Cover_WHO_nr25_Mise en page 1 17/11/11 15:54 Page1 25 REFORM STRATEGIES AND THE MOVEMENT TOWARDS INSTITUTIONAL AUTONOMY INSTITUTIONAL TOWARDS THE MOVEMENT AND STRATEGIES REFORM GOVERNING PUBLIC HOSPITALS GOVERNING Governing 25 The governance of public hospitals in Europe is changing. Individual hospitals have been given varying degrees of semi-autonomy within the public sector and empowered to make key strategic, financial, and clinical decisions. This study explores the major developments and their implications for national and Public Hospitals European health policy. Observatory The study focuses on hospital-level decision-making and draws together both Studies Series theoretical and practical evidence. It includes an in-depth assessment of eight Reform strategies and the movement different country models of semi-autonomy. towards institutional autonomy The evidence that emerges throws light on the shifting relationships between public-sector decision-making and hospital- level organizational behaviour and will be of real and practical value to those working with this increasingly Edited by important and complex mix of approaches. Richard B. Saltman Antonio Durán The editors Hans F.W. Dubois Richard B. Saltman is Associate Head of Research Policy at the European Observatory on Health Systems and Policies, and Professor of Health Policy and Management at the Rollins School of Public Health, Emory University in Atlanta. Hans F.W. Dubois Hans F.W. Antonio Durán, Saltman, B. Richard by Edited Antonio Durán has been a senior consultant to the WHO Regional Office for Europe and is Chief Executive Officer of Técnicas de Salud in Seville. Hans F.W. Dubois was Assistant Professor at Kozminski University in Warsaw at the time of writing, and is now Research Officer at Eurofound in Dublin. Observatory Studies Series No. 25 9 789289 002547 Governing Public Hospitals Th e European Observatory on Health Systems and Policies supports and promotes evidence- based health policy-making through comprehensive and rigorous analysis of health systems in Europe. It brings together a wide range of policy-makers, academics and practitioners to analyse trends in health reform, drawing on experience from across Europe to illuminate policy issues. Th e European Observatory on Health Systems and Policies is a partnership between the World Health Organization Regional Offi ce for Europe, the Governments of Belgium, Finland, Ireland, the Netherlands, Norway, Slovenia, Spain, Sweden and the Veneto Region of Italy, the European Commission, the European Investment Bank, the World Bank, UNCAM (French National Union of Health Insurance Funds), the London School of Economics and Political Science, and the London School of Hygiene & Tropical Medicine. Governing Public Hospitals Reform strategies and the movement towards institutional autonomy Edited by Richard B. Saltman, Antonio Durán, Hans F.W. Dubois Keywords: HOSPITALS, PUBLIC – trends HOSPITAL ADMINISTRATION HEALTH CARE REFORM STRATEGIC PLANNING EUROPE © World Health Organization 2011, on behalf of the European Observatory on Health Systems and Policies All rights reserved. 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Th e views expressed by authors, editors, or expert groups do not necessarily represent the decisions or the stated policy of the European Observatory on Health Systems and Policies. ISBN 978 92 890 0254 7 Printed in the United Kingdom Cover design by M2M Contents Preface vii Acknowledgements ix List of tables, fi gures and boxes xi List of abbreviations xiii List of contributors xv Introduction: innovative governance strategies in European public hospitals 1 Richard B. Saltman, Antonio Durán and Hans F.W. Dubois PART I Hospital governance in Europe Chapter 1 The evolving role of hospitals and recent concepts of public 15 sector governance Antonio Durán, Hans F.W. Dubois and Richard B. Saltman Chapter 2 A framework for assessing hospital governance 35 Antonio Durán, Richard B. Saltman and Hans F.W. Dubois Chapter 3 Mapping new governance models for public hospitals 55 Richard B. Saltman, Hans F.W. Dubois and Antonio Durán Chapter 4 Conclusions and remaining issues 75 Richard B. Saltman and Antonio Durán Appendix Eight case studies: case study responses to key governance 87 questions vi Governing public hospitals PART II Hospital governance in eight countries Chapter 5 Czech Republic 99 Tomas Roubal and Pavel Hroboň Chapter 6 England 113 Nigel Edwards Chapter 7 Estonia 141 Triin Habicht, Jarno Habicht and Maris Jesse Chapter 8 Israel 163 David Chinitz and Avi Israeli Chapter 9 Netherlands 179 Hans Maarse and Léon Lodewick Chapter 10 Norway 201 Jon Magnussen Chapter 11 Portugal 217 Vítor M. dos Reis Raposo and Ana P. de Jesus Harfouche Chapter 12 Spain 241 Arturo A. Álvarez and Antonio Durán Preface For hospital governance to be eff ective, it must incorporate two powerful and well-developed lines of health sector logic: on the one hand, national health policy and objectives; on the other, operational hospital management. One sphere is political, the other is technical. One is subjective and value based, the other is objective, with performance that can be measured both clinically and fi nancially. Th e challenge for hospital-level governance is to integrate these two disparate logics into a coherent and eff ective institutional-level strategy. Th is study explores key developments in public hospital governance in Europe. In doing so, it highlights the central role of hospital-level decision-making and how it is shaped by the various participants and stakeholders. In particular, it examines the degree to which granting an individual hospital the ability to make its own strategic, fi nancial and clinical decisions – to become semi-autonomous within the public sector – may improve institutional-level functioning and outcomes. In the initial chapters of this study, we draw on a substantial body of literature in a number of related health policy, public management and institutional governance arenas. How these diff erent concepts might apply to public hospitals is the subject of considerable discussion here. It is in the interface of these diff ering conceptual approaches, with the evidence and experience seen in the eight country cases, that we catch a glimpse of the future of public hospital governance in Europe. We hope that this study can serve as a solid conceptual and practical contribution to future quantitative as well as qualitative research on this important subject. Richard B. Saltman, Antonio Durán and Hans F.W. Dubois Acknowledgements Th e editors are grateful to the substantial number of individuals and institutions that helped to produce this volume in a relatively short period of time. First, we thank our country case study authors, who worked under tight deadlines and produced the empirical information upon which this volume is based. We also want to express our gratitude to Arturo Álvarez, who contributed substantially to the ideas on governance developed in Chapters 1 and 2. Additionally, we are grateful to the Andalusian School of Public Health in Granada, which hosted the author’s workshop, as well as to the Regional Government of Andalusia, which provided support for that meeting. Further, we would like to thank Josep Figueras of the European Observatory on Health Systems and Policies, Pascal Garel of the Hope Foundation and Hans Maarse (also one of our case study authors), all of whom read the fi rst draft of Part I and participated in a Brussels-based meeting that provided important comments and suggestions. A subsequent draft was further reviewed by Nigel Edwards, Hans Maarse and Pascal Garel. We also benefi ted greatly from testing Chapter 3 at a meeting of the European Health Policy Group in Paris, hosted by IRDES, and at which the comments by the discussant Nick Mays and by the participants helped us to shape our conceptual and practical approach. An early seminar at the London School of Economics and Political Science (LSE) was essential in helping to develop our thinking, and Champa Heidbrink and LSE also graciously provided rooms for a series of editors’ meetings as the study took shape. While none of the above-mentioned parties are in any way responsible for how we used their wisdom and support, we are very grateful to them for their assistance in making this what we hope will be a useful contribution to the growing literature on hospital governance.