A holistic view on implementing hospital autonomy reforms in developing countries: a systematic review

The excessive use of resources, inefficiency and poor service quality in public hospitals has led developing countries to create reforms in public hospital governance, including autonomization. Hospital autonomy refers to the delegation of administrative rights to the hospital management team. The purpose of the present research is to review different aspects of hospital autonomy reforms in developing countries, such as incentives, preparations, obstacles and facilitators to change prior to implementation, impacts on achieving Universal Health Coverage (UHC) goals, challenges, outcomes and implications for implementation. A systematic review of the evidence from developing countries was performed. The results showed that these countries have undertaken autonomy reforms in order to improve the efficiency, quality and accountability of their hospitals. Also, studies emphasized the role of the World Bank in facilitation and guidance, and identified bureaucratic culture and political instability as barriers to change for the implementation of hospital autonomy reform. Preparations were limited to two key areas, i.e. ensuring access to healthcare services and ensuring the implementation of these reforms. The main challenges were lack of infrastructure, poor planning and policymaking, poor programme control, limited decision rights, inappropriate incentives and weaknesses in the accountability system. The results indicated that these reforms had no discernible effect on quality, efficiency and other management indicators, while leading to an increase in hospital costs and out-of-pocket payments. Also, implementing these reforms affected the progress toward achieving UHC. Overall, the results showed that there are two factors in failed implementation of these hospital reforms in developing countries: (1) lack of a systematic and holistic view, and (2) incomplete or poor implementation of different aspects of these reforms.

Fail to prepare and you can prepare to fail: the experience of financing path changes in teaching hospitals in Iran

Background

In 1995, teaching and public hospitals that are affiliated with the ministry of health and medical education (MOHME) in Iran were granted financial self-sufficiency to practice contract-based relations with insurance organizations. The so-called “hospital autonomy” policy involved giving authority to the insurance organizations to purchase health services. The policy aimed at improving hospitals’ performance, hoping to reduce government’s costs. However, the policy was never implemented as intended. This was because most participating hospitals gave up to implement autonomous financing and took other financing pathways. This paper analyses the reasons for the gap between the intended policy and its execution. The lessons learned from this analysis can inform, we envisage, the implementation of similar initiatives in other settings.

Methods

We conducted semi-structured interviews with 28 national and 13 regional health policy experts. We also gathered a comprehensive and purposeful set of related documents and analyzed their content. The qualitative data were analyzed by thematic inductive-deductive approach.

Results

We found a number of prerequisites and requirements that were not prepared prior to the implementing hospital autonomy policy and categorized them into policy content (sources of funds for the policy), implementation context (organization of insurance organizations, medical tariffs, hospitals’ organization, feasibility of policy implementation, actors and stakeholders’ support), and implementation approach (implementation method, blanket approach to the implementation and timing of implementation). These characteristics resulted in unsuitable platform for policy implementation and eventually led to policy failure.

Conclusions

Autonomy of teaching hospitals and their exclusive financing through insurance organizations did not achieve the desired goals of purchaser-provider split in Iran. Unless contextual preparations are in place, hospital autonomy will not succeed and problematic financial relations between service providers and patients in autonomous hospitals may not be ceased as a result.