A review of the experience of hospital autonomy in Pakistan

M. Tanweer Abdullah*,y and Jane Shaw

Nufeld Centre for International Health & Development, Leeds University, Leeds, UK

SUMMARY
This paper examines the recent trends in public hospital autonomy as an integral part of health systems reforms. It reviews literature produced on the subject across a range of developing countries and explores varying viewpoints, arguments, and rationale for hospital autonomy developed over the past two decades. It then leads onto a discussion of two experiences of autonomy reforms in Pakistan: the provinces of Punjab and NWFP. Derived from the lessons learned from these initiatives, a set of guidelines is suggested as sustainable frameworks for reviewing the current measures and for designing future autonomy initiatives in Pakistan. Copyright # 2006 John Wiley & Sons, Ltd. key words: hospital autonomy; developing countries; health services decentralization; comparative health systems reforms; Pakistan

BACKGROUND The issue Public sector hospitals in the developing countries are generally characterized by inefcient resource management, low productivity, unfriendly or unprofessional patient care, rigid hierarchical structures, ineffective administrative and nancial controls, and an absence of performance-based incentives. They are often compared, to their detriment, with relatively efcient and cost-effective NGO hospitals, or with more exible and patient-friendly private hospitals. After many years in which health policy concentrated on Primary Health Care, and hospitals were seen as expensive and irrelevant level of care, recent policy trends in health system reforms have advocated for granting autonomy to public hospitals as a solution to their problems. It is claimed that with autonomy, hospitals can plan their services effectively, manage staff and other resources efciently, respond exibly
* Correspondence to: Dr M. T. Abdullah, Programme Coordinator, Health Planning and Management, Institute of Management Studies, University of Peshawar, Pakistan. E-mail: mtabdullah@hotmail.com y At the time of writing this paper, the co-author was also placed as Visiting Scientist at the Tavistock Institute of Human Relations, London, and on permanently basis as the Associate Professor of Health Planning and Management at the Institute of Management Studies, University of Peshawar, Pakistan.

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and sensitively to patients needs, and provide appropriate and cost-effective secondary or tertiary care as an integral part of the health system. This article sets out to review and examine some recent experiences of hospital autonomy in Pakistan, draws out the preliminary lessons that must be learned from these, and, on their basis, proposes a framework for further work.

Current published views on autonomy Commentators have not been slow to criticize the management performance and quality of medical care of public hospitals in developing countries. When comparison is made with the private sector or the non-government sector hospitals, it is almost always to the detriment of the public hospital (Green, 1987; Ssengooba et al., 2002; Preker and Harding, 2003). They are also costly: in a study of 29 countries (Barnum and Kutzin, 1992), it was reported that government hospitals consume about 60% of the total state expenditure on health, which, in the light of their failings, outlined above, becomes a serious concern for social researchers, policy makers, and managers. Hence it is often proposed that allowing autonomy to these hospitals could provide solutions to many problems. In making that6 presumption, in the case of several developing countries,1 the scope of and the rationale for autonomy have been drawn out from, among others, clear shifts in the international political-economy of health and development (World Bank, 1987; Mosley et al., 1991; Newbrander et al., 1992; World Bank, 1993; Zaidi, 1994; Preker and Harding, 2003), the macro- or meso-level policy options and strategic initiatives (Hildebrand et al., 1993; Mills, 1995; Govindraj et al., 1996; Collins et al., 1996), institutional reforms (Cassels, 1995; McPake, 1996; Govindraj and Chawla, 1996), the doctrines of the New Public Management, or publicprivate mix and partnerships (McPake, 1993; Chawla and George, 1996), and the scope for organizational change (Bossert et al., 1996; Collins and Green, 1999). Several concerns may be raised at this point: How to dene institutional autonomy and make sure that it is contextually appropriate? How to design the autonomygranting process and ensure the viability of its stages? How to create conducive environments for an effective implementation process for translating an ambitious policy agenda to effective operational procedures? How to fairly evaluate the impact of the granted autonomy with regard to successful or desirable outcomes? And, how to sustain such interventions in the health systems of the developing countries that frequently operate in impermanent, inconsistent, and turbulent environments? (Abdullah, 2000) Some critical insights into the answers for these questions can be drawn from the literature that has been produced on this subject over the past about 10 years. However, researchers and critics have also been conscious of the fact that the experiences of implementation and evaluation of autonomy has produced relatively little academic documentation, in terms of the range of limitations and challenges experienced in the mainstream practice, or in dening the scope of
1

