Is the Colombian health system reform improving the performance of public hospitals in Bogota?

Abstract

Many countries are experimenting with public hospital reform - both increasing the managerial autonomy with which hospitals conduct their affairs, and separating 'purchaser' and 'provider' sides of the health system, thus increasing the degree of market pressure brought to bear on hospitals. Evidence suggesting that such reform will improve hospital performance is weak. From a theoretical perspective, it is not clear why public hospitals should be expected to behave like firms and seek to maximize profits as this model requires. Empirically, there is very slight evidence that such reforms may improve efficiency, and reason to be concerned about their equity implications. In Colombia, an ambitious reform programme includes among its measures the attempt to universalize a segmented health system, the creation of a purchaser-provider split and the transformation of public hospitals into 'autonomous state entities'. By design, the Colombian reform programme avoids the forces that produce equity losses in other developing countries. This paper reports the results of a study that has tried to track hospital performance in other dimensions in the post-reform period in Bogotá. Trends in hospital inputs, production and productivity, quality and patient satisfaction are presented, and qualitative data based on interviews with hospital workers are analyzed. The evidence we have been able to collect is capable of providing only a partial response to the study question. There is some evidence of increased activity and productivity and sustained quality despite declining staffing levels. Qualitative data suggest that hospital workers have noticed considerable changes, which include greater responsiveness to patients but also a heavier administrative burden. It is difficult to attribute specific causality to all of the changes measured and this reflects the inherent difficulty of judging the effects of large-scale reform programmes as well as weaknesses and gaps in the data available.

Assessing performance of Botswana’s public hospital system: the use of the World Health Organization Health System Performance Assessment Framework

“…Giving health managers decision rights over key resources is viewed as an incentive to improve performance (6). While evidence on the impact of such an intervention on hospital performance is limited (6,42), some studies reported some degree of improvement. In Uganda, autonomous private not-for-profit hospitals had better quality of care and were more successful in managing personnel and medicines than public hospitals with limited autonomy (43).…”

A review of the experience of hospital autonomy in Pakistan

“…Ssengooba et al (2002) compare public hospitals with private not-for-profit (PNFP) hospitals in Uganda, and report some positive changes with regard to better management of drug supply, improved human resource management, and a higher level of cost recovery. On the other side, McPake et al (2003) could not find enough evidence for any increased productivity and sustained quality, except that while the hospital workers became more responsive to patients they also felt that their ultimate clerical burden had also increased. They conclude, disconcertingly, that it is inherently difficult to judge the effects of large-scale hospital reforms.…”

“…This framework enables the entering of a relative judgment about the level and scope of autonomy exercised in each institution, which they demonstrate for the countries under study. McPake (1996) and Maxwell (1997) also examine how close the relationship is between the autonomy of public hospitals and any improvements in their overall performance, and recently, Ssengooba et al (2002) and McPake (2003) have even questioned whether there is any correlation between the two at all. Ssengooba et al (2002) compare public hospitals with private not-for-profit (PNFP) hospitals in Uganda, and report some positive changes with regard to better management of drug supply, improved human resource management, and a higher level of cost recovery.…”

Implementación de la política de hospitales autogestionados en Chile: percepción de los profesionales hospitalarios

“…por otra parte, la etapa de implementación de otras experiencias de autonomía hospitalaria en américa latina ha presentado como factor común, y obstáculo para la implementación, el alto grado de incertidumbre organizacional en los equipos de salud 25,26 . en el caso de la implementación de la autogestión hospitalaria en el hospital estudiado, la incertidumbre ha estado relacionada principalmente a los niveles de coordinación dentro y entre las propias organizaciones hospitalarias, así como de los lineamientos de parte de la rectoría del sistema.…”