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REGIONAL EXPERIENCES
Quarterly Health Bulletin | December 2010, 3 (2) 40
INNOVATION AND PERFORMANCE IMPROVEMENT:
SHARING EXPERIENCES FROM FOUR HOSPITALS IN OROMIA REGION
Shallo Dhaba1, Siraj Abdulahi2, Asnake Waqijira3, Ashenafi Beza4, Gaetano Azzimonti5, Abraham Mengistu6,
Venanzio Vella7, Stephen Batts8, Sandro Accorsi7, Dereje Mamo9, Jemal Adam10
1Head of Oromia Regional Health Bureau (ORHB) 2Chief Executive Officer, Adama Hospital 3Chief Executive Officer, Bishoftu Hospital 4Director of Medical Services, Limu Genet Hospital 5Director of Medical Services, St. Luke Wolisso Hospital 6Director of Medical Services, Federal Ministry of Health (FMOH) 7Italian Cooperation Technical Advisor at the Policy, Planning and Finance General Directorate (FMOH) 8Ethiopian Hospital Management Initiative, Clinton Health Access Initiative, Addis Ababa 9Director, Policy and Planning Directorate (FMOH). 10Deputy Head of ORHB
Summary
Hospital reform is a priority in the health sector strategic plan, with the aim of increasing the efficiency in service delivery and improving ac-cess and quality of services. The Regional Health Bureau (RHB) of Oromia recently assessed the status of implementation of hospital reform in 21 government hospitals. Hospitals were evaluated against several criteria related to Business Process Re-engineering, Health Care Fi-nancing, Infection Control and Environmental Hygiene. According to the above mentioned criteria, Bishoftu, Limu Genet and Adama Hospi-tals were the first three government hospitals in Oromia Region. Of note is the fact that other private-not-for-profit hospitals are also perform-ing well in the region. The importance of leadership, governance and management for improving performance in hospitals is highlighted by the fact that the 3 top rated government hospitals in Oromia Region have Governing Boards which are well-functioning, with Chief Executive Officers, manage-ment and staff being committed and prepared to be innovative, creative, enthusiastic and persistent to make radical changes in their hospi-tals in different ways. This empowerment is encouraged by the Oromia RHB leadership which wants their hospitals to innovate and show the way. This article aims at presenting experiences in different areas of hospital management in Oromia hospitals, taking as examples the three top ranking governmental hospitals (Bishoftu, Limu Genet and Adama) and a private-not-for-profit hospital (St. Luke Wolisso) showing high per-formance. It demonstrates how these hospitals introduced innovations, achieved performance and addressed challenges so that these prac-tices may be disseminated to promote performance improvement through benchmarking (which is the identification of “best-in-class” per-formance and analysis of the process by which that performance is achieved). Major areas of success included revenue generation and utilization, control of hospital-acquired infections, improvement in volume and qual-ity of services, increase in staffing and implementation of outreach services, demonstrating that strengthening leadership and good manage-ment, motivating staff and managers, and ensuring accountability, can contribute to improve the accessibility to health services and in-crease the efficiency in health care delivery.
1) Introduction
Hospital reform is a priority in the health sector strate-
gic plan (FMOH, 2005), with the aim of increasing the
efficiency in service delivery and improving the quality
of services.
The Business Process Re-engineering (BPR) for hospi-
tals identified the following priority thematic areas to
strengthen hospital management: (i) human resource
management; (ii) governing boards; (iii) global budget-
ing and financial management; (iv) patient flow; (v)
medical records management; (vi) pharmaceutical in-
ventory and warehouse management; (vii) nursing stan-
dards and practice; and (viii) hospital acquired infection
prevention. Health Care Financing (HCF) strategy has
been implemented to collect, retain and use additional
revenues obtained from different sources. The Regional
Health Bureau (RHB) of Oromia recently assessed the
status of implementation of hospital reforms in 21 gov-
ernment hospitals. Hospitals were evaluated against
several criteria related to BPR, HCF, Infection Control
(IC) and Environmental Hygiene (EH).
The BPR performance was judged against the availabil-
ity and implementation of team charter, the ability to
conduct customers’ satisfaction surveys, the measure-
ment of performance against the BPR objectives and the
number of monthly meetings conducted to discuss BPR
issues.
Quarterly Health Bulletin | December 2010, 3 (2)
REGIONAL EXPERIENCES
41
The achievements in HCF were measured against the
number of monthly board meetings on HCF, the rate of
increase of internal revenues and their utilization, the
establishment of private wing services and the presence
of a functioning fee waiver system.
Performance in IC was judged against the proportion of
staff trained in IC, the availability of protective materi-
als, the presence of posters for health education on IC
and the availability and functionality of autoclaves.
The score for EH was based on the type of medical
waste management systems, latrine availability, hygi-
enic conditions in the kitchen, bed side cleanliness,
presence of a placenta disposal pit and of a functioning
incinerator.
A score was given for each criterion met by the hospital
and the sum of all the scores was used to rank the 21
government hospitals which were assessed. According
to the above mentioned criteria, Bishoftu, Limu Genet
and Adama Hospitals were the first three government
hospitals in Oromia Region.
Table 1 shows the grading of the hospitals according to
the BPR, HCF, IP and EH criteria. Bishoftu ranked first
for all the criteria except for BPR, for which Limu
Genet had the highest score, while the strong point for
Adama was in the area of HCF.
