Hospital performance contract: the Senegalese experience [Article in French]

Abstract

In 1998 Senegal launched an ambitious hospital reform program which aimed to transform hospitals into government-owned health enterprises, corporations endowed with a legal entity and autonomy for management. Within this agenda, administrative logic was substituted with the concept of performance management, while simultaneously re-affirming the public service mission that had to remain prominently in the name of the State and public authority. The accompanying measures of the reform implemented by the central level did not produce the expected results in terms of management and quality of care; therefore, the authorities concluded that it was necessary to create more incentives and to link at least a portion of the resources allocated by the State to public hospital establishments in the form of grants which required the demonstration of the achievement of some pre-defined objectives according to a common memorandum of agreement with hospital officials. Thus the idea of contracting was born, an idea which ensued from an expression of political will translated through a national policy document on contracting in the health sector in 2004, but it was also translated through an agreement between the Senegalese government and the World Bank specifically within the framework of budgetary support. The preliminary work necessary to develop these performance contracts, namely, the choice of the domains to be contracted, criteria and performance indicators to be retained, was the subject of a significant process of dialogue with the hospital community. Fifteen contracts were signed during the first quarter of 2006, and then evaluated in July 2007. The results of the evaluations were utilised to substantiate the calculations of the performance subsidy that will be allocated in 2008 to the hospitals having achieved the required eligibility level. Despite the limitations and insufficiencies noted in the contracts' content and in the implementation methods, they had an overall positive impact:--at the operational level, where in certain cases, they were a powerful force to leverage better team work, and in the establishments were the results were less evident, they were able to be used to put certain practices into question; but also--at the institutional level, by laying the foundations of a new organisational relationship between the administrative supervision and the public hospitals. This approach is actively being pursued within the framework of the second generation contracts to be established in the near future, taking into account the lessons learned from this first experience