesocial services shrink or falter, every time volunteer services have theirfunding cut, the unpaid workload increases... The strain shows first inwomen’s lives, as they try to stitch our disintegrating social fabric backtogether. But the holes just keep getting bigger.’’

The RHAs are not accountable to the people. Though there is astatutory obligation to consult with the people of the Region, consulta-

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tion has become rather a public relations exercise. The nature of consul-tation in health has been criticised:

‘‘Consultation on social policy has moved from being a pre-policy activ-ity to being a post-policy making activity. Instead of explicitly initiatingpublic debate before the policy is made, public relations efforts are usedto educate the public or to sell the policy at the implementation stage’’

( )Blank, 1994, p. 135

Blank argues that a move away from the accepted processes such asconsultation are damaging for a society such as New Zealand. Actionsof policy makers work against open public debate.

If services are perceived to be inadequate people have no publicmeetings to go to express their needs. If funds are restricted andservices cut, both the RHAs and the CHEs can disclaim responsibility.Their funds are limited by Government. The new institutional arrange-ment seems to many people to have allowed the steering media to‘‘get out of hand’’ and allow money rather than health or social ratio-nality to rule. In general terms, Habermas refers to this phenomenon asa constant feature of capitalistic mode of organisation. The subsystemsof the economy and the state become more and more complex andpenetrate ever deeper into the symbolic reproduction of the lifeworld.The next move towards greater complexity has been foreshadowed. Thepurchasing responsibilities may be delegated to general practitioners. Anew layer will be inserted into the contracting network. GPs in NewZealand, contrary to other places such as the UK, have always beenprivate practitioners and the possibilities of fundholding on behalf ofGovernment has resulted in the emergence of groups of GPs joined

( )together in Independent Practitioner Associations IPAs . Such larger unitswould be necessary to spread financial risks in a fundholding regime. Itdoes however eliminate consumer choice since the IPAs in New Zealandcover whole cities.

IPAs have begun to construct new facilities duplicating those in publichospitals. In the North Island city of Hamilton, with a population of100,000 and a CHE employing about 5000 people, a new private hospitalis to be built to provide day-stay surgery, cardio-thoracic and breastsurgery, neurology, obstetrics, oncology, paediatrics, urology and otherservices. Since all these services are available at the local publiclyowned CHE, and would employ surgeons already employed there, onewonders why the duplication is necessary. If one suspects it has some-thing to do with competition, the promoter of the private hospitalassured the public that this was not the case. Company Director, BrianLinehan, is quoted:

‘‘We are looking at the possibility of taking over some services but weintend to complement rather than compete... our new hospital will en-

( )able Health Waikato the CHE to concentrate on its core services’’( )Waikato Times, 1996, p. 1

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So it seems the CHE intends not to bother to compete. The Coalitionfor Public Health asks why would the public hospital be trying to getout of health care that is publicly provided and funded? Customersurveys continually show high levels of satisfaction with the serviceprovided at the CHE. Indeed, the public of Hamilton and New Zealandare puzzled.

Another mechanism for transferring work from the public sector isthrough joint-ventures. Joint ventures are employed for what the PSA

( )Journal 1997, p. 1 called:

‘‘lopping the profitable bits off the public health sector’’

The PSA Journal gave examples which have occurred of privatisationof profitable services and cuts to public service provision in HealthcareOtago, Capital Coast Health, Hawkes Bay Healthcare, Good Health Wan-ganui, and Wairarapa Health. It also reported on a joint venture betweenHealthcare Otago and surgeons and cardiologists who work for theChristchurch CHE. This will replace a service provided by the ChristchurchCHE.