Awards were provided by the RHB to the first three
hospitals in a formal ceremony (Figures 1 and 2).
RANK HOSPITAL BUSINESS
PROCESS RE-
ENGINEERING
HEALTH CARE
FINANCING
INFECTION
CONTROL
ENVIRON-
MENTAL HY-
GIENE
TOTAL
1 Bishoftu 42.8 35.0 15.0 5.0 78.5
2 Limu Genet 45.0 31.5 12.5 5.0 74.5
3 Adama 40.5 35.0 13.5 2.5 73.0
4 Bisidimo 40.5 29.8 15.0 5.0 72.5
5 Fiche 36.0 33.3 12.0 5.0 69.5
6 Galamso 40.5 21.0 14.3 5.0 64.3
7 Ginir 40.5 22.8 12.8 5.0 64.3
8 Abomsa 40.5 24.5 10.4 5.0 63.4
9 Ambo 31.5 31.5 10.5 2.5 61.0
10 Deder 31.5 26.3 13.5 2.5 59.5
11 Ginda Barat 33.8 24.5 12.0 2.5 58.0
12 Chiro 37.4 21.0 10.5 2.5 55.9
13 Goba 31.5 21.0 11.3 5.0 55.3
14 Nejo 31.5 24.5 10.5 2.5 55.0
15 Dambi Dolo 36.0 19.3 11.3 2.5 54.3
16 Nekemte 33.8 22.8 9.0 2.5 53.5
17 Shashamene 31.5 21.0 11.3 2.5 52.8
18 Negele 28.4 17.5 8.3 5.0 47.2
19 Mettu Karl 13.5 28.0 8.0 5.0 46.0
20 Shambu 27.0 14.0 8.3 5.0 43.3
21 Bule Hora 20.3 26.3 4.5 2.5 43.0
Table 1. Ranking of 21 government hospitals in Oromia.
REGIONAL EXPERIENCES
Quarterly Health Bulletin | December 2010, 3 (2) 42
Figure 1 shows the award ceremony with Ato Asnake
Waqijira (Chief Executive Officer of Bishoftu Hospital)
receiving the cup from H.E. Abdulaziz Mohamed (Vice
-President of Oromia) and H.E. Shallo Dhaba (Head of
Oromia RHB); Ato Driba Tura, the Chairman of the
Bishoftu Hospital Governing Board and Mayor of
Bishoftu, also attended the ceremony.
Figure 2 shows the representatives of Limu Genet Hos-
pital (2A) and Adama Hospital (2B) receiving the
award.
This demonstrates the important contribution of the hos-
pital management to the improvement of the efficiency
in service delivery. This has been documented in arti-
cles published in previous editions of the Health Bulle-
tin “Policy and Practice” showing high variability in
performance across hospitals which may have resulted
not only from differences in resources (financial, human
and logistic) availability and case mix, but also from the
relative efficiency of input use, highlighting the fact that
a number of factors subject to management intervention
can contribute to low or high efficiency (Bilal et al.,
2009; Accorsi et al., 2010). Another key finding is that
high performance was found in both public and private
sectors. Perhaps more than public or private status, what
matters is the context, the incentives and the manage-
ment framework which governs a facility, regardless of
ownership status.
This article aims at presenting experiences in different
areas of hospital management in Oromia hospitals, tak-
ing as examples the three top ranking governmental
hospitals (Bishoftu, Limu Genet and Adama) and a pri-
vate-not-for-profit hospital (St. Luke Wolisso) showing
high performance. It demonstrates also how these hospi-
tals introduced innovations, achieved performance and
addressed challenges so that these practices may be dis-
seminated to promote performance improvement
through benchmarking (which is the identification of
“best-in-class” performance and analysis of the process
by which that performance is achieved). Some of the
Figure 1. The Chief Executive Officer of Bishoftu Hospital receiving the cup.
Figure 2. Representatives of Limu Genet Hospital (2A) and Adama Hospital (2B) receiving the award.
Quarterly Health Bulletin | December 2010, 3 (2)
REGIONAL EXPERIENCES
43
governance, leadership and management qualities that
have contributed to these achievements are also high-
lighted.
2) Hospital experiences
2.1) Bishoftu Hospital
2.1.1) Background
This was previously a district hospital which has been
upgraded to zonal hospital. It is located 47 km from Ad-
dis Ababa and is serving 1.2 million people living in
three towns and five districts. The hospital has medical,
paediatric and surgical wards, 2 operation theatres, a
pharmacy, a radiography unit, a delivery room and an
emergency unit. Outpatient department (OPD) services
cover general medicine, maternal and child health care,
HIV/AIDS and TB, ophthalmology, dental service,
physiotherapy and mental health. The hospital also
manages 2 medical clinics.
The formation of the Governing Board in July 2007 and
the appointment of the Chief Executive Officer (CEO)
steered the planning and management processes envis-
aged in the hospital reforms, improving the link be-
tween the hospital and the community. The members of
the Governing Board include the Mayor (chairman), the
City Head of Finance and the City Head of Health De-
partment, a community representative, the hospital
CEO, the Director of Medical Services and a staff repre-
sentative.
2.1.2) Performance
Areas of success were revenue generation and utiliza-
tion, control of hospital-acquired infections, improve-
ment in volume and quality of services and increase in
staffing. Regular meetings of the Governing Board,
early morning operational efficiency meetings of the
senior management team and team motivation contrib-
uted to these achievements.
