Publication: A Tale of Excessive Hospital Autonomy? An Evaluation of the Hospital Reform in Senegal
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2012-05
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2012-12-04
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This report evaluates the hospital reform that took place in Senegal in 1998. The reform was successful in granting hospitals considerable autonomy in all management areas, yet resulted in many hospitals closing to bankruptcy. After the reforms the population continued to regard hospital care as unaffordable and of inadequate quality. The very mixed results of the hospital reform are due to a lack of efficiency and built-in accountability. The report concludes that it might have been possible to avoid the current situation if in addition to empowering hospitals, an accountability mechanism had been implemented. The priorities will be to restore some government control over hospitals, restore the efficiency of hospitals, and create some progress on equity of access to hospital care.
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“Turbat, Vincent; Lemière, Christophe; Puret, Juliette. 2012. A Tale of Excessive Hospital Autonomy? An Evaluation of the Hospital Reform in Senegal. © World Bank. http://hdl.handle.net/10986/11880 License: CC BY 3.0 IGO.”
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Publication A Tale of Excessive Hospital Autonomy : An Evaluation of the Hospital Reform in Senegal(World Bank, Washington, DC, 2012-06)In 1998, Senegal launched an ambitious hospital reform. More than ten years later, despite a massive injection of government funds in hospitals, many of them are now close to bankruptcy. However, this reform clearly had the effect of 'bringing back patients' to hospitals. While hospitals were largely empty (as in many Sub-Saharan African countries), the number of hospital-based outpatient visits has increased by over 20 percent every year since 2000. This increased activity also suggests that hospitals have become more attractive for patients and that the quality of care may have improved. In contrast, equity of access to hospital care (especially for the poorest) has clearly deteriorated. While the proportion of poor is estimated at nearly 51 percent of the Senegalese population, this group constitutes only 3 percent of hospital patients. Last but not least, the hospital reform has resulted in a major deterioration in the technical efficiency of the hospital system. The first reason is the uncontrolled increase of the wage bill, both because of massive recruitment of unqualified staff and because of the creation of numerous and inconsistent staff bonuses. A second reason is the underfunding of several free care programs, especially of the Plan Sesame (that is, free care for the elderly). The mixed results of this hospital reform are due to several factors. The 1998 reform is a textbook case of granting very large management autonomy to hospitals without implementing any serious accountability mechanism. Hospitals have indeed acquired considerable autonomy in all management areas. It might have been possible to avoid the current situation if, in addition to empowering hospitals, some accountability mechanisms had been implemented; however, this did not happen. Among the various remedies proposed, the utmost priority is to restore some government control over hospitals. This can be done by establishing mechanisms for evaluating hospital managers and controlling ex ante their budgets, especially their decisions about recruitments and compensation. A second priority would be to restore the efficiency of hospitals, which would require (i) revision of rates for hospital user fees so that they better reflect actual costs, (ii) reduction of overstaffing with nonqualified workers, and (iii) restructuring of the hospital system in Dakar.Publication The Impacts of Public Hospital Autonomization : Evidence from a Quasi-Natural Experiment(World Bank, Washington, DC, 2012-07)This paper exploits the staggered rollout of Vietnam s hospital autonomization policy to estimate its impacts on several key health sector outcomes including hospital efficiency, use of hospital care, and out-of-pocket spending. The authors use six years of panel data covering all Vietnam s public hospitals, and three stacked cross-sections of household data. Autonomization probably led to more hospital admissions and outpatient department visits, although the effects are not large. It did not, however, affect bed stocks or bed-occupancy rates. Nor did it increase hospital efficiency. Oddly, despite the volume effects and the unchanged cost structure, the analysis does not find any evidence of autonomization leading to higher total costs. It does, however, find some evidence that autonomization led to higher out-of-pocket spending on hospital care, and higher spending per treatment episode; the effects vary in size depending on the data source and hospital type, but some are quite large -- around 20 percent. Autonomy did not apparently affect in-hospital death rates or complications, but in lower-level hospitals it did lead to more intensive style of care, with more lab tests and imaging per case.Publication Lessons for Hospital Autonomy(World Bank, Washington, DC, 2011-07)The Government of Vietnam sees hospital autonomy policy as important and consistent with current development trends in Vietnam. It is based on government policies as laid out in government Decree on financial autonomy of revenue-generating public service entities; and to 2006, it is replaced by decree on professional, organizational, human resource management and financial autonomy of revenue-generating and state budget-financed public service entities. These policies apply to public service entities in all sectors, including the health sector and hospitals. 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The paper draws on recent publications, grey literature, media reports, and interviews with key stakeholders.Publication Hospital Sector Reform in Uzbekistan : A Policy Note(World Bank, Washington, DC, 2012-01)Since the mid-1990s, Uzbekistan has undergone reforms in the health sector focused on restructuring of primary health care in Uzbekistan as well as the establishment of an emergency medical care network. Reform and development initiatives in at secondary and tertiary care level have been limited to gradual downsizing of sub-national hospitals, with the exception of the emergency medical care network, and expansion of Republican specialized tertiary centers. Recent years have seen increases in out-of-pocket payments (both official and informal) for hospital and other health services, which now present a barrier to accessing health services and pharmaceuticals for some patients. The Ministry of Health (MOH) is implementing a program of development of new standards for diagnostic/curative services at each level of care that are intended to modernize practice and increase quality and efficiency. Twenty disease areas have been covered to date. Standards for equipment requirements at each level are also being defined. The Ministry now faces the challenge of developing a strategy to changing clinical and managerial practice in hospitals to bring them into line with the new standards. Uzbekistan has a large and fragmented network of hospitals and specialist clinics, characterized by multiple vertical programs and many single-specialty facilities. There is lack of clarity regarding the specific roles and linkages between the numerous hospitals and specialized care facilities. The Government has pursued a policy of increases in official user fees or "self-financing", alongside offsetting reductions in budget provision for non-salary operating costs in Republican hospitals and many Oblast hospitals in recent years. City and oblast hospitals have self-financing beds. User fees are projected to amount to an average of 18 percent of revenue in 2008 for oblast hospitals (compared to an average of 1.4 percent in 2000). Republican Specialist Centers (tertiary level hospitals) now obtain up to around 65 percent of revenue from user fees, and have a target of 80 percent. By contrast, rayon hospitals collect little user revenue (projected to be a little under 1percent in 2008, a level that is approximately unchanged since 2000). Budget funds for oblast hospital now cover little more than the costs of staff salaries and benefits, following budget reductions that offset increases in user fees.
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