In addressing to the main themes, this article focuses only on the developing countries. A number of the developed nations, which had similar or different experiences and approaches to hospital autonomy, and are extensively reported in the literature produced since the mid-1990s, have not been covered. Copyright # 2006 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2007; 22: 4562. DOI: 10.1002/hpm

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effectiveness in the actual improvement of performance (Govindraj and Chawla, 1996). Although it is generally assumed that autonomy leads to increased productivity, it is feared that enhancing the quality of care that has been one of its leading arguments may take a second priority to improved economic efciency dened as: allocation of resources among alternative activities in such a way that will produce the same output at the lower cost (Govindraj and Chawla, 1996, p. 5). The World Bank raises another concern by questioning whether autonomy may result in a compromise on equity in the nancing and delivery of health care (Chawla and Berman, 1995). Therefore, any attempts to examine the intended aims and objectives of government in granting autonomy to hospitals must interpret efciency fairly sufcient to allow for quality consideration, and for equitya major component of Primary Health Care and a universal indicator of access to basic health care provision in the developing countries (Collins and Green, 1994). Efforts have been made in the past decade to develop general frameworks for assessment of hospital autonomy. In particular, Govindraj and Chawla (1996) at the Harvard School of Public Health, proposed a provisional conceptual framework to examine the experiences of hospital autonomy in ve countries: Ghana, Kenya, India, Indonesia, and Zimbabwe. Each case study was guided by ve main objectives: (1) (2) (3) (4) Analysis of reasons why autonomy was given to the selected hospitals; Description of the approach and process of giving autonomy; Description of the nature and extent of autonomy; Assessment of the impact of autonomy on resource mobilization, efciency, accountability, equity and quality of care; and (5) Suggestions for successful implementation of autonomy. The ndings of Govindraj and Chawla (1996) are based on both qualitative and quantitative analyses, hence, quite useful. But, since they are being derived from case studies, there remains the question of consistency and generalization. For instance, the levels of hospital facilities selected vary from tertiary to secondary and primary, and the timing of their autonomous status varied between 1975 and 1993a time gap of 18 years. Presumably, all the hospitals had different reasons, motivations and rationale, enough for comprising very diverse and broad parameters; internal and external, with regard to their size, structures, stages of the transformation and change processes, and the extent of politicization of the intervention. The authors also concluded that the issue of equity had worsened in general, especially in the case of a charge or an increase in the user fees; and that any clear evidence of improvements was found only in the development of systems for physician payments. Ensuring a fair amount of effectiveness and viability into the processes of institutional transformation is also a key consideration in designing autonomy. Collins and Green (1999) propose a classication of hospital organizational change to examine the cultural and social environment in which the processes of transition and change could be sustained. The key areas they identify are (a) human resource managementstaff establishment, recruitment, conditions of service, rewards, and discipline; (b) Financesubmission of own budget, obtaining grants and loans,
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raising income; (c) Planningdeveloping own capital plan; and (d) Logisticsown tender process, decision on in-house services or contracts. In a comparative analysis of decentralization in Ghana, Zambia, Uganda, and the Philippines, Bossert and Beauvais (2002) introduce the concept of decision spacean analytical framework for examining autonomy in hospitals. With a similar focus on nance, service organization, human resources, access rules, and governance, we nd their concerns to be more or less the same as Collins and Green (1999). They produce a decision matrix (to delineate the decision space) by plotting three degrees of decentralized decision making, that is, narrow, moderate, and wide, on the vertical axis, and the above-indicated management functions, on the horizontal axis. 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-prot (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 nd 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 difcult to judge the effects of large-scale hospital reforms. The task of designing a framework for an effective autonomy process and then constructing an evaluation of its impact on a range of complex areas such as equity, public accountability and quality of medical care, is certainly a very challenging one. Social scientists, consultants, and practitioners in this eld must therefore recognize and project the importance of aligning their interventions to the indigenous contexts of the developing countries. Cassels (1995) reports several countries where a disregard for contextual understanding of the existing health care systems and policies, and the sources of ideas, experiences and information, had resulted in weak implementation and poor outcomes. Taking these parameters for granted or simply transferring the reforms agenda as a package from one country to another (Moore, 1993; Collins et al., 1994; Cassels, 1995) may not be helpful (Abdullah, 2000; Mills et al., 2001). As a subject of the recent trends in decentralization, hospital autonomy has generated a fair amount of literature (some of which has been discussed above), however, very few studies are carried out on public hospitals in Pakistan. Any documentation on the design of the autonomy processes or their evaluation is certainly missing. We therefore attempt to review the countrys experience of hospital autonomy over the past few years and identify the salient features and issues. We then propose frameworks, which may be used by researchers in further studies and by practitioners and policy makers in Pakistan to assess the past interventions, and may guide the design of future initiatives.
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THE EXPERIENCE OF PAKISTAN The issue of autonomy of public hospitals in Pakistan, with its assumed linkage with the improvement in quality of medical care has been under discussion since the mid-1990s. But it took a controversial turn and has been heavily debated in the political and journalistic circles only since the early 2000s. Autonomy for hospitals is a natural concomitant of decentralization to local level for community-based services, but it has been generally perceived as a manifestation of the economic liberalism imposed by the World Bank and IMFthe new right thinking (Collins and Green, 1993, p. 58), and a part of the international political-economic interventions for health sector reforms in Pakistan: the agenda from abroad since the 1950s (Zaidi, 1994). The Social Action Programme, for example, initiated in the early 1990s, was a multi-donor initiative in the health and education sectors and required the development of interventions largely reecting donor preoccupations, such as family planning, women and child health. . .and of course decentralization. Zaidi (1994) reviews different studies to conclude that changes within the health sector of Pakistan are often determined by consequences outside the health sector: . . . international pressure in the form of aid, foreign policy and political imperatives, and more importantly, the changing World Climate . . . (p. 1391). With the perceived linkage of autonomy with privatization and deregulation, a restrain on the role of the state, and practice of open market economics, the very basis of public hospital policy reforms in Pakistan has become a politicalideological question.