Income generating activities included the charging for
OPD visits, the rental of the newly built meeting hall,
the charging from the cafeteria, the student fees from
the nursing school (including a few foreign students)
and the sale of old materials. The internal revenues in-
creased from 0.8 to 2.6 million ETB between 2007/08
and 2009/10, and have been used to increase the number
of staff (Table 2), the availability of essential drugs and
supplies, the purchase of medical equipment, the reno-
vation of delivery rooms and the construction of addi-
tional OPD and inpatient blocks.
HCF has resulted in outsourcing services (such as food,
STAFF 2007 2010
General Surgeons 1 2 *
Gynaecologists 1 1 *
Internists 0 1 *
General Medical Practitioners 6 9
Health Officers 0 6
Nurses 37 75
Technicians Radiographers Dental Professionals Anaesthetists Pharmacists Druggists Laboratory Professionals Environmental Health Staff Midwives Ophthalmology Professionals Physiotherapists
2 1 3 2 3 8 1 5 0 0
4 2 3 3 5 11 1 7 1 2
Administrative staff 47 85
TOTAL 117 218
Table 2. Increase in staff in Bishoftu Hospital (2007-2010).
* on specialist training in Addis Ababa
REGIONAL EXPERIENCES
Quarterly Health Bulletin | December 2010, 3 (2) 44
laundry and general maintenance services) to increase
efficiency and allow management to focus more on the
provision of clinical services. The introduction of pri-
vate practice by hospital staff after regular working
hours has increased access to OPD services, providing
more choices for those who can pay, increasing the
commitment of the staff and improving the quality of
services.
Overall results from HCF between 2007 and 2010 have
included the following: (i) the hospital compound was
asphalted by the city council; (ii) a staff meeting hall
was built; (iii) the TB/ART block and the pharmacy
were renovated and a MCH clinic is under construction;
(iv) ten committees to cover specific areas of hospital
management have been appointed to follow up daily
activities; (v) details of the outpatients are entered at the
time of the visit in the electronic medical record system;
(vi) total staff increased from 117 to 218; (vii) the num-
ber of OPD visits increased from 70 to 400 per day;
(viii) latest staff and client satisfaction estimates were
reported to be above 90%; (ix) the total expenditures
increased from ETB 4.6 million to 7.0 million between
2007/08 and 2009/10; and (x) accreditation for preven-
tion of infection was obtained from the Johns Hopkins
Program for International Education in Gynaecology
and Obstetrics (JHPIEGO).
The hospital has also implemented nursing standards
and practices. These have included proper dressing/
uniforms (Figure 3), respect for others, compliance with
treatment protocols, and efficient written and verbal
communication with staff and clients.
The hospital implemented several activities to prevent
hospital-acquired infections. A committee has been
formed to deal with infection prevention and waste
management and has been holding regular meetings
twice a month. The committee is formed by staff com-
ing from each ward and the laboratory and is chaired by
a gynaecologist following up the deliberations of the
committee, which have been guided by the hospital pol-
icy on infection control and waste management. A train-
ing manual is available in the library and the staff is
regularly trained once a year in infection control and
waste management. Autoclaves are available in OPD
units and wards, and staff has easy access to soap, disin-
fectants and running water at various service points to
implement hand hygiene practices. Protective barriers
such as masks, gloves and aprons are widely available
and the hospital applies post-exposure prophylaxis for
HIV. The wards have baskets with different colours to
segregate infectious from non-infectious materials and
sharp objects are disposed in puncture resistant contain-
ers. Waste is incinerated and buried according to the
waste management policy and the final disposal area is
well maintained and fenced. Nonetheless some prob-
lems still need to be solved to make infection control
more effective. Usually TB patients are hospitalized in
the same room, but because of space constraints this
practice cannot be always assured. Because of shortage
of space, there is no designated room to isolate infec-
tious patients to limit the transmission of infections. A
new hospital block (80 beds) currently being planned
will address this problem in the near future.
The improvement in the performance and quality of
health services has been measured through the standards
-based management and recognition (SBM-R). This is a
practical management approach produced by JHPIEGO
(Necochea E and Bossemeyer D., 2005) to systemati-
cally measure the implementation of operational per-
formance standards for the organization and functioning
of health services. A total of 281 standards are estab-
Figure 3. Nurses at Bishoftu Hospital.
Quarterly Health Bulletin | December 2010, 3 (2)
REGIONAL EXPERIENCES
45
SERVICES BASELINE (%)
1ST FOLLOW-UP
(%)
2ND FOLLOW-UP
(%)
3RD FOLLOW-UP
(%)
EXTERNAL
VALIDATION (%)
Adult anti-retroviral treatment
(ART)
69.70 81.82 96.97 94.30 82.35
Paediatric ART 65.52 72.41 86.21 89.70 88.89
HIV/AIDS counselling and testing
(HCT)
61.76 70.59 94.12 84.20 82.35
Prevention of mother to child trans-
mission (PMTCT)
48.15 57.41 87.04 85.30 80.40
Pharmacy 14.29 78.57 78.57 80.40 85.71
Management System 47.62 85.71 95.24 84.73 80.95
Laboratory 32.29 62.86 74.29 81.30 82.86
Human and Physical Resources 44.44 74.07 88.89 89.30 85.19
Infection Prevention 12.00 48.00 92.00 87.40 84.00
Information, Education and Com-
munication (IEC)
28.57 57.14 85.71 100.00 85.71
TOTAL 46.59 68.10 88.17 88.04 83.33
Table 3. Progress in standards-based management and recognition in Bishoftu Hospital.
