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Hospital Meeting in Albania

Hospital Strengthening

Background and Strategy

Hospitals in developing countries often consume the lion's share of the health budget, squeezing the amount available for priority services delivered at the primary care level. Moreover, hospitals, particularly tertiary ones, are often a highly visible symbol of the sophistication of the health care system. Consequently, people bypass primary care to seek hospital care, resulting in overcrowding and unsanitary conditions that cause substantial discomfort not only to patients but also to MOH officials. It's not surprising therefore, that PHRplus is frequently requested to work on the hospital sector, generally with the aim of improving the efficiency and quality of the sector.

In Eritrea, Jordan, and Malawi, PHRplus is involved in strengthening management systems within hospitals. The Project has also been asked to assist countries with their efforts to grant increasing autonomy to hospitals. The rationale behind this strategy is that hospitals that have greater autonomy and are held accountable to a hospital board which includes local representatives will be more likely to innovate, to seek cost-cutting measures, and to be more responsive to the local community. PHRplus believes however, that improvements in the hospital sector cannot be achieved without supportive policies that clearly delineate the role of hospitals within the health care sector more broadly. For example, hospital overcrowding is generally due primarily to perceived inadequacies in the primary care sector and lack of trust in providers at this level. Sustainable improvements in the hospital sector may be difficult to achieve without innovative attempts to restructure the relationships between different levels of the system.


  • Management strengthening: in all three countries where PHRplus is working at the hospital level, there is a focus on strengthening management and financial management systems. For example, in Jordan, PHRplus is building hospital capacity to track and control costs, working to better identify and charge non-poor users and manage revenue collected, and monitoring performance against quality and efficiency indicators.
  • Implementing hospital autonomy: both Eritrea and Malawi plan to give hospitals greater autonomy and PHRplus is supporting this strategy. In Eritrea, PHRplus is helping establish new governance structures for pilot autonomous hospitals, training hospital board members, and working with hospital board members, hospital officials, and MOH officials to agree on the process and outcomes of decentralizing authority from the central ministry to hospitals. In Malawi, PHRplus inputs to management strengthening at the two large tertiary hospitals are seen as a necessary precursor to any initiative to devolve authority to the hospitals. PHRplus will build upon its experience to develop a primer for national governments on how to monitor and evaluate hospital autonomy policies.
  • Hospital policy: in Eritrea, PHRplus is working to develop methods to rationalize the further expansion of the hospital sector and consolidate selected services of three national referral hospitals. In Malawi, one Project goal is to reduce overcrowding at the tertiary hospitals through an innovative hospital reform strategy that considers the links between hospitals and the community. PHRplus is also developing a briefing paper that reviews hospital policy in developing countries more broadly.

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