Senegal’s hospital reform was adopted by the National Assembly on February 12, 1998 in the form of two complementary laws, the first entitled
“The aim of this reform is to improve hospital performance in terms of management and quality of care. The reform gives hospitals a high degree of autonomy, under the supervision of a Board of Directors and controlled by mechanisms equivalent to those used in public establishments.
The Reform takes account of the recent law on decentralization, which gives local authorities new prerogatives in the management of healthcare establishments.
- Before the reform
In terms of internal organization, the responsibilities of the Hospital Director were severely limited. Aware of the problems facing the establishment he was in charge of, he had no institutional means of correcting them. Their room for manoeuvre is indeed narrow :
- In the financial sphere, the budget allocated to it had already been practically used up by the time it arrived ;
- In the field of human resources : personnel are directly managed by the Ministry of the Civil Service . The Director has no real possibility of sanction (positive or negative).
In terms of financial management, the establishment was not equipped to manage such a complex institution. It had no tools to evaluate the cost of the services produced.
- Whether we’re talking about management, control or sanction procedures, a rationalization and optimization effort was absolutely essential.
- Care was not evaluated.
All this and more prompted us to take stock of the situation at :
- Failure to apply management procedures and tools
- Significant weakness in the covering system ;
- Deficit on forecast grants receivable ;
- Cost policy does not take sufficient account of the requirements of a balanced budget ;
- No human resources management ;
- Inadequate organization and implementation of work performance.
- The reform
Following the adoption of Law 96-07, which enshrines the current decentralization process, hospital management and maintenance have been transferred from the State to the region.
This transfer, based on the model of shared responsibilities, aims to make the three levels of local government (region, commune, rural community) responsible for managing the health sector, while leaving policy orientations and certain strategic responsibilities to the State, with the aim of accelerating health development.
The organization of the health system had to be brought into line with the new regulatory and legal framework, which makes local management a fundamental option in state policy to drive socio-health development.
With this in mind, Senegal’s hospital reform was adopted by the National Assembly on February 12, 1998 in the form of two complementary laws Laws 98-08 and 98-12 the first entitled ” loi portant réforme hospitalière “, the second entitled ” loi relative à l’organisation et au fonctionnement des Etablissements Publics de Santé “.
This reform is based on three fundamental points :
- Hospitals’ management autonomy is underpinned by a performance-based rationale that replaces the administrative rationale ;
- Access to high-quality, affordable care for all (public service mission) ;
- A participatory approach to managing health problems ;
It is the expression of a desire for efficiency in hospital services, which must obey a logic of performance through management autonomy and public participation.
In view of the shortcomings noted in hospital operations, both under central government administration and during the concession management period, it was essential to take corrective action and rehabilitate the threatened public service.
In order to meet the challenges of the reform, hospitals established as public health establishments by Decree No. 98-856 of August 27, 1998, are required to produce a project, a technical and financial document whose purpose is :
ensure coherence between policy orientations, strategic health objectives, organizational models and prevention and treatment activities, within a global vision of health issues ;
make choices that are described and planned for the medium term, based on a forward-looking vision and a participatory dynamic that takes into account changing needs.
- Why reform
The hospital was finding it very difficult to satisfy both the population and hospital staff. These findings revealed that public hospitals were not generally frequented by affluent customers. Most of the time, they preferred to head for the more expensive care facilities, which have the advantage of high-quality technical facilities and recognized skills, as well as good hotel conditions.
As a result, many hospitals were so destitute that they were unable to carry out their mission of providing quality care to citizens of all social classes, as well as opportunities for research. The technical platform of public hospitals is reduced to its simplest form : lack of equipment, lack of consumables, lack of medicines, staff shortages, etc.
Moreover, hospital management lacked flexibility and did not encourage staff empowerment, because hospitals were seen as mere departments of a central administration responsible for applying directives and using the funds allocated to them. This management method has led to excesses in some cases.
This is why the health authorities felt it necessary to undertake a reform of this sector to meet the requirements of a policy geared towards health for all, and the demands of modern society for increasingly efficient medicine. So, whatever their social category, all citizens should be able to attend public hospitals, whose essential mission is to provide quality healthcare services.
The aim of the reform is to improve hospital performance in terms of management and quality of care. It gives public-sector healthcare establishments a high degree of autonomy, under the supervision of a Board of Directors, with mechanisms equivalent to those used in private-sector establishments. It provides hospitals with management autonomy and the status of a public establishment. This should enable more flexible hospital management. Finally, the aim of the reform is to rehabilitate the public hospital service by redefining its missions and clarifying the rights and duties of patients.
The new hospital will have to balance its books and provide the quality of care required to meet its performance obligations. From now on, the notion of performance will replace the administrative logic that has always characterized hospital operations. Hospital services are considered as ” services ” in economic terms ; they can generate resources if they are able to respond to specific demand.
It should be emphasized that the aim of the reform is to restructure the hospital system, but not to lead to a withdrawal of the State from the sector, and even less to the privatization of healthcare.
It was enacted in response to the profound and recurring dysfunctions observed in the public hospital service, despite the administrative innovations introduced.
The situation at the Saint-Louis Regional Hospital at the time of the reform was typical of the failure of the hospital management policy seen almost everywhere in Senegal.
- What does the reform mean for users?
As part of the missions entrusted to it by the State, the hospital is responsible for ensuring that all citizens have access to certain essential services, whatever their living conditions.
The public service mission is based on three fundamental principles :
- service continuity ;
- equal access for all to essential healthcare ;
- providing the best possible care.
The expected improvements are as follows :
- permanent availability of a service
All users, whether rich or poor, must benefit from healthcare services in a given geographical area, day and night.
- treatment of all emergencies
In the event of an emergency, the patient must be treated before any financial procedure is initiated. In addition, emergency services must have at their disposal the minimum necessary to act effectively : doctors, medicines, para-clinical examination services, equipment, etc.
- affordable rates
The reform emphasizes the affordability of care for the vast majority of the population, because hospitalization costs are high and sometimes restrictive. Care fees will be set according to a range established by order of the Ministers of Finance, Health and Trade.
- care for the underprivileged : refusing exclusion
Many indigent people turn away from hospitals after their first experience, convinced of their inability to meet the costs of treatment and hospitalization. These people will have to be cared for if their state of indulgence is established.
- setting up a computerized system for each hospitalized patient
An individual computer file with an identification number will be opened for each hospitalized patient.
- the introduction of a patient charter
It sets out the patient’s rights and obligations towards the hospital and its staff. As a result, patients should feel much more at ease in the hospital environment.
- user representation on the Board of Directors of l’hôpital
User representatives are chosen from among members of consumer associations or any association concerned by hospital operations, in particular the Health Committees.