An analysis of hospital autonomy reforms in Albania, Bulgaria and Slovakia
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An analysis of hospital autonomy reforms in Albania, Bulgaria and Slovakia. Jeremy Veillard WHO Regional Office for Europe Technical Officer Hospital Management [email protected]

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An analysis of hospital autonomy reforms in Albania, Bulgaria and Slovakia

Jeremy Veillard

WHO Regional Office for Europe

Technical Officer Hospital Management

[email protected]


  • Autonomy is Bulgaria and Slovakia the extent of decision rights hospitals have over various aspects of production, including inputs, outputs and management processes

  • Autonomy is important because:

  • It provides the critical instrument that enable organizations to respond to incentives

  • The ability to tackle a problem locally is likely in most cases to lead to faster and better decisions

  • Local circumstances vary sufficiently to call for local flexibility

  • If central government control is to be made less rigid, then local accountability should be strengthened



  • Autonomy and accountability should be closely linked autonomy

  • If management autonomy is increased at hospital level, managers should bepublicly accountable (to central and local levels) for how they exercise that autonomy:

  • Financial probity and accountability in use of funds

  • Conformity with central government policies

  • Satisfying local community on range, quantity and quality of services provided

  • Fitting into the local pattern of services






Discussion (1/2) overview

  • Well-designed provider payment mechanisms have proven to be not sufficient conditions for restructuring hospital systems

  • Lack of alignment between reform of provider payment mechanisms and organizational reforms (including hospital autonomy & accountability)

  • Albania, Bulgaria, Slovakia: three different socio-economic profiles but have all started decentralization of decision rights to hospitals even if achievements are very different

  • More decentralization of decision rights is not going with appropriate accountability mechanisms and incentives


Discussion (2/2) overview

  • Steering role of the Ministry of Health is crucial in building up an aligned architecture of hospital reforms

  • Need to update the quality of information systems: need to produce smart information to decision-makers and to communities (central and local accountability)

  • Need to develop national capacities for reform management

  • Focus on accountability and governance


The way forward: key components for hospital reforms in Albania, Bulgaria and Slovakia

  • Strengthening capacities of the Ministry of Health to fulfil a strategy-setting stewardship function

  • Introducing new accountability mechanisms through more effective use of contracts, quality assurance and performance monitoring

  • Aligning incentives and decision rights including completing the transition to a more proactive health-service purchasing model

  • Clarifying the role of local governments

  • Improving hospital governance


Assessment of hospital autonomy reforms effects Albania, Bulgaria and Slovakia

  • What are the effects of the new mix of hospital autonomy and accountability on the hospital and its performance?

  • How has the mix of funding sources changed, and have funding levels increased?

  • Has management become more efficient and responsive, as anticipated?

  • What have been the effects of the new mix of hospital autonomy and accountability on the allocative efficiency and equity of resource allocation patterns in the health sector?

  • Are the services provided by the hospital more closely aligned to its intended role and function in the health system? Or has the autonomy policy caused a divergence, suggesting a negative impact on sectoral efficiency?


Selected references Albania, Bulgaria and Slovakia

  • Robert J. Maxwell: “Decentralizing authority to health facilities: a framework for descriptive analysis and assessment of hospital autonomy”, WHO, Geneva, August 1997

  • Mukesh Chawla et al., “Improving hospital performance through policies to increase hospital autonomy: methodological guidelines”, Harvard University, August 1996

  • Martin McKee et al., “Hospitals in a changing Europe”, European Observatory on Health Care Systems and Policies, 2002

  • Alexander S. Preker et al., “Innovations in Health Service Delivery: the corporatization of public hospitals”, The World Bank, January 2003

  • Health in Transition Profiles for Albania, Bulgaria and Slovakia, European Observatory on Health Care Systems and Policies


Acknowledgments Albania, Bulgaria and Slovakia

  • Dr Silvana Novi, Chief expert, Hospital Directorate, Ministry of Health, Albania

  • Dr Mariette Hristozova, Head of the Regional Public Health Directorate, Stara Zagora Region, Bulgaria

  • Dr Eugen Nagy, Chief expert, Health Sector Directorate, Ministry of Health, Slovakia

Contact: [email protected]


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