Health systems prole of Pakistan Administratively, Pakistan is made up of four provinces: Punjab, Sindh, the NorthWest Frontier Province (N-WFP), and the Baluchistan; along with the Federally Administered Tribal Areas (FATA), the Northern Areas, and the Azad and Jammu Kashmir. Each province is divided into Divisions, consisting of Districts, which in turn comprise Tahsils/Talukas (sub-Districts) each again having a number of Union Councils. A Union Council is the lowest administrative level in rural areas comprising 10 villages (Ministry of Health, 1991). At the provincial level the Health Department is responsible for the overall planning and management of health services and direct management of teaching hospitals, specialized hospitals and medical colleges. The provincial Secretary of Health is at the top of its administration and the Director General of Health at the provincial level is supervised by the Secretary and is responsible for the overall organization and management of the public health system throughout the province. The delivery of health care services at lower administrative levels is carried out within this structure which is headed by the provincial Director General of Health. At the Divisional level the services are organized under the Deputy Director and at the District level by the District Health Ofcer (Ministry of Health, 1991). At the District level the health services are delivered at the following health care facilities:
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(i) District headquarters hospitals, (ii) Sub-District (Tahsil/Taluka) hospitals, (iii) Government-owned primary-level health care facilities like dispensaries, Maternal and Child Health (MCH) centres, Rural Health Centres (RHCs), Basic Health Units (BHUs), and Sub-centres, (iv) Social security service outlets, (v) Health establishments of the Red Crescent Society, (vi) Private clinics, (vii) Population welfare centres, and (viii) Local government health facilities [Ministry of Health, 1991] Efforts have been made in Pakistan to produce an administrative and nancial viability with regard to the WHO model of district health management (Tarimo, 1991). For the purpose of decentralizing administrative authority, the Government in Pakistan launched a new plan in August 2001 to establish and re-organize Local Governments in all the districts of the country. In theory, and according to promises made by the government, this initiative creates both an opportunity and a challenge for strengthening the district health system, including some local accountability and discretion in service delivery. But in the absence of any standardized operational policies, procedures and regulations, and their documentation, the National Reconstruction Bureau (the founder of this policy), and the Provincial Health Departments have still not been any clear about their functions and responsibilities. Even within the Health Department there have been conicts, with policy units arguing for early devolution and resource departments such as Finance very reluctant to lose control so promptly. While a demand for local accountability could effectively promote hospital autonomy at the district level, it does not inuence the autonomy of the larger urban hospitals, which remain the direct concern and domain of the Provincial Health Department. In the following section we describe the experience of autonomy in two settings: in the Punjab and the NWFP. We then analyze and assess the outcomes and identify the key factors and issues. Health services decentralization reforms in the Punjab A series of health service reforms was undertaken in the Punjab during the 1990s, all involving attempts at decentralization. The initial trigger was the World Bankfunded Second Family Health Project that was established as part of the Social Action Programme (referred above). The two initiatives, which are relevant to autonomy, are the Sheikhupura Pilot Project and the granting of institutional autonomy to a number of public hospitals. Sheikhupura pilot project (SPP). The Project, as described by Collins et al. (2002), was seen to link the creation of semi-autonomous district hospitals (as an appropriate system and level of health management) with attempts at decentralization reforms of the health sector in the whole province. The SPP (also reported by UNICEF Project Management Team 1994), as designed for this purpose, aimed at, rst, producing,
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and then testing a model of decentralization and community participation. The motivating force was understood to be international interest in health system reform, mediated though the donors who funded the parent project. It was hoped that if successful, this could be replicated over the rest of Punjab and then all over Pakistan on the wider scale. The decentralization component covered devolving authority from the District Health Team to Tehsil (sub-district) Health Teams, delegation of nancial powers to lower levels, and some restructuring and development of the community public health programs.