Table 4. Indicators of hospital performance in Bishoftu Hospital.
SERVICES YEAR
2007/08 2008/09
2009/10
Number of beds 56 102 102
Number of OPD services 36,000 108,577 103,143
Total expenditures 4,613,499 6,143,240 6,999,971
Raised Revenues 750,000 1,835,192 2,638,870
Deliveries
-vaginal births
-Caesarean Sections
920
28
1,890
136
1,673
120
Surgeries
-minor
-major
510
490
1,291
1,020
1,320
1,105
lished and the percentage of the standards met is esti-
mated according to specific criteria. Table 3 shows the
gradual increase in the proportion of SBM-R standards
achieved by Bishoftu Hospital for several services, with
all of them finally achieving more than 80%, which is
considered the critical cut off point to be met. The
above improvements have been reflected in other hospi-
tal indicators, showing a sharp increase in services de-
livered (Table 4).
2.2) Limu Genet Hospital
2.2.1) Background
Limu Genet Hospital is located 76 kilometres (2 hours)
from Jimma. It has 60 beds, and staff composed of 5
Ethiopian and 3 Korean doctors, 43 nurses, 16 other
clinical staff and 86 non-clinical staff (Figures 4A and
4B). In 2009/10 the hospital service indicators were as
follows: 42,228 OPD visits, 1,322 admissions with 7.2
REGIONAL EXPERIENCES
Quarterly Health Bulletin | December 2010, 3 (2) 46
days of average length of stay (ALOS), 491 vaginal
births and 39 Caesarean Sections, 482 minor surgeries
and 73 major surgeries. The total expenditures were
ETB 4,625,776, with the total raised revenues from all
sources amounting to ETB 1,246,111.
The leadership of the hospital clearly demonstrates per-
sistence. The Governing Board with the management is
a committed force, with the Chairman and Board Mem-
bers always meeting once per month and sometimes
weekly. The hospital strategic and annual plans focus
on the community needs.
The team culture is facilitated by a structure of daily,
weekly and monthly meetings at various levels which
were designed to empower staff, recognize team and
individual contributions, and ensure the smooth opera-
tion of the hospital. There is a very good system of case
team meetings, weekly and monthly meetings at which
all staff present agree and sign the minutes and action
items. This ensures that actions are implemented and
allows monitoring and evaluation. Everyone participates
in the weekly total clean up of the site and buildings,
and the social commitment has translated into a high
rate of blood donations which resulted in an award from
the Ethiopian Red Cross for the high number of units
donated.
2.2.2) Performance
Areas of success were revenue generation and utiliza-
tion, community participation and implementation of
outreach services.
Community appreciation is demonstrated by the 3 mil-
lion ETB raised at a recent Teletone where over 3 days
the hospital organised Addis and Jimma City bands and
a fair to raise money. The infrastructure areas prioritised
by the hospital Governing Board includes a new inpa-
tient ward, an antenatal care (ANC) waiting area, a tri-
age area, an incinerator, an electric line installation,
road repairs, a clinic block, staff residence, and an ad-
ministration office at a total cost of ETB 8 million. The
new infrastructure is primarily required to facilitate the
influx of students and interns from Jimma University as
the hospital is now a major training site and its strategic
plan includes developing a College for Healthcare Di-
ploma students to serve in its catchment population of
around 500,000.
This is the renowned Jimma coffee area and health care
financing encourages innovation. On its vacant land
10,000 coffee trees were planted 2 years ago to assist in
providing sustainable improvements to the hospital and
low cost subsidised services to the community in the
future. There is even a vegetable garden providing fresh
produce for patients and staff meals. The private wing
revenue also helps the hospital finances and staff reten-
tion, although additional revenue for staff from the pri-
vate wing is low due to the socio economic level of the
surrounding community.
Community and Social Health Insurance Schemes are
now functioning with the technical assistance of the
Unites Stated Agency for International Development
(USAID) and Abt Associates experts. It is hoped that
additional revenue will allow the hospital to continue to
send its outreach teams to the health posts (HP) to attain
the Millennium Development Goals (MDG) 4, 5 and 6
related to child and maternal health and disease control.
Like other rural areas in Ethiopia only between 9-11%
of births occur in health facilities, with the remaining
approximately 90% of births occurring at home with
mothers being assisted by traditional birth assistants
(TBAs), relatives, neighbours, Health Extension Work-
ers (HEWs) and community workers. The struggle to
reduce maternal and infant mortality needs the addi-
tional assistance of the hospital teams at the health post
level to support the health workers there. This outreach
model is a low cost initiative which virtually all rural
district hospitals can adapt to their catchment areas with
Figure 4. Young doctors (4A) and pharmacists (4B) at Limu Genet Hospital.
Quarterly Health Bulletin | December 2010, 3 (2)
REGIONAL EXPERIENCES
the support of their woredas and communities.
