Balancing autonomy and accountability in national public hospitals – a qualitative case study

This study examines the interplay of accountability and autonomy within Denmark’s decentralised public healthcare system. Drawing on Christensen and Lægreid’s transformative perspective and elite interviews with state, regional and hospital-level managers, we explore how accountability mechanisms are enacted – not simply imposed – within complex institutional settings. Our findings highlight persistent tensions between centralised financial control and the autonomy of clinical managers and practitioners. Denmark’s use of diagnosis-related group (DRG) funding and national quality assurance frameworks is designed to promote accountability and efficiency. However, the standardisation inherent in these mechanisms may conflict with local practices. We find that managers accept accountability systems such as the DRG framework, yet regain autonomy by exploiting inconsistencies in DRG cost data to deviate from prescribed efficiency targets. This behaviour hampers uniform implementation and ultimately undermines the legitimacy of top-down governance. Our analysis shows that managers further expand their autonomy by supplementing the DRG system with non-financial quality metrics – an approach that, in turn, constrains clinical autonomy. Furthermore, our analysis shows that as accountability pressures constrained clinical discretion, clinicians regained a degree of autonomy by pushing back against the national quality accreditation model and challenging the dominance of DRGs. Our study contributes to the public sector accounting literature. Effective accountability mechanisms in decentralised healthcare systems require a context-sensitive approach that recognises the institutional history and context. Our findings suggest that if financial controls are not adapted to local governance structures, they may face resistance, necessitating hybrid models that integrate managerial oversight with clinical autonomy.