What happened? According to Tarin [2003], a project ofce and eld ofce
were established in 1992. A devolved management structure for the district level health sector, with relevant job descriptions and a detailed analysis of delegated powers were developed. Communities were mobilized and a network of organized village communities was also created. But the delegation of powers was frustrated by a lack of enabling action from the Health Department, for example, the district accounts staff were not allowed to take up positions to effect the delegation of nancial powers. The project was never integrated with the District Health Ofce and mainstream health services; a proposal was made for the eld team to report to the DHO, but this required amendment to the Rules, which was beyond the purview of the Health Department. After about 4 years the interest of the donors and senior ofcials shifted to other reforms and the project gradually lost momentum. It closed, unnished, in 1998, but it is reckoned (without any evaluation studies linked to that argument) to have inuenced other reforms in health services, such as District Health Authorities and District Health Government and, according to one senior ofcial, to have also spurred other government departments to change. Institutional autonomy. Tarin [2003] outlines the principles and purposes of the reorganization that granted autonomy to teaching and other hospitals under the Punjab Medical and Health Institutions Ordinance 1998, as the following: (a) to improve quality and efciency, including better availability and accessibility of services; (b) to promote local decision making and reduce the role of the central state; and (c) to promote the economic viability of the institutions. Some other motivating factors could include the removal of overlapping and poor resource management, the impending desire to reform consultants private practice, and a growing need to distance provincial government from direct involvement in health care delivery.

What happened? Under the Ordinance (Government of Punjab, 1998a), all the
9 medical colleges and associated teaching hospitals, and 16 other hospitals in the Punjab were granted autonomy in three phases, with each medical college and associated teaching hospital brought together under a Chief Executive (CE), a contractual employee of the provincial government. For each set-up, an Institution Management Committee (IMC) was established, headed by the CE and had members
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from the public and the private sectors. Contrary to expectations, the College Principals were not automatically promoted to CE, but the new Chief Executives were appointed for these institutions in open competition. The nance directors were also appointed and the institutions were given some administrative and nancial authority: they were allowed to open commercial bank accounts, which enabled them to save rather than return unspent balances; and user charges were authorized and levied. But controversies soon developed. The powers of the CEs were predicated on them working through the IMC, but the initial nominations of members for these committees, proposed by the CEs were blocked by the Provincial Government on the grounds that it went against the spirit of autonomy for an ofcial to nominate non-ofcial committee members. Consequently, the powers of the CE were practically limited to those of the Medical Superintendent of any other government hospital. Financial rules giving effect to autonomy were only framed some three years later; but they still gave full nancial powers to a CE only through the IMC, and as few IMCs were in place, autonomy never became fully effective, and on the change of government, the project was shelved.

Public hospitals autonomy in the N-WFP In 2000, the four largest public sector, tertiary care and teaching hospitals in the N-WFP were granted autonomy by the provincial government. These were the Lady Reading Hospital (LRH); Khyber Teaching Hospital (KTH); and Hayatabad Medical Complex (HMC) in Peshawar; and the Ayub Medical Complex (AMC) Abbottabad. Since the instruments of policy implementation in each of these were broadly similar and so were the institutional performance outcomes, we take the case of the 1200-bed KTH and examine these reforms in what may fairly be considered a representative teaching hospital.