Examples of actions contrary to ordinary common-sense abound. The( )PSA Journal March 1997, p. 1 reports of a $3 million contract for the

provision of artificial limbs being awarded to a newly established privatecompany, Rehabilitation Management Ltd. This company took over theprevious contract serviced by the public company, Auckland Artificial

( )Limb Centre ALB . This was despite a Coopers and Lybrand effective-ness review which rated ALB’s costs, productivity and amputee accep-tance as ‘‘excellent’’. None of the ALB’s staff wanted to work for thenew private company, and it was attempting to recruit staff from abroadone week before it took over the service. The rationality for suchdecisions by government purchasing agents is not revealed. Accountingrationality might have been invoked to support the government’scommitment to efficiency and effectiveness. Yet the public see no effi-ciency gains in the privatisations. The steering media seem to be drivenby interests which are not being made explicit.

A striking example of the removal of democratic processes in thehealth system was the abolition of the NZ Public Health Commission.The Commission had been established as an independent authoritycharged with expenditure on public health. It became controversial whenits prominent members began to speak out about the detrimental effectson the public health of tobacco and alcohol, and about meat products.The latter in particular was considered threatening to the commercialinterests of New Zealand. A Government Minister, Murray McCully, wroteto the Associate Minister of Health and referred to the members of theCommission as ‘‘a bunch of cretins’’ and ‘‘pointy-headed wasters’’( )Waikato Times, 1994 . The Government forced the transfer of the re-sponsibilities of the Commission to the Ministry of Health and closedthe Commission even before legislation was passed through Parliamentto that effect. There was outrage from health lobby groups and opposi-

Civil society 241

tion MPs who argued that the Commission was being abolished becausethe policies it pursued were embarrassing to parts of the liquor andfood industries.

It is exactly this silencing of opposition to capitalist interests whichHabermas emphasises in his theory of distorted communication. Allcommunications may be distorted to some extent in the sense that theyfall short of the ideal situation of perfect communication, but manydistortions are not inevitable and are intentionally perpetrated distortionsfor political reason. Examples of such distortions evident in advancedcapitalist countries such as America and Western Europe are claimed by

( )Forester 1980 to be the deceptive legitimation of great inequalities ofincome and wealth; consumer ideologies inherited and generated bycapitalist productive relations; the manipulation of public ignorance indefence of professional power; pretence by politicians that a politicalproblem is a technical one; misrepresentations of benefits and dangersto the public by private, profit seeking interests; and when establishedinterests in society avoid humanitarian social and economic policies( )such as a comprehensive health service with misleading rhetoric andfalsehood. They are artificial distortions of pretence, misrepresentationand ideology with immobilising, depoliticising and disabling conse-quences.

Consequences of Reform

This is the crisis of legitimation which Habermas highlights in his theoryof communicative action. We feel overwhelmed by the global economicsystem which is largely beyond people’s control. The system changesthreaten social identity. We feel we have no choice. There is a feelingof loss of human control over the system.

‘‘I would say the universal emotion in New Zealand is fear... I don’tthink that I can honestly look at my grand kids, I’ve got seven of themnow, and say to them, well by my conscious efforts I’ve made theworld a better place for you than it was when I came into it. And thatworries me.’’

( )Ken Douglas, Trade Unionist, quoted in Russell, p. 251

In New Zealand proponents of the new economic arrangements claimedwe had no choice. There was no alternative. It is as if human agency isoverwhelmed by structural forces of money and power and instrumental-ist rationality. While these systems speak a great deal about freedom,there is a significant loss of democracy and the possibility of a juridifi-cation process in which accounting and law mould the behaviour of

( )social systems Laughlin & Broadbent, 1993 . Communicative reason isundermined as the lifeworld is colonised by the steering media ofpower and money and language and logic of accounting and economics.

Intersubjective, open and free communication of a non-instrumentaland non-strategic orientation is becoming increasingly alien to modern

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capitalist states. In the latter, public affairs and administrative actioncome to be regarded not as areas for public conversations about direc-tion and values but as technical problems to be solved by experts

( )employing instrumental rationality Craib, 1992 .Market forces have been used to allow technicist solutions to displace

public participation in NZ health care. This has been done in the nameof ‘‘efficiency’’. But do the outcomes suggest improvement? There islittle evidence to suggest improvement to date.

