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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)


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.



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.



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



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.



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



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


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.



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



2.3.2) Performance


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



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



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



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



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



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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