A Tale of Excessive Hospital Autonomy : An Evaluation of the Hospital Reform in Senegal
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...
| Main Authors: | , , |
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| Format: | Working Paper |
| Language: | English en_US |
| Published: |
World Bank, Washington, DC
2013
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| Subjects: | |
| Online Access: | http://documents.worldbank.org/curated/en/2012/06/16760902/tale-excessive-hospital-autonomy-evaluation-hospital-reform-senegal http://hdl.handle.net/10986/13665 |
| Summary: | 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. |
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