Towards improving hospital performance in Uganda and Zambia: reflections and opportunities for autonomy

Abstract

Hospitals have been relatively neglected although their high resource consumption implies that gains from improving the services they deliver may be substantial. Nevertheless, the challenges posed by hospital reforms are great. Hospital autonomy usually consists of both decentralization and a greater measure of exposure to market forces. In Uganda and Zambia, more traditional ‘decentralization’ of authority to district level authorities includes district hospitals; and some measure of ‘autonomy’(known as ‘self accounting status’ in Uganda) has been applied to some or all second and third level referral hospitals. The hospital policies pursued in both countries present opportunities to tackle their hospital sectors. In Zambia, purchasing of services means that new incentives and hospital mechanisms can come into play. Little advantage has been taken of these opportunities to date. In Uganda, there is no financial link between districts and higher levels of the system, but decentralization of control over personnel is more advanced. These two components – the alignment of incentives (to promote access and quality for those intended to be covered by the public budget) and the effective decentralization of control over key resources – seem to us the key tools to address the stubborn problems of hospitals.