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The tenuous financial viability of many of Georgia’s rural hospitals has driven increased scrutiny of the hospital authorities (HAs) that own and govern them. HAs are a type of “special district” established in state law to allow for specialization of function, while evading statutes that can limit local government borrowing and multi-year contracts. The paper aims to discuss this issue.

This paper uses a case example to introduce transparency and accountability in one local Georgia hospital and expands to include a descriptive analysis of transparency measures in 29 rural Georgia HAs.

Findings indicate that, like many other special districts in Georgia and the USA, Georgia’s rural HAs often act more like private entities than the public organizations they are. The lack of transparency demonstrated in this sector limits access to public information and reduces opportunities for citizen engagement, a necessary component of representative institutions.

This case study is limited to Georgia HAs; however, the data support the lack of accountability and transparency found in many special district governments.

The lack of transparency in all of the organizations reviewed in this study demonstrates blurred lines between between public matters and private interests and raises questions of transparency, a key value in democracies.

For a good part of the U.S. system of federalism municipal incorporation has been the formal structure for local communities. Over the last 60 years there has been a shift in this structure to special district government. The Woodlands, Texas presents an interesting case study on the incremental development of a former New Town community, the change in formal government organization and the potential for a different model of local governance structure in the 21st Century. The authors explore the four stages of development for The Woodlands over the past 40 years and assess this development through several model theories including institutional, urban regime, and urban governance. Contrary to some current literature on governance, The Woodlands appears to have transitioned from decentralization to more centralization while at the same time avoiding full incorporation as a municipality. It may be indicative of the new governance.