Simple environmental health measures and early inter-
ventions are implemented through the hospital outreach
program. The communities are provided with curative
and preventive services by liaising with HEWs and
TBAs, educating them about the need for referrals and
basic life saving skills, and generally establishing the
rapport necessary to gain trust to manage poor rural ar-
eas with intermittent communications, poor roads and
limited transport. Some of the HPs are 98 kilometres
distant from the hospital and are reached by horse and
cart. It doesn’t read like a very great distance but some
HPs are 4-5 hours away from the hospital and therefore
the teams need a week to visit all 5 HPs in a woreda.
The hospital outreach teams include a general practitio-
ner, a health officer, a midwife or nurse and a laboratory
technician. Intestinal parasites, malaria and other water
and food born diseases that can be prevented at the HP
level are now less frequently seen at the hospital. High
risk pregnant mothers are more frequently identified
during their ANC follow ups at the health post level and
referred to the hospital.
This outreach program was designed by 4 young enthu-
siastic doctors from the same graduation class from Ad-
dis Ababa who came to Limu Genet to make a differ-
2.3) Adama Hospital
2.3.1) Background
Adama Regional Referral Hospital (ARRH) is over 100
km east of Addis Ababa and has a capacity of 182 beds.
Currently the hospital provides services for more than
4.6 million population living in Adama city, East Shoa
Zone, West Hararge Zone, Zone 3 of the Afar Region
and some parts of the Arsi Zone, Shinile Zone of the
Somali Region and the North Shoa Zone of the Amhara
Region.
Currently the hospital has a total staff of more than 300.
It has 18 specialist physicians with 4 expatriate medical
volunteers, 14 general practitioners, 118 nurses, 17
laboratory staff, 12 pharmacy technicians and 5 X-Ray
technicians, with 103 other staff on permanent basis and
40 on contractual basis.
Under the hospital health service provision core process
there are 20 case teams. ARRH provides medical, surgi-
cal, gynaecology/obstetrics, pediatrics, ophthalmology,
psychiatry and dental services. In addition, it provides
private wing OPD services. ARRH in collaboration
with an NGO has a unit for supporting abused children
where psycho-social support is provided. The hospital
has a Governing Board that is accountable to the RHB
(Figure 5 A and B).
ence, and they are an inspiration to the community, staff
and their colleagues.
After a visit to Limu Genet Hospital, the Federal Minis-
ter of Health H.E. Tedros Adhanom Ghebreyesus com-
mented that he was greatly impressed with the hospital
vision.
The board members include the Mayor of Adama City,
the Head of Adama City Health Office, the Head of the
Adama Finance and Economic Development Office, a
representative from the community, the Chief Executive
Officer, the Director of Medical Services and an em-
ployees’ representative.
Figure 5. Governing Board meeting of Adama Regional Referral Hospital (5A and B).
47
REGIONAL EXPERIENCES
Quarterly Health Bulletin | December 2010, 3 (2)
2.3.2) Performance
Areas of success were revenue generation and utiliza-
tion and improvement in volume and quality of ser-
vices.
The annual recurrent budget in 2009/10 was 18.2 mil-
lion, of which 25.9% was for salary and the rest for op-
erating cost. Out of the total budget, 60% was from re-
tained revenues, while 40% was allocated from the gov-
ernment. ARRH has implemented major hospital re-
forms including BPR, HCF, Health Management Infor-
mation System (HMIS) and FMOH Standards for Ethio-
pian Hospitals (FMOH, 2010). In addition, it has imple-
mented Income Budget Expenditure Software (IBEX)
for its financial management and Human Resource In-
formation System (HRIS) for human resource manage-
ment.
There was an increase in gross revenues from 1,599,148
ETB in 2005/06 to 7,284,384 ETB in 2009/10 (Table
5). The major sources of revenue are sale of drugs, diag-
nostic services, hosting private students undertaking
practicum sessions, sale of non-medical scrap materials
and private wing outpatient fees.
The OPD private wing is open on working days from
5.00pm to 10.00pm and on weekends and public holi-
days from 8.00am to 10.00pm. In 2008/09 the number
of private patients treated was 8,179 with staff sharing
revenue of ETB 370,773. In 2009/10 13,073 private
patients were treated and the staff shared 1,259,510
ETB. According to the CEO, the objectives of the pri-
vate wing are being met: (i) staff retention and motiva-
tion; (ii) choice of treatment for clients who are willing
to pay the additional price; (iii) increased hospital reve-
nue to improve the quality of services; and (iv) in-
creased availability of equipment and infrastructure.
User fees at the private wing are lower than prices
charged at private clinics and hospitals. The private
wing facility allows a physician to earn an average of
ETB 7,013, a nurse an average of ETB 3,265 and a
laboratory technician an average of ETB 3,600 per
month. The hospital collected 15% of the total revenue.
New and revised revenue policies and procedures have
been implemented including: (i) consolidation of price
catalogues; (ii) creating awareness among cash collec-
tors at different payment points; (iii) assigning collec-
tors at point of service provision; (iv) supplying all re-
agents and improving diagnostic facilities such as X-
Ray, laboratory and ultrasound; and (v) introducing new
tests and procedures.
As a result, there was a steep increase in the number of
radiology (Figure 6A) and laboratory services (Figure
6B) in the last few years.
The CEO, management team and staff are self critical of
their performance and are always searching for ways to
improve quality of their services to the community.