The khyber teaching hospital. Under the N-WFP Medical and Health Institutions Reforms Act 1999, a new set of rules to govern the health institutions of the province were promulgated (Government of NWFP (Department of Health), 2001). Fairly similar to the case of Punjab, following are its salient features that relate to hospital autonomy: (1) The appointment of a Chief Executive (CE) for each institution; combining the constituent medical colleges and other related institutions under a common Head; (2) The establishment of a Institutional Management Committee (IMC), chaired by the CE, and consisting of members from public and private sectors; (3) The Principal/Dean of the constituent medical college(s), the hospitals Medical Superintendent (MS) and the Finance Director all to report to the CE; (4) All the nancial resources received by the institution in the form of grant-in-aid from the government, donations, user charges, rents etc, to constitute a fund of the institution. The institution to be self-budgeting and generate a proportion of its own income;
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(5) Private practice, to be carried out within the institution and its earnings to be shared by the professional practising staff and the institution, to be decided by IMC; (6) The government employees posted in the institution who do not opt for absorption in the service of the institution, to continue to work as civil servants till retirement (p. 5). (7) The annual performance evaluation reportnormally called Annual Condential Report (ACR), of the Principal/Dean and Medical Superintendent be initiated by the CE and countersigned by the Secretary Health, and of the Director Finance, to be countersigned by the Secretary Finance.

What happened? As in the case of Punjab, the NWFP hospitals also became a
victim of weak and hurried documentation. While all the four hospitals had a CE each in early 2000, the notion of autonomy from the Department of Health kept oscillating between little and more. This went on for quite some time, until some CEs discontinued their jobs. The successful CEs among them were those who understood and accepted the transitional requirement of adjusting to both the preand post autonomy administrative frameworks and did not complain or assert for more autonomy. A similar negotiated order was maintained regarding the role and authority conict with the MS and the principals and deans of the medical colleges. The problems faced by the KTH prior to the autonomy reforms were more or less the same as other large public hospitals of developing countries. They included absence of rules and regulations for governance; staff absenteeism and unionism; lack of staff incentives; physical and hygienic deterioration of the building; shortage of facilities and equipments, non-availability of hospital inventory system and scarcity of funds. Although no independent pre- or post-autonomy evaluation of KTH or any other similar hospitals has been conducted, a critical account of some reports that outline its performance over a period of 3 years (April 2000April 2003) is given as following: (1) It was able to develop some structural frameworks for future inputs into: (a) targets for nancial and administrative restructuring from within; (b) verication and valuation of hospital assets and production of a Balance Sheet, and subsequently, the development of an autonomous entity that was required under the Reforms Act. (2) Measures were taken for accountability and regular internal auditing, for the purpose of internal controls against pilferage and shortages. The deputation of the Director of Finance from the government was an effective transitory approach towards institutional checks and balances that was mandatory until the system had matured. This scheme has proved fairly successful in the past for the newly established semi-autonomous public institutions. (3) An Oxford Policy Management (2002) notes the positive and intelligent use of the freedom of autonomy and the exibilities that were found to be in operation, such as appreciation payments to staff, regularization of 300 contractual staff, a pay increase of Rs. 600 to all the staff across the board, and the
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(4)

(5)

(6)

(7)

introduction of incentive payments for attracting or retaining staff in rare specialties (pp. 1213). The policy of Institution-Based (private) Practice did not prove any effective or sustainable for other hospitals, but in KTH some achievements were reported in the 3 years of operation, including: creation of additional job opportunities, part-time employment, revenue generation for hospital needs, and improved utilization of its resources. The net prot of the hospital reported for about one year period (from March 2002 to February 2003) was Rs. 10 million. It was spent on the provision of space and equipment for the establishment of out-patient facilities in the nephrology, oncology and orthopaedic departments, and for providing round the clock emergency and diagnostic services within the hospital premises. Regarding human resource management, some initiatives were reported in the selection and recruitment against vacant posts; re-designation and up-gradation of several posts and infusion of younger and technically qualied staff in key areas like Information Technology, and for the audit of documentation produced and its computer-generated access for internal and external uses and public accountability. The public-private partnership initiated in the hospital covered the costs of diagnostic services at subsidized rates and the repair and installation of an old oxygen concentrator plant that was lying damaged since 1998, and saved the purchase of medical gases from the open market, potentially saving an estimated Rs.5 million annually. A database development project was initiated in the early stages of autonomy. Initially, it covered patient registration and admission system, payroll system, store procurement system, personnel information system, and inventory management system. After its successful completion, in the second phase, an IT department is being established, with a separate computer-based nancial audit. In the third phase, it is planned that computerization and web-based research and admission facilities shall be introduced for students and researchers from the constituent medical colleges.

