In many countries, as in Haiti, hospitals have been built or reconstructed without any reform or even prior reflection on the feasibility and sustainability of their functioning and financing.24 More research is needed to better understand how hospital reform can be integrated into broader health system reform,25 especially in the context of global prioritisation of quality and equity in access to UHC.
Alma Ata: hospitals to complement, not replace, primary healthcare
Along with comparative studies of reform attempts,26 a critical and retrospective analysis of previous debates and reform attempts would be enlightening.27 What organisational models were promoted? Why were they generally not successful?
In 1978, the WHO conference in Alma Ata promoted primary healthcare as the best way to achieve health for all in 2000. That conference positioned community health workers as the backbone of health systems and emphasised the need for community participation, adequate financing and national and international support for the strategy.28 Less was said on the role of hospitals, but the Alma Ata report insisted that their primary function was to support—not replace—primary healthcare. Indeed, Halfdan Mahler, then Director-General of WHO, was reported to have said, ‘A health system based on primary care cannot be realised without support from a network of hospitals’.4 The concept of ‘appropriate technology’ was invoked to justify the concentration of resources in urban hospitals for the provision of secondary and tertiary care.29
To compensate for the inconsistent implementation and disappointing results of primary healthcare strategies in the 1980s, international agencies tried to promote the district hospital level as a key component in an efficient referral system,30 less costly and more advantageous for the population than big national or regional urban hospitals, and more in line with the PHC strategy.31 In the 1990s, the international community acknowledged that big public hospitals in LMICs were too costly and inefficient and defended the necessity of granting more autonomy to hospitals and even privatising them to ensure their efficiency.32 33 It was believed—a belief still dominant—that financial and administrative autonomy of public hospitals would produce better health outcomes.34 This inspired a wave of national hospital reforms and the transformation of public hospitals into public autonomous hospitals.26 35 Most of the intended results (in terms of quality, satisfaction, equity and so on) did not materialise.36
This makes the wave of reforms in recent years based on New Public Management (NPM),16 a business-oriented approach to public services, all the more surprising. Equally disconcerting are the occasional attempts at performance-based financing in hospitals—an approach generally implemented at the PHC level—without any strong evidence of its effectiveness.34 The interest in PPPs (whether for building infrastructures or for private management of hospitals) remains intense. Even though PPPs offer some potential (availability of financial resources, advanced technologies), they also present serious limitations (costs, risks, corruption). Tertiary or ‘reference’ hospitals are seen as profitable investments offering good market opportunities. Promotion of the private sector and the ‘business of health’ in Africa37 has not resolved issues of accessibility and equity. On the contrary, these investments often go to high-end urban hospitals, benefitting wealthier citizens, and as such, they do not expand the population’s access to healthcare.38
How can hospitals be transformative? Infrastructure for resilient, high quality health systems
Published after the 2018 conference in Astana, the WHO report titled The Transformative Role of Hospitals in the Future of Primary Health Care4 called for ending the dichotomy between hospitals and the rest of the health system and dissolving the walls, to create a ‘networked and people-centred hospital’ with a view towards achieving UHC. Hospitals, whether new or renovated, can play a transformative role if they are closely integrated within strengthened healthcare systems in a way that is consistent with national priorities and that acknowledges the role of infrastructures.
Hospital projects need to be understood in the context of larger and more intense socioeconomic and demographic changes within dynamic, mobile, urban societies and fast-growing economies. There is an urgent need to address the growing burden of non-communicable and chronic diseases, the long-neglected cancer epidemic and mental health—in short, a need for curative and preventive medicine.
Hospitals’ transformative role and the development of patient-centred hospitals will be a ‘trickle-down’ effect of infrastructure development, because healthcare staff need, first of all, to be supported by a functioning infrastructure in which equipment is smoothly maintained, and where water, power and waste are securely managed.39 Local governments and international donors need to dedicate resources to the maintenance of ‘resilient hospitals’, beyond disaster preparedness, to nurture day-to-day resilience and ensure the safety and quality of care.40 41
How can international cooperation support local and national dynamics in ways other than building hospitals that are not sustainable? The different typologies of hospital cooperation actors and programmes, some of which have been mentioned in this paper, need to be systematically analysed. Other partnerships are of interest, especially those giving preference to training, such as the hospital partnerships or ‘jumelages hospitaliers’ (hospital twinning) initiated by French hospitals for AIDS research and treatment.42 India, Brazil and Cuba also have their own—more or less outmoded— cooperation tools that may or may not help transform hospitals from inside, either by supporting capacity-building and medical training, or by local drug production, as in the case of Brazil.43 Medical training remains a crucial issue, and large urban university hospitals should not be the unique sites for clinical training: clinics and district hospitals should also be given larger roles in this area.
Many research organisations and international agencies can play a role in collecting and monitoring data on access to hospital care, bed occupancy, quality of care and—of course—patients’ satisfaction, of which we know very little. Useful tools are being developed, such as the service readiness index, constructed with data from the Service Provision Assessment.44 In addition to creating a resilience index,40 41 there should be a call for establishing a citizens’ observatory of healthcare equity and quality in hospitals that would help to create patient-centred and transformative hospitals, with a view to transitioning towards UHC.
