title: 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 decentralisation, and a greater measure of exposure to market forces. In Uganda and Zambia, more traditional 'decentralisation' 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 policy 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 decentralisation 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 decentralisation of control over key resources--seem to us the key tools to address the stubborn problems of hospitals.
authors.affiliation: Health Policy Unit, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. kara.hanson@lshtm.ac.uk
authors.forename: Kara
authors.initials: K
authors.lastname: Hanson
authors.forename: Lynn
authors.initials: L
authors.lastname: Atuyambe
authors.forename: Jolly
authors.initials: J
authors.lastname: Kamwanga
authors.forename: Barbara
authors.initials: B
authors.lastname: McPake
authors.forename: Oswald
authors.initials: O
authors.lastname: Mungule
authors.forename: Freddie
authors.initials: F
authors.lastname: Ssengooba
mesh_terms: D017598:Efficiency, Organizational; D015276:Health Care Rationing; D018166:Health Care Reform; D019981:Health Care Sector; D006739:Hospital Administration / Q000191:economics / Q000592:standards*; D010557:Personnel Administration, Hospital; D011057:Politics; D017009:Professional Autonomy; D012051:Reimbursement Mechanisms; D017749:Total Quality Management; D014454:Uganda; D015024:Zambia