Discussion The experience of these initiatives could be useful for us to understand decentralization and specically hospital autonomy in Pakistan. From the concerns initially outlined in the rst section, we may question further into the nature and extent of autonomy, its linkage and integration with the broader health sector reforms, appropriation of autonomy reforms within the existing organizational models, analysis of the internal factors of the hospitals, and the design of integrated systems for consensus-building and goal attainment, quality of care, and performance evaluation. First, in case of autonomy of the Sheikhupura Pilot Project, since it was never devolved from its parent institution into the mainstream health structure, nor were changes to administrative and management systems properly followed through and made effective, for instance, with regard to the crucial drawing and disbursing powers the required amount of functional autonomy was not achieved. The development of village committees however facilitated the expression of local views
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which could act as a counter-balance to central power. In the case of the Punjab autonomous institutions, problems with a weak and incomplete documentation on the ofce of CE, the IMC and other structures resulted in unclear authority, role-conicts, and ultimately poor outcomes. In NWFP however, KTH was able over time to use its new powers effectively to generate income, negotiate with professionals and manage its own staff. But it was still rmly under the ultimate control of the Health Department, since the staff was posted civil servants, and the key managers had their Annual Condential Reports signed off by the Secretary Health. At best therefore, its position could be termed semiautonomous. In this regard, the management of the Annual Condential Report (ACR) has an intriguing administrative psychology behind it. In many cases, it is perceived as a major threat from the superior to the subordinate in the public management cultures (Qureshi, 1985). It can never produce a participative or decentralized work environment; rather, it induces status quo and conformity-driven cultures. Second, the SPP, because it never became part of mainstream district management, suffered from both obstructionism and neglect by the centre, and consequent delays in resource use and staff deployment. Owing to a mixture of patronage and rivalry among staff (Collins et al., 2002, p. 137) the turnover within the district level health systems was very high. This model did not appear to be sustainable and consistent enough to manage the human resources and survive the inevitable disruption and turbulence of institutional change. The Punjab autonomous institutions faced opposition initially from disappointed college principals, who now had a boss, and continuing frustration from the lack of rules to enact their promised delegated powers. The KTH, by contrast, was enabled to practice delegated management, but faced difculties with a lack of clarity in managerial roles The ` concept of management and administration needed clear documentation vis-a-vis the tasks of the CE and the MS. The Reforms Act outlined management of the hospital as a function of both the CE and the MS, and it also required the MS to report to the CE. Since the position of the MS is historically established (traced back to the colonial era), and therefore well institutionalized, a new denition of its role and documentation of job description was not taken seriously. It could be argued that ideally, the CE could leave the administration of the entire hospital to the MS and concentrate only on strategic management (generation of funding sources and quality improvement etc), coordinating the IMC and the constituent colleges, and improvement of external relations. Further, since the CEs employment was contractual, it was difcult for him to maintain a directing relationship with the senior professors and deans, who all enjoy sustained professional power in the mainstream (in many cases more than the CE). Even sharing a power domain in running the affairs of the IMC was a challenging task. Interestingly, in comparison with the other three hospitals, only the CE of the KTH survived and completed his 3-year contractual period (April 2000April 2003), which appears to be a reason for fairly successful institutional outcomes. Third, in the Punjab reforms, with regard to hospital nancing and resource allocation, in addition to the standard amount of Rs. 100 million annual provincial grants, each district was expected to generate its own additional funds. The Concept
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Paper (Government of Punjab, 1998b) for district health government also asked for alternative sources of nancing in the form of user fees to incorporate equity: people who can afford shall be paying fees whereas the poor shall be subsidized by enhanced cost recovery, however, Collins et al. (2002) comment that: on the assumption that the districts would be able to generate additional funds (and this by no means clear), then it would be the richer districts that would generate the additional funds and not necessarily the poorer ones . . . decentralization can sow the seeds of health care inequity (p. 142). Both the Punjab institutions and KTH had considerable success in generating additional income, and the additional exibility they had been granted enabled them more efcient appropriation of all their resources. Fourth, quality of care and equity of access prove to be the acid test of autonomy and that still remains a challenge, and even a threat to the future of public hospitals. No technical evaluation of pre- and post-autonomy stages has been done for developing comparisons and establishing a convincing rationale for autonomy reforms. The policy makers and the general public (the end-users) still remain confused about the current potential and the future status of these reforms. Fifth, it was felt important to develop pre-requisite conditions that were conducive for decentralizationtaking it as a conscious effort, and an imperative process of change and transformation; structuring and restructuring of autonomy. This required the production of operational plans and implementation guidelines with insights into how to effect change and remove common obstacles in way of successful implementation. These could be focused on ve-key areas: (i) governance and administration; (ii) nance; (iii) human resource management; (iv) procurement; and (v) hospital information systems.

