2012年-世界发展银行全球_A_Tale_of_Excessive_Hospital_Autonomy__An_Evaluation_of_the_Hospital_Reform_in_Senegal_50页_2mb

报告摘要

Summary of the 1998 Hospital Reform in Senegal

Core Content

The 1998 hospital reform in Senegal aimed to increase hospital autonomy by granting them significant management rights, inspired by the French model. Despite the reform, the outcomes have been mixed, with improvements in some areas and severe declines in others. The report highlights the need for better accountability mechanisms and financial oversight to address the inefficiencies and inequities in the hospital system.

Main Points

1. Context and Objectives of the 1998 Reform

Before the reform, Senegalese hospitals had minimal legal and financial autonomy, leading to poor performance.
The reform aimed to enhance hospital management autonomy, including legal personality, board of directors, and the ability to charge patients for services.
It was inspired by the French hospital reform and implemented through two bills (n98-08 and n98-12) in March 1998.
The reform was intended to improve the responsiveness and efficiency of the hospital system.

2. Mixed Results of the Reform

2.1 Effectiveness

Ambulatory activity increased sharply: Outpatient visits rose by nearly 20% annually from 2000–2009, outpacing population growth.
General inpatient activity stagnated: Hospitalization rates remained flat, with only a 31% increase over the period.
Obstetrical activity: Hospital-assisted deliveries increased slightly (21%), but the rate of caesarean sections more than doubled (175%), indicating a possible supply-induced demand.

2.2 Quality of Care

There is no standardized method to measure hospital quality in Senegal.
The increase in hospital activity is seen as a proxy for improved quality, though no formal quality assurance systems are in place.

2.3 Equity in Access

Equity has declined significantly, especially for the poorest.
Poor individuals, who constitute 51% of the population, make up less than 3% of hospital patients.
The proportion of social cases (presumed to be poor) in outpatient and inpatient visits has decreased over the period.

2.4 Efficiency and Financial Situation

Technical efficiency declined: Despite increased resources, hospitals have not used them efficiently.
Staff costs surged: Recruitment and wages, especially for non-qualified staff, have increased dramatically.
Financial instability: Many hospitals are close to bankruptcy, with debt levels rising sharply and not being sustainable in some cases.
Inadequate subsidies: Government subsidies do not align with hospital production, and direct revenues from patients are not sufficient to cover costs, especially for poor patients.

Key Information

Hospital Autonomy: Hospitals gained significant autonomy in management and pricing, but accountability mechanisms were not effectively implemented.
Financial Autonomy: The ability to charge patients without rate caps (until 2005) led to increased revenues but also to inefficiencies and financial mismanagement.
Staffing Issues: The number of hospital staff increased by 10% annually, with a high proportion of operating expenses allocated to salaries and bonuses.
Inequity: The poor are underrepresented in hospital users, with their share of outpatient and inpatient visits remaining low.
Caesarean Sections: The rate of caesarean sections has risen significantly, possibly due to financial incentives rather than medical necessity.
Debt and Subsidies: Hospital debt has increased since 2006, and government subsidies have not been aligned with actual hospital needs or production.

Conclusion

The 1998 hospital reform in Senegal has led to a mixed outcome. While it increased hospital attractiveness and outpatient activity, it failed to improve equity, efficiency, and financial stability. The lack of accountability mechanisms and the uncontrolled increase in staffing and wage costs are key factors in the reform's failure. To move forward, the report suggests restoring government oversight, improving financial management, and addressing the inefficiencies in staffing and service delivery.

Recommendations

Reinstate Government Control: Strengthen the Hospital Directorate (DES) and establish mechanisms to evaluate and control hospital managers.
Revise User Fees: Adjust hospital user fees to reflect actual costs.
Reduce Overstaffing: Cut down on non-qualified staff and revise compensation structures.
Restructure Hospital System: Particularly in Dakar, where hospitals are overstaffed and inefficient.
Improve Equity: Allocate a portion of operating subsidies to support outpatient and inpatient care for the poorest.

Appendices

Appendix 1: Overview of financial bonuses for hospital staff.
Appendix 2: Analysis of nurse shortages in Senegalese hospitals.
Appendix 3: Evaluation of hospital efficiency.
Appendix 4: Details of hospital performance contracts.

Figures

Figure 1: Increase in hospital outpatient activity (2000–2009).
Figure 2: Stagnation in hospitalization rate (2000–2009).
Figure 3: No significant increase in hospital-assisted deliveries (2000–2009).
Figure 4: Sharp increase in caesarean sections (2000–2009).
Figure 5 and 6: Low proportion of unpaid patients in outpatient and inpatient revenues.
Figure 7: Decline in social cases treated by Hoggy hospital.
Figure 8: Technical efficiency of hospitals is still low.
Figure 9: Overstaffing in Dakar hospitals.
Figure 10: Hospital debt has increased since 2006.
Figure 11: Debt levels in two most indebted hospitals are unsustainable.
Figure 12: Annual increase in hospital workforce (2000–2009).