Because the infrastructure is old, a Master Infrastructure
Development Plan for the site was prepared by consult-
ants. This is expected to be implemented over the next
few years together with the Oromia RHB and key stake-
holders. Local partners, such as the Oromia Develop-
ment Association, have recognised the potential impact
on attracting industry and investments to Adama by
supporting the development of a first class hospital with
ETB 50 million. The Urban Development Association
has committed around ETB 20 million to reach this
goal. The support of the ARRH Governing Board has
been essential in promoting this endeavour. Interna-
tional development partners have also been essential in
improving the facilities and services.
The major strategy used to increase the revenue was to
invest the retained revenue to improve the quality of
service provided. Hence, a modern ultrasound with 4
probes was bought for ETB 580,000 as well as a new X-
Ray machine with fluoroscopy for ETB 1.5 million.
Other medical equipment such as pulse oximeters, ECG
machine and oxygen concentrator were purchased. In
order to maintain sustainable electricity supply, a diesel
generator was purchased and installed and all internal
electrical wiring was replaced at a cost of ETB 1.2 mil-
lion.
Other improvements include: (i) the state of the art
laboratory; (ii) 24/7 electricity; (iii) new radiology
equipment; (iv) cobble stone paving of internal roads;
(v) condominium housing for doctors and land allocated
for hospital workers with the assistance of the City Ad-
ministration; (vi) in-service training for nurses and a
training plan for all staff; (vii) gold awards for the top
YEAR 2005/06 2006/07 2007/08 2008/09 2009/10
REVENUES (ETB) 1,599,148 1,390,976 2,106,336 6,645,868 7,284,384
Table 5. Revenues in Adama Referral Hospital (2005/06-2009/10).
48
Quarterly Health Bulletin | December 2010, 3 (2)
REGIONAL EXPERIENCES
16 hospital staff performers; (viii) pharmacy warehouse
management; (ix) emergency care management; (x) a
new 35 bed surgical ward under construction; (xi) re-
search conducted on diabetes and day surgery; and (xii)
2 awards from the International Center for AIDS Care
and Treatment Programs (ICAP) for standing first
among hospitals in the Oromia Region in the number of
People living with HIV/AIDS (PLWHA) enrolled in
care and treatment in both 2008/09 and 2009/10. The
latter awards from ICAP justify the large financial in-
vestment for the Comprehensive Chronic HIV Care and
Training Center and Laboratory showing the strong
partnership existing with ICAP, the Centers for Disease
Control (CDC) and the President’s Emergency Plan for
AIDS Relief (PEPFAR).
The facility provides integrated services in a convenient
“one-stop” approach, including HIV and tuberculosis
care and treatment and laboratory testing. Family-
focused features include a unique Children’s Corner. In
addition, the centre has a state-of-the-art training facility
to provide didactic and practical experiences for various
cadres of providers from across the Oromia Region.
Currently, the hospital provides HIV care to more than
12,000 people, including antiretroviral therapy to more
than 7,300 individuals.
The hospital’s proactive approach to implementing new
ideas is illustrated in the 2009 T-shirt motto “Zero toler-
ance to change resistance”.
2.4) St. Luke Wolisso Hospital
2.4.1) Background
St. Luke Catholic Hospital and College of Nursing
(referred to as “Wolisso Hospital”) is a private, not-for-
profit facility owned by the Ethiopian Catholic Church
and located in Wolisso town, the capital of the South-
west Shoa Zone in Oromia Region. It is the referral hos-
pital in the zone (which has a population of over
1,175,000) and is supported by an Italian NGO (Doctors
with Africa-CUAMM). It began services in January
2001, with the number of beds increasing over time
from 83 in 2001 to 169 in 2009. The hospital has a full
range of clinical, diagnostic and ancillary services, in-
cluding OPD with outreach services, antenatal and un-
der five years clinics, public health department, psychi-
atric clinic, voluntary counselling and testing (VCT)
services, PMTCT and ART services, pharmacy, labora-
tory, x-ray and ultra sound services, a physiotherapy
unit, a maternity waiting area for high risk mothers and
a therapeutic feeding for malnourished children (St.
Luke Wolisso Hospital, 2010).
2.4.2) Performance
Areas of success were high hospital performance and
quality of services as well as public health and outreach
services provided at the community level. The annual
report of the hospital is of very high quality containing a
comprehensive picture of the activities, with many other
Figure 6. Trend in the number of radiology services) (6A) and laboratory services (6B) in Adama Regional Referral Hospital
49
0
2,000
4,000
6,000
8,000
10,000
12,000
2005/06 2006/07 2007/08 2008/09 2009/10
YEAR
NU
MB
ER
0
2,000
4,000
6,000
8,000
10,000
12,000
2005/06 2006/07 2007/08 2008/09 2009/10
YEAR
NU
MB
ER
X-ray services Ultrasound services
REGIONAL EXPERIENCES
Quarterly Health Bulletin | December 2010, 3 (2)
hospitals in Ethiopia intending to model their reports on
Wolisso.
There was a constant increase in services provided in
the period 2002-2009, with an increase in out-patient
visits (OPD) from 20,570 to 69,073, in admissions from
3,312 to 9,597, in major surgeries from 332 to 3,164
and in Caesarean Sections from 96 to 407 (Table 6).