GUIDELINES FOR AUTONOMY EVALUATION In the light of the literature reviewed earlier, and the experiences of Pakistan, there is clearly a scope for further understanding, research, and policy development on public hospital autonomy, and for a consistent and systematic framework for the evaluation of the institutions which have been granted autonomy. The following considerations derived and the lessons learned from the studies above, could be used as a general checklist for planned initiatives and as parameters for initial measures of evaluation. Documentation It is quite clear that both in the Punjab and N-WFP, accurate and complete documentation of the design and operational planning of autonomy reforms was missing. This created difculties not only during immediate implementation but also for subsequent measures of evaluation. It would be helpful to have a published Mission Statement for each hospital, to dene the purpose, objectives and the scope of the institutional autonomy granted with clear and detailed expectations of the Department of Health regarding its results. These documents would work as guidelines for the design of institution-level operational planning and policy
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development and would ultimately determine the hospitals prioritieswhether generation of revenues, increasing access, improving service standards, or public accountability and so on. The value of such a statement was evident in the case of KTH, where its success was partly linked to clear targets and phase-by-phase implementation (Ofce of the Chief Executive, 2003). Similarly, a clearly stated job description and functional responsibilities of the institutions like the Chief Executive and the Institutional Management Committee and the domain of their authorities would also reduce the confusions and role-conicts. Further, the autonomy documentation must not be considered a one-off activity. It must be taken as long-term and continuous process of institutional development; with an identication of and development of protocols for its different stages of institutional change, transition, and transformation and the respective approaches required for managing these. Similarly, the training requirement of different levels and categories of hospital staff must also be identied during these stages and incorporated accordingly. This could be achieved within the existing infrastructural capacities: for the purpose of integration and sustainability, the design and documentation part of the autonomy reforms could be entrusted to the HSSRU of the NWFP Health Department, and the mandatory institutional training and development (e.g., Quality Control, Clinical Audit etc.) may be carried out by the Provincial Health Services Academy. Clarifying management roles Linked to the above argument is the importance of clarity of managerial roles, which was the underlying source of tension at the KTHthe overlapping roles of the CE and the MS, and the lack of effectiveness in the functional role of the IMCs in the Punjab. The Management Committee in an autonomous hospital should effectively assume a pseudo-model of corporate Board of Directors, where the members would know their power stakes, however, checks and balances would operate, and designated institutional sub-committees could be made responsible for overseeing the specic aspects of the hospital administration. Since, a majority of the IMC afliates are busy professionals, whether clinicians or external members, they may not (even if they wish to) be able to practically involve themselves in mainstream operational planning and management, and could conne the Committees major thrust of work to strategic matters, policy issues, monitoring, and evaluation. The CE is therefore not only ultimately responsible for the hospital but also needs to be physically present and available in his ofce. Any effort in the future to make this position part-time, adjunct or honorary would only prove futilelike in the past. The decision-making powers, whether formal or informal, would revert back to the ofce of the MS, which could be seen as a U-Turn of the autonomy initiative. Ensuring sustainability The political-policy environment for health planning in Pakistan is characterized with the challenges of turbulence, inconsistency and impermanence and strongly inuenced by the international political-economic factors (Abdullah, 2000), of which management decision-making for a hospital cannot be independent
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(Abdullah, 1992). Social researchers, planners, and practitioners must be aware of the gravity of this factor and take substantive measures to allow the effect of these in their design processes and to ensure the planned reform is sufciently robust to survive turbulence. In a country like Pakistan, it would be inappropriate to expect the autonomy process to lead public hospitals to behave like rms and corporations, with a major focus on maximization of revenues as their major interest [McPake, 2003]. Nevertheless it is observable that this perverse incentive is often built in to the relevant regulations. It may be argued that public sector hospitals, by their nature, can never achieve the level of autonomy that potentially exists as in the private sector, and indeed this should not be their major concern (Govindraj and Chawla, 1996); and the autonomy issue should be taken by the state as a generic need in the future drawn out from a long-term, consistent, and broader political agenda, rather than having a specic thrust only on its implementation in hospitals.