Implications and Questions for Accounting

Many theoretical approaches could be taken to understand and explainthe introduction of accounting to the public sector and in particular thehealth sector. The major advantage of adopting a Habermasian approach

( )is that an evaluatory stance becomes possible Habermas 1976, 1984 .( )As Arrington and Puxty 1991, p. 31 argue the legitimacy of the use of

accounting depends on democratic adjudication of reasons for and pro-tests against particular forms of accounting practice. It is a systemicapproach and encourages a critical analysis of change. Questions areraised}can the changes be rationally justified? How were the variousinterests apparent in the adoption of or resistance to accounting prac-tices? Was use of steering media regulative or constitutive? These arethe possible questions opened up by Habermas.

In relation to accounting, questions can be asked about its regulative( )or constitutive properties. As explained by Broadbent et al. 1991, p. 6

‘‘Regulative rules regulate some pre-existing on-going activity, e.g. rulesof safe driving. Constitutive rules on the other hand constitute someform of activity e.g. rules of chess. Regulative rules are claimed to be‘ freedom-guaranteeing’ in the way they moderate systems of behaviourto reflect existing lifeworld norms and values. Constitutive rules, on theother hand, are deemed to be ‘ freedom reducing’ ’’

It seems clear from the foregoing descriptions that the accountingchanges introduced by the state to the health sector of New Zealandwere constitutive. There were to be new rules of behaviour. Activitieswere to be accounted for and justified in economic and commercialterms instead of medical terms. The state’s agency, the RHAs, werenewly instituted steering media designed to purchase particular volumesof services and to contain expenditure within state authorised limits.Medical practice at the operational level was colonised by accountingpractices, including DCF calculations of the most obvious equipmentreplacement decisions.

It remains to be argued whether the colonisation of the social life ofhealth service providers could be viewed as necessary from the interestsof the population generally. The Government problematised health provi-sion claiming gross inefficiencies and its reforms were intended toprovide a more efficient and business-like health service. The public

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reaction suggests that most people do not want hospitals to be run asprofit-making capitalistic enterprises. Indeed, the extreme policies of suc-cessive governments and the abandonment of the welfare state was amajor factor in the choice of New Zealanders in a national referendum

( )to have a new system of mixed member proportional representation.Such a system would necessitate coalition government based on rea-soned consensus rather than extreme ideology. The expectation seemedjustified as the first coalition government, an agreement between Natio-nal and New Zealand First, stated that its health policy:

‘‘has the overriding goal of ensuring principles of public service replacecommercial profit objectives for all publically provided health and disabil-ity services’’

Furthermore, the coalition agreement stated the coalition partners were:

‘‘committed to publicly funded health care that encourages cooperationand collaboration rather than competition’’

The public voted for such a return to public service ethos. What hashappened since has been widely perceived as the continued deviousnessof politicians. Since the coalition agreement, there has been more andmore Government funding transferred to private provision of services.

In evaluating the actions of steering media we need to ask whetherthe actions are ‘‘amenable to substantive justification’’ or can only be

( )‘‘legitimised through procedure’’ Broadbent et al., 1991, p. 7 . Thismeans whether the changes reflect ‘‘informed commonsense’’ and canbe easily justified by powerful elites. The purchaser/provider split inhealth has been very difficult to convince average New Zealanders abouteither as a concept or as a sensible practical steering mechanism. Thecontracting regime with its associated large bureaucracy and lack ofdemocratic input has been a major difficulty with health reforms. Theneed for sophisticated accounting systems has been viewed as necessaryto support the contracting activities of such bureaucracies rather than ashelpful adjuncts to rational decision making by providers of health ser-vices. The purchaser/provider split was necessary to the Government’sideology of market place and competition. Yet the market is apseudo-invention of government and viewed as an expensive instrumentof state hegemony rather than a natural and commonsense means ofallocating health services in a public service. In this sense accountingtechnology and profit calculations can be said to be colonising influ-ences considered inappropriate by most New Zealanders. The fragmenta-tion of provision and possibility of increased privatisation goes against along and cherished tradition of provision according to need rather thanability to pay. Most people could well accept that public hospitals wereinefficient before the reforms, but the instruments of control introducedby means of capitalistic business-like procedures including accounting for

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decentralised profit centres in hospitals has not been easy for averageNew Zealanders to appreciate.