Since 2006, the hospital has been providing PMTCT
and ART services, with 57 HIV-positive mothers re-
ceiving ART and 1,305 PLWHA currently on ART in
2009. These upward trends required the expansion of
the existing services and the establishment of new ones
to cope with the rising demand and emerging needs. At
the same time it imposed the introduction of long term
strategies aimed at ensuring both sustainable hospital
development and consolidation of what has been
signed to operate most efficiently at a level of 80-90%
occupancy (Barnum and Kutzin, 1993) and the hospital
performance across the region was below these stan-
dards. In the 2005-2010 period, the patterns of perform-
ance in Wolisso Hospital were consistently high, with
the BOR ranging between 85% and 101%, while the
average length of stay ranged between 5.7 and 6.4 days
and the bed turnover rate ranged between 51 and 60
inpatients per bed per year, meaning that almost the full
capacity in hospital beds was utilized, and every hospi-
tal bed was used to service an average of about 55 pa-
tients during the year.
The hospital attempted to address the demand for health
care by stretching its limited resources (e.g., maintain-
ing a high bed occupancy with a relatively short length
of stay, taking into account the complexity of case-mix)
Table 6. Trend in service provision at Wolisso Hospital (2002-2010).
SERVICE YEAR
2002 2003 2004 2005 2006 2007 2008 2009
Number of OPD visits 20,570 32,059 42,210 57,159 47,088 52,799 56,510 69,073
Number of admissions 3,312 5,332 6,460 8,161 7,176 7,807 8,282 9,597
Number of major surgeries 332 691 1,093 1,319 2,085 2,607 2,753 3,164
Number of Caesarean Sections 96 166 249 428 519 497 444 407
achieved. The reputation of the hospital for high quality
has led to a high proportion of patients attending from
outside the catchment area, including Addis Ababa,
(Accorsi et al., 2008).
Hospital performance is assessed through a set of ser-
vice indicators (FMOH, 2008), including bed occu-
pancy rate (BOR), bed turnover rate (BTR), and average
length of stay (ALOS). Each of these indicators pro-
vides useful information, but their comparative and ex-
planatory power is multiplied when they are jointly ana-
lysed to assess hospital performance (Pabòn Lasso,
1986). A graphical technique is currently used for moni-
toring hospital performance (Figure 7): the graph is sub-
divided into four quadrants by two lines drawn accord-
ing to the average Bed Occupancy Rate (53%) and Bed
Turnover Rate (30 patients per bed per year) in Oromia
Region, with the upper right quadrant (with BOR and
BTR above the regional average) representing the area
of more efficient provision of inpatient services.
However, it is worth noting that health facilities are de-
and by targeting the most vulnerable groups in order to
ensure equity of access. Of note is the fact that a rela-
tively short duration of hospital stay with high bed oc-
cupancy enables turnover rates to increase and thus al-
lows hospital benefits to be extended to a greater num-
ber of people. This increases the cost-effectiveness of
services by reducing the average cost per admission for
specific treatments. As a result, despite the fact that
Wolisso is acting as a referral hospital, with more com-
plex case-mix (e.g., high number of major surgical in-
terventions, long-term care orthopaedic services, com-
plicated deliveries in need of caesarean sections etc.) as
well as a training institution, the cost per patient-day
equivalent (ETB 218) in 2008 was only slightly higher
than the overall national average (ETB 196), while its
productivity (4,661 and 409 inpatient days per physician
and nurse, respectively) was much higher than the na-
tional average (2,150 and 369 inpatient days per physi-
cian and nurse, respectively) (Accorsi et al., 2010).
Since socially marginal and economically deprived
50
Quarterly Health Bulletin | December 2010, 3 (2)
REGIONAL EXPERIENCES
groups have the greatest overall need for health care but
are least able to obtain it (the so-called “inverse care
law”) (Hart, 1971), the policy of the hospital is to give
priority to access to quality services for the poor and
vulnerable, providing care at subsidized price with low
fees. The focus on infant, child and maternal care pro-
vides more of a poverty orientation than reliance on
other services, since the disease burden at an early age
or at childbirth is particularly important among the poor
(Gwatkin, 2001).
In the framework of the quality assurance system in
place at Wolisso Hospital, and in addition to the audit
for maternal and neonatal deaths and for key sentinel
events, a set of indicators was used to monitor quality of
care, based on international standards and experiences
and adapted to the local situation (Accorsi et al., 2008).
Furthermore, “exit interviews” have been periodically
conducted to obtain information regarding patients’ sat-
isfaction related to quality of care, cost of services re-
ceived as well as the environmental conditions of the
hospital.
Training and skill levels, motivation, teamwork, and the
organization of services are all complementary co-
determinants of the quality of the services provided by
the hospital. It is for this reason that the training of the
health staff is a priority for the hospital, with intense
“on the job training”, including an articulated program
of “Continuing Medical Education” involving the entire
hospital staff in terms of both facilitation and participa-
tion. Furthermore, in partnership with Jimma Univer-
sity, the hospital is involved in the national Accelerated
Health Officer Training Program (AHOTP), in the Mas-
ter of Science in Emergency Obstetric Care (EmOC)
and Emergency Surgical Care and in the training of the
peripheral health staff, including the HEWs.
The institution of the Public Health Department has
given a boost to support the implementation of the
Health Extension Program and the service delivery at
Health Centre level in the catchment area, thereby
strengthening the overall referral system and the conti-
nuity of care across levels of the health system. An ad-
ditional innovation is the hospital’s Engineering Depart-
ment which designs and constructs wells in the commu-
nity to ensure access to clean water: at the end of 2009
there were 46 safe water sites serving about 17,400
households.