Maintaining and enhancing quality of care Although this may be the most serious challenge for social planners as much as institutional economists, the primary focus must remain on quality of care, and the designers and implementers must not make compromises simply because in the case of Pakistan the users of health care services are uninformed of their rights and not very demanding. The consumers of health services hardly ask any hard questions on the quality of services provided to them because they have an unconditional respect for the medical professionals. But there are clearly problems with the quality of public health care in the N-WFP where a survey reported that as a rst choice only 27% people go to the public sector; while 63% show a dissatisfaction regarding overall quality of care, with reasons ranging from indifferent attitudes of providers to non-availability of essential drugs (Oxford Policy Management, 2002, p.14). The quality of care is also compromised with regard to the physicians consultation time, which in public hospitals is an average of 13 min per patient. It may be argued that if the quality of care is not improved the whole exercise of autonomy is pointless. But, as indicated above, quality is not always the rst priority on the agenda for a newly autonomous hospital. Therefore, there is value in formal quality assurance systems, including accreditation or certication, but also through systems for patient feedback and consultation. As part of health sector reform for the NWFP in 2002, the Department of Health in technical consultation with Oxford Policy Management, UK produced a strategic agenda for integrated health sector reforms in a series of 16 reports. This includes some key recommendations regarding decentralization and autonomy, which require letting the community perceive and supervise the quality of medical care provided to them. The notion of quality assurance in the case of Pakistan is very broad, and could be used for any systematic effort to improve performance of health institutions simply by achieving the targets in comparison with the set standards. Again, systematic documentation is essential on procedures for monitoring and evaluation: quality must not only improve but also be demonstrated to improve.
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Ensuring public accountability In order to effectively balance autonomy of action with public accountability, the public hospitals that are granted autonomy must be regulatedautonomy may not be confused with deregulation. In Pakistan, the public opinion (citizen groups and consumer watchdog organizations), the pressure groups and the media are not vigilant enough to correct any malpractices. For this reason, the state must maintain a watching presence, at least initially, through networking and a system of checks and balances (for example, in the case of Director Finance for the public hospital, to be deputed from the federal government Audit and Accounts department) to monitor and regulate these institutions. One possibility, as in NWFP, is the recently established Health Regulation Authority, which could be granted complete independence in executing its operations for this purpose. Other additional quasiregulatory mechanisms and tools for consideration, include: (i) accreditation of hospitals by an independent agency, as a mechanism aimed to ensure that the quality of health services is acceptable and there is a systematic compliance with set quality standards (Oxford Policy Management, TR No. 9, p. 11); (ii) development and enhancement of hospital management information systems, and regular publication of reports; (iii) development of Standard Operating Procedures (SOPs) for individual hospitals to regulate and improve levels performance; and (iv) developing a quality culture with patient involvement. Balancing nancial health with equity of access Two conicting imperatives have to be balanced in the design of autonomy for public hospitals. The positive economic rationale include: managerial and budgetary reforms, technical efciency, choice of optimizing and prioritizing functional inputs and outputs by types and levels, increased public nancial accountability, and encouragement of competition within the sectorand this means increasing access to care for patients. The negative economic rationale is likely to include cost recovery and fee-setting, which may have a damaging effect on equity, changing the culture of the hospital to a commercial corporation, reallocating public money meant for the essentially poor into the mainstream hospital management and subsequently, in many ways, jeopardizing the quality of care. Parallel management evaluation systems While the hospital staff remain public servants, subject to posting and discipline from the center, and while the top managers annual reports are countersigned by Secretary Health, the Hospital will never be free to develop its own identity and culture, much less make its own decisions. Even if the ACR (discussed above) could still be used as one of the methods of evaluation in the autonomous setups, it would have to be counter-balanced by a gradual introduction of parallel assessment systems for grading the quality of service, management performance, and professional interest in the workplace; and the chain of accountability should mean that the ultimate signing-off would be contained within the institution.
Copyright # 2006 John Wiley & Sons, Ltd. Int J Health Plann Mgmt 2007; 22: 4562. DOI: 10.1002/hpm

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Public sector institutional environments especially of the large-sized urban hospitals in Pakistan are complex and demand not merely managerial performance but transformational leadership to take up the mainstream challenges that we have highlighted above. This shall ensure the creation of initiatives and capacities for inducing an institutional-cultural change and sustainable working relationships with stakeholders across different levels and categories. The processes leading to autonomy over the years that we have discussed, may be viewed as a transitional phase that should subsequently lead into its second generation, whereby the autonomy reforms are not only publicized and recognized for their obvious merit but also owned by all the stakeholders and implemented in letter and true spirit.

ACKNOWLEDGEMENTS Dr M Tanweer Abdullah deeply acknowledges the nancial support of the Higher Education Commission of Pakistan and the Charles Wallace Pakistan Trust that was partly contributed to the completion of this research project.

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