The ownership elephant: ownership and community-governance in primary care.

Ownership of primary care is an often neglected but important health systems design parameter. The New Zealand Primary Health Care Strategy has established Primary Health Organisations (PHOs) as non-profit umbrella organisations, however in most instances their constituent general practices are for-profit small businesses. This viewpoint paper aims to: (a) define ownership and community participation; (b) summarise some of the evidence from the NatMedCa study pertaining to ownership-related differences; and (c) discuss the policy implications of different ownership forms in primary care, and the implications of merging different ownership forms under the umbrella of PHOs. Ownership confers governance responsibility (ultimate control) for an organisation, and accountability for its actions. Community governance involves vesting overall control of resources in users and the community, rather than with health service managers or health professionals. Results from three studies using the NatMedCa survey indicate that community-governed non-profits in New Zealand differ in a number of respects from their for-profit counterparts. As non-profit and for-profit ownership forms have different social roles, and as meaningful community participation in governance is determined in large part by ownership structures, there is a need for ownership frameworks to be used more widely in health policy making. Because of the ownership boundary that exists between non-profit community-governed PHOs and their constituent for-profit general practices PHOs may have little real ability to effectively govern their practices.