In recognition of these activities, the hospital receives
financial support from the Oromia RHB in the frame-
work of the “Public-Private Partnership”. The third five
year Project Agreement was signed in May 2008 with
the Oromia Bureau of Finance and Economic Develop-
ment and the Oromia RHB.
3) Discussion
The importance of leadership, governance and manage-
ment for improving performance in hospitals is high-
lighted by the fact that the 3 top rated government hos-
pitals in Oromia Region have Governing Boards which
Figure 7. Hospital performance in Wolisso Hospital (2005-2010).
51
0
10
20
30
40
50
60
70
80
90
100
0 10 20 30 40 50 60 70 80 90 100 110
BED OCCUPANCY RATE
BE
D T
UR
NO
VE
R R
ATE
ALOS=5.7ALOS=5.8ALOS=5.9
ALOS=6.4
2008 2005
2009
2006
2007
ALOS=6.2
REGIONAL EXPERIENCES
Quarterly Health Bulletin | December 2010, 3 (2)
are well-functioning, with CEOs, management and staff
being committed and prepared to be innovative, crea-
tive, enthusiastic and persistently making radical
changes in their hospitals in different ways. This em-
powerment is encouraged by the Oromia RHB leader-
ship which wants their hospitals to innovate and show
the way.
This is a complex endeavour. As stated by P.F. Drucker
“Even small health care institutions are complex,
barely manageable places…large health care organiza-
tions may be the most complex organizations in human
history.” (Drucker, 2001). It is for these reasons that it
is important to document best practices and share ex-
periences in different areas of hospital management,
such as the increase of operational transparency, the
extension of the role of nurses and the implementation
of patient safety measures.
However, in the labour-intensive health system, man-
agement of human resources, teamwork, motivation and
education are all key determinants of hospital perform-
ance. Management in hospitals and health care is about
human behaviours, making people capable of working
together efficiently to make their strengths effective and
their weaknesses irrelevant. This is what organization is
all about, and it is the reason why management is the
critical, determining factor for the integration of people
in a common venture. As business schools and manage-
ment gurus were pushing technical excellence, technol-
ogy innovation, and ''command and control,'' Drucker
focused on the human qualities of leadership and the
need for clear and compelling goals. To improve care
processes management and patient safety in the hospi-
tal, several interlinked factors are needed: transparent
performance data, education and training, resources
availability, customer services ethos and, most impor-
tantly, permanent collaboration amongst managers, phy-
sicians, nurses and other staff. This article shows that
doctors and nurses are taking up new roles in patient
care, infection prevention, hygiene management and
community outreach.
Another key finding is related to the functioning of the
referral system. Because of the predominantly urban
location of hospitals serving largely rural and dispersed
populations, it is essential to develop a functional refer-
ral system and to ensure the quality of care provided in
lower level facilities. This article has documented that
hospitals can provide substantial support to primary
health care services as well as outreach specialist ser-
vices and training of skilled manpower.
This is crucial to ensure continuity of care across places
of care giving (households and communities, outpatient
and outreach services, and clinical-care settings). An
example is provided by maternal services to achieve
MDG 5. Delivery of safe motherhood services requires
access to quality maternity care linking community ma-
ternal health services through HEWs to clinics and dis-
trict hospitals and, when necessary, to higher level fa-
cilities by providing transportation and communication
systems. Outreach services have been also used to ad-
dress infections at the community level. Both the supply
of health services and the demand for such services
need to be improved simultaneously to have lasting im-
pact. This implies dealing with complex set of issues
related to cultural reasons, perceptions about maternal
services and price constraints. From the supply side,
ensuring financial accessibility to health services, as
well as quality of care, are key issues to be urgently ad-
dressed. Hospitals in Oromia are striving to meet these
objectives and are looking to expand potential addi-
tional policy options for the future such as program
budgeting, performance-based financing and contract-
ing.
4) Conclusions
Every hospital and health care organization requires
commitment to common goals and shared values, and
must have simple, clear and unifying objectives. The
mission of the organization has to be clear and big
enough to provide a common vision with clear, public,
and constantly reaffirmed goals. Management's first job
is to set and exemplify those objectives, values and
goals. Management must also enable the organization
and each of its members to grow and develop as needs
and opportunities change. Every organization is a learn-
ing and teaching institution, and training and develop-
ment must be built into it at all levels - training and de-
velopment that never stop.
This article has shown that strengthening leadership and
good management, motivating staff and managers, and
ensuring accountability, can contribute to improve the
accessibility to health services and increase the effi-
ciency in health care delivery, considering improve-
ments in both the distribution of resources to priority
activities (allocative efficiency) and the management of
resources that are allocated (technical efficiency). The
subsequent system-wide efficiency gain would provide
savings that could be translated into provision of ser-
vices to a greater number of patients (Bilal et al., 2009).
The single most important thing to remember about any
organization is that results exist only on the outside. The
52
Quarterly Health Bulletin | December 2010, 3 (2)
REGIONAL EXPERIENCES
result of a business is a satisfied customer. The result of
a school is a student who has learned something and
puts it to work ten years later. The result of a hospital is
a healed patient. It is our common objective to work
together to prevent disease, promote healthy life styles
and save lives.
Acknowledgements
We wish to thank Ato Haile Ayana and David Conteh
(EHMIS, Clinton Health Access Initiative) for their
valuable contribution to this article.
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