Management Accounting Change in the Saudi Public Health Sector: A Neo-Institutional Perspective

This research has investigated and analysed why and how Management Accounting (MA) has contributed, at the institutional level, to improving Health Care Quality (HCQ) within the Saudi Arabian Public Health Sector (SAPHS). Analysing these developments as a form of change consistent with the dynamics found in the emergence of New Public Management (NPM), this study draws on Neo-Institutional Sociology (NIS). The research studies how MA change operated across institutional contexts within an NPM-based approach to improving health care and public health in the Kingdom of Saudi Arabia (KSA). It focuses on how, in this context, the roles and practices of MA have been defined, designed and implemented to promote ‘quality outcomes’ in health care. Methodologically this has involved two extensive case studies of MA change in two carefully selected hospitals, including semi-structured interviews with accountants, management, consultants and clinicians along with the collection and analysis of key documentary information used in managing the human and financial resources within the hospitals. The findings show how and how far new management accounting practices (MAPs) have promoted the ability and ‘right’ of management to coordinate control and monitor the human and financial resources, but in a way that specifies HCQ outcomes for patients, thus meeting both economic and social/political objectives. It is argued that MAPs had significant success because the allocation of budgetary resources by the Ministry of Health (MOH) was based on hitting non-financial quality and productivity targets. In both hospitals MAPs came to operate within a ‘non-accounting budgetary style’ (Hopwood, 1973) de-emphasising cost control, and managers and staff focussed just on effectiveness and efficiency measures. However, this initiative can also be seen as a response to significant institutional pressures and concerns at both government and professional levels, responding to ‘public voice’ concerns over HCQ. The response drew on world-leading medical research and practitioners to introduce best-practice HCQ solutions allied to internationally accredited quality standards into the KSA hospital sector. The study found that coercive, mimetic and normative isomorphism all contributed to the successful implementation of the HCQ agenda, and the new MAPs here contributed to strengthening the internal and external legitimacy of certain key KSA institutions. There was some institutionally significant resistance from clinicians who saw these MAPs as compromising their professionally-defined focus on quality outcomes for patients. But over time, the mix of ‘soft’ quality and ‘hard’ MA derived targets was increasingly accepted and internalised as integral to delivering HCQ.