The Introduction of Market Forces in the Public Hospital Sector : From New Public Sector Management to Organizational Reform
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World Bank, Washington, DC
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This Discussion Paper was prepared as a
background document for the Hospital Reform Module of the
Joint Harvard/World Bank Institute Flagship Course on Health
Sector Reform and Sustainable Financing. The Flagship course
provides a practical review and update of current issues in
health systems reform and financing for senior policy makers
from developing countries. Since its inception, the Flagship
course has reached more than 3,000 participants from over 50
countries. Heavy investment over the past 30 years has made
the hospital sector the largest expenditure category of the
health system in most developed and developing countries.
Despite shifts in attention and emphasis toward primary care
as a first point of contact for patients, in most countries,
hospitals remain a critical link to health care, providing
both advanced and basic care for the population. Often, they
are the provider "of last resort" for the poor and
critically ill. Although, it is clear that hospitals play a
critical role in ensuring delivery of health services there
is much less agreement about how to improve the efficiency
and quality of care provided. This Discussion Paper provides
insights into recent hospital reforms undertaken throughout
the world, with an emphasis on organizational changes such
as increased management autonomy, corporatization, and
privatization. It provides some insights about these popular
reform modalities from a review of the literature, reform
experiences in other sectors and empirical evidence from
hospital sector itself. The material presented tries to
answer three questions: (a) what problems did this type of
reform try to address; (b) what are the core elements of
their design, implementation and evaluation; and, (c) is
there any evidence that this type of reform is successful in
addressing problems for which they were intended? While this
paper focuses on issues related to the design of the
reforms, the paper also reports the findings from a larger
study that examined the implementation and evaluation of
such reforms so that they will be available to countries
that are considering venturing down this reform path.
Palabras clave
ACCOUNTABILITY, ALLOCATIVE EFFICIENCY, BUREAUCRACIES, BUREAUCRACY, BUREAUCRATS, BUSINESS MANAGEMENT, CLINICS, COMMUNICABLE DISEASES, COMMUNITIES, CORRUPTION, DECENTRALIZATION, DECISIONMAKING, DELIVERY SYSTEMS, DOCTORS, DRUGS, EMPLOYMENT, FAMILIES, FINANCIAL MANAGEMENT, FIXED COSTS, FRAUD, HEALTH CARE, HEALTH CARE WORKERS, HEALTH FACILITIES, HEALTH FINANCING, HEALTH POLICY, HEALTH SECTOR, HEALTH SERVICES, HEALTH SYSTEM, HEALTH SYSTEMS, HOSPITAL BEDS, HOSPITAL CARE, HOSPITAL SERVICES, HOSPITALS, LABORATORIES, MANAGEMENT STRATEGY, MANAGEMENT TECHNIQUES, MANAGERS, MARKETING, MINISTRIES OF HEALTH, MOTIVATION, NUTRITION, OCCUPANCY, OCCUPANCY RATES, ORGANIZATIONAL REFORM, ORGANIZATIONAL STRUCTURE, PATIENTS, PHYSICIANS, PRIMARY CARE, PRIVATE SECTOR, PROCUREMENT, PUBLIC HEALTH, PUBLIC HOSPITALS, PUBLIC SECTOR, PURCHASING, REFORMS, RESOURCE MANAGEMENT, RETIREMENT, SERVICE DELIVERY, SERVICE PROVIDERS, SOCIAL SERVICES, STRATEGIC MANAGEMENT, TELECOMMUNICATIONS, USER FEES, WASTE, WORKERS HEALTH CARE, HEALTH ECONOMICS, HEALTH FINANCE, HEALTH FINANCING, HOSPITAL REFORM, PUBLIC HOSPITALS, PRIVATIZATION, HEALTH CARE QUALITY