Public hospital autonomy: lessons from Pakistan

For many years health policy in developing countries concentrated on primary health care. State hospitals were seen as expensive and somewhat irrelevant. Health system reforms have led to public sector hospitals increasingly being granted autonomy as a solution to their problems. What lessons can be learned from two such initiatives in Pakistan?

Public hospitalsin developing countries are often criticised for poor management performanceand poor quality of medical care. They are also considered to be costly. Astudy of 29 countries in 1992 showed that public hospitals used about 60percent of total state expenditure on health. Considering their failings, thisis cause for serious concern. Not surprisingly, it is often suggested that theybe granted autonomy as a possible solution.

Research by theNuffield Centre for International Health and Development (Leeds, UK) reviewsthe literature on hospital autonomy in a variety of developing countries and assessestwo recent cases of hospital autonomy reforms in Punjab province and theNorth-West Frontier Province (N-WFP) in Pakistan.

In the 1990s, thePunjab initiated health service reforms, which included steps towards decentralisation.Linked to this was the province’s Sheikhupura pilotproject, which involved creating semi-autonomous district hospitals. It alsogranted institutional autonomy to some of its teaching and other hospitals. Inthe N-WFP, the four biggest public hospitals were granted autonomy in 2000. Inassessing these initiatives, the study makes a wide range of findings,including:

• The Punjab and N-WFP cases both lackedaccurate and complete documentation of the design and operational planningof their autonomy reforms, making implementation and later, evaluationdifficult.  
• At Khyber Teaching Hospital in theN-WFP, the roles of the chief executive and medical superintendentoverlapped, causing tension, as did the ineffectiveness of the Punjab’sinstitutional management committees.
• Quality of public health care inPakistan is problematic. Only 27 percent of the population reported publicsector facilities as a first choice. 63 percent were dissatisfied with thequality of care overall. Physicians’ consulting times are on average 1-3minutes per patient.

The reportrecommends a number of considerations as a checklist for new initiatives beingplanned and as guidelines for evaluation measures:

• A mission statement shouldbe published for each hospital, setting out the purpose, objectives and scopeof the autonomy. It should also clarify the hospital’s priorities, clearjob descriptions and responsibilities, plus detailed expectations from theDepartment of Health regarding results.
• Managerial roles should be clearlydefined. The management committee should assume a strategic focus with‘checks and balances’ in place and institutional sub-committees shouldhandle specific aspects of administration.  
• In Pakistan, thehealth planning environment is unstable, inconsistent and impermanent. Theplanned reform needs tobe strong enough to withstand this turmoil to be sustainable.
• The main focus mustbe quality of care.
• Autonomous public hospitals must beregulated by the state to ensure that autonomy of action is balanced withpublic accountability, as the media and civil society are not vigilantenough.