So accounting in the new regime could be seen as a colonisinginfluence, constitutive and legitimised by procedure rather then regulativeand amenable to logical justification. Habermas allows such argumentsto be mounted for enlightenment and possible emancipatory action.

Discussion

Tensions in hospitals and in society are apparent. The reforms havebeen socially divisive and the medical profession itself seems divided.Despite long and continuing denials by government about intentions toprivatise health care institutions in New Zealand, the possibility is everpresent. The way in which reforms were introduced in order to achieveefficiencies was to establish hospitals as profit seeking corporations.Decisions about services are now to be business decisions no longeropen to public debate. The use of intermediaries in the form of apurchasing authorities means that the government is no longer directlyaccountable to the public.

Habermas’ communication theory is concerned with what he refers toas a legitimation crisis. The crisis of legitimation arises because ofinequalities that cannot be justified. There arises what Habermas refersto as systematically distorted communications. These arise when es-tablished interests attempt the deceptive legitimation of great inequali-ties; when they avoid humanitarian, social and economic policies, suchas comprehensive health services, with misleading rhetoric and false-hood, such as the public sector is always less efficient than the privatesector. The distorted communications and ideology act against demo-cratic institutions and are disabling and immobilising.

‘‘Accompanying this has been the commodification of existence. Healthcare and education are not human needs or social goods but areproducts to be marketed and to be provided in a manner that furthersthe ends of business. So extreme is this trend that people’s preferencesas consumers of goods now mean more than their preferences forvalues and society and community.’’

( )Dannin, 1996, p. 2

Against such critique, the leaders of business can argue in favour of amore free and liberal society, and question how we can explain thecontinued appeal of collectivism. They argue for individual responsibilityand a civil society, not one dependent on handouts by the state. It istrue that there have been economic gains since the reforms began, andthe state’s finances are greatly improved. The losers have been thepoor. There is no bashfulness among business leaders or politiciansabout the increasing inequalities. Indeed Professor Bryan Gould,ex-Labour MP in Britain and now Vice-Chancellor of a New Zealand

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(University finds the attitudes in New Zealand unusual quote in Russell,)op. cit., p. 250 :

‘‘I think what is remarkable about the New Zealand experiences is theextent to which the pain, the unfairness, the inequality, has been cele-brated’’

There is a sense that among the children of NZ there is a greater( )determination to look after self Russell, 1996 . That may be the legacy

of the reforms. The denial of a sense of depending on each other. Acelebration of growing inequality by those in powerful positions. Govern-ment policy has been to reverse a tradition of social welfare and beginto support the strong and sacrifice the weak in the name of bettereconomic performance. Market based solutions, employing accountingtools to direct resources, have been viewed as necessary constitutivesteering media for a move away from a welfare society towards a civilsociety.

Critical theory aims to contrast the distorted communications of powerelites with those of ordinary, common-sense communication of mutualunderstanding and consensus. Critical theory is idealistic in seekingemancipation from power structures and the enabling power of demo-cratic political criticism and mutual understanding and self-determinedconsensus. People in NZ may be ready for such an ideal. The choice byNew Zealanders of a new form of proportional representation, resultingin coalition, and a more consensual type of government, may be aturning point. However, the evidence from actions of the first coalitiongovernment has been discouraging. The need for future researchers isto continue the critical examination of government policy so that in aproperly functioning democracy government is held accountable for the‘‘reforms’’ it undertakes on our behalf.

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