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Implementing health care reform: implications for performance of public

hospitals in central Ethiopia

Article  in  Journal of Global Health · February 2018

DOI: 10.7189/jogh.08.010403

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Implementing health care reform: implications
for performance of public hospitals in central

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Ethiopia
Tsegahun Manyazewal1,2, Mokgadi
Background Understanding the way health care reforms have succeed-
C Matlakala1 ed or failed thus far would help policy makers cater continued reform
efforts in the future and provides insight into possible levels of im-
1
 epartment of Health Studies, College of
D
provement in the health care system. This work aims to assess and de-
Human Sciences, University of South Africa,
Pretoria, South Africa scribe the implications of health care reform on the performance of
2
University of California San Diego, Anti-Viral public hospitals in central Ethiopia.
Research Center, ADDIS VP Project, Addis Methods A facility-based, cross-sectional study was carried out in five
Ababa, Ethiopia
public hospitals with different operational characteristics that have
been implementing health care reform in central Ethiopia. The reform
documents were reviewed to assess the nature and targets of the reform
for interpretive analysis. Adopting dimensions of health system perfor-
mance as the theoretical framework, a self-administered questionnaire
was developed. Consenting health care professionals who have been
involved in the reform from inception to implementation filled the
questionnaire. Cronbach’s alpha was measured to ensure internal con-
sistency of the instrument. Descriptive statistics, weighted median
score, 2, and Mann-Whitney U and Kruskal-Wallis tests were used
for data analysis.
Results Despite implementation of the reform, the health care system
in public hospitals was still fragmented as confirmed by 50% of re-
spondents. Limited effects were reported in favour of quality (48%),
access (50%), efficiency (51%), sustainability (53%), and equity (61%)
of care, while poor effects were reported in patient-provider (41%) and
provider-management (32%) interactions. Though there was substan-
tial gain in infrastructure and workspace, stewardship of health care
resources was less benefited. The predominant hindrances of the re-
form were the working environment (adjusted Odds Ratio (aOR) = 2.27,
95% confidence interval (CI): 1.15-4.47), financial resources
(aOR = 3.54, 95%CI = 1.97-6.33), management (aOR = 2.27, 95%
CI = 1.15-4.47), and information technology system (aOR = 3.15, 95%
CI = 1.57-6.32).
Conclusions The Ethiopian health care reform has laid the ground-
Correspondence to: work for health system improvement, but progress was slow and the
health care delivery system was still fragile. Healthcare reform efforts
Tsegahun Manyazewal, PhD
Department of Health Studies in such settings are feasible, but with regular mapping of programmat-
College of Human Sciences ic outcomes and bringing a common understanding of the reform
University of South Africa among stakeholders.
PO BOX 392
Pretoria
South Africa
tsegahunm@gmail.com

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 Manyazewal et al.

In the wave of the pressure combating health care challenges and visioning quality of care, the Ethiopian
government urged a countrywide health care reform initiative in the form of Business Process Reengineer-
ing (BPR). Tracking clients’ allegations about quality of health care, the initiative imposed the Ethiopian
Federal Ministry of Health (FMoH) transform the country’s health care system [1]. Rooted on BPR prin-
ciples [2], the FMoH conducted “as is” analysis to capture credible evidences of the existing health care
system and realize the different dynamics that should be considered in the redesign of the new reform.
With these, the “to be” business processes were designed, public health sector standards formulated, and
standard operating procedures and implementation tools developed [3]. The reform was progressively
implemented through a series of training sessions for managers and technicians at all levels followed by
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changes in staff deployment, specific job assignments and the recruitment of new staff. Stretched objec-
tives were synthesized and sub-processes that form the core process sorted out. Public hospitals’ services
were re-structured into three major case teams, namely; Emergency, Outpatient, and Inpatient; where
Outpatient and Inpatient case teams were further classified into eight and nine case teams, respectively
[4]. Gradually, Ethiopia implemented the BPR in all government sectors to solve the problems of hierar-
chical bureaucracy.
Beyond the health care reform in Ethiopia, there have been debates on implications of health care reform
in resource-limited countries. In Uganda, while official reports developed by donor funded expatriate staff
have tended to show a positive picture of the Ugandan health sector reform [5], other studies indicate
that despite these reforms, the Ugandan health sector remains challenged by under-funding [6] and poor
quality of care [7]. Kenya has been in the process of implementing health care reforms to secure a funda-
mental change in the functioning and performance of its health care services. Despite these efforts, the
health system in Kenya is inequitable and the health financing is fragmented, requiring a systematic ap-
proach to health financing reforms to ensure health coverage and equity [8] and to reinforce Health Sec-
tor Costing Model to reach the target of the country’s Vision 2030 [9]. In Tanzanian, the government’s
Decentralization by Devolution health reform deemed to improve the delivery of public health services
has gained successes and faced challenges [10]. The approach benefited from the increased accountabil-
ity of health workers and reduced bureaucratic procedures in decision-making, however, it was challenged
by funding constraints, unnecessary political interference, lack of sufficient and technically qualified per-
sonnel, and weak supportive supervision activities [10]. In South Africa and Zimbabwe, the attempts for
health care reform end with ambiguity; as key aspects of the proposed National Health Insurance (NHI)
scheme remains unclear and mandatory national health insurance has been discussed for decades with-
out a system implemented in the two countries respectively [11]. In South Africa, funding was not the
central problem of the public health system; but rather the enormous inefficiencies in management and
low productivity, with an urgent need to re-engineer the way health facilities are internally organized to
achieve better productivity and responsiveness [12].
Similar to countries in Africa, many countries’ governments in other regions have been implementing
health care reforms to review their health care systems and health care services financing and delivering
approaches. China has recently been compelled to undertake health sector reforms in response to inequi-
tably distributed health services, but tackling high medical costs has not been fruitful [13,14] and sustain-
ing positive gains has been difficult [15]. Healthcare reform in China may succeed if vertical monitoring
of the quality, equity, efficiency and effectiveness of the health sector is improved [16,17]. Brazil and Co-
lombia have implemented extensive health care reforms for decades with the major goal of improving ac-
cess, increasing efficiency and reducing health inequities, but in neither case have reforms seemed to have
had a decisive positive impact on the health outcomes, instead, the countries’ health improvement decel-
erates in the years following the reforms [18]. During the financial crisis in European countries, health care
facilities have become a focal point for health care reform strategies, which consist of reducing cost as a
short-term strategy and improving performance in the long run, but the reforms emphasize cost contain-
ment measures rather than embarking on structural redesign of the health care sector [19].
Analysis of literatures reviewed reveals that health care reform efforts in Africa have limited implications
on the overall health system improvements, which was mainly due to minimum commitments the coun-
tries had exerted in the implementation of the reforms. The effects of the reforms were shown to be high-
ly influenced by political principles and the unique health concerns of each country.
Healthcare institutions intend to use different business models such as total quality management, continu-
ous quality improvement, just-in-time, BPR, benchmarking and among others to re-design their processes
[20]. BPR, which is the focus of this study, is the fundamental rethinking and radical redesign of business
processes to achieve improvements in critical, contemporary measures of performance, such as cost, qual-

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 Implementing healthcare reform

ity, service, and speed to achieve substantial gains in the overall organizational performance [2]. It relies
upon questioning, challenging, evaluating, and redesigning every element of an institution’s operational
process [21]. BPR project requires specific steps to succeed to a positive outcome. The process begins with
defining the scope and objectives of the reengineering project, followed by evaluating the existing (As-Is)
performance of the organization and the commitment of senior management to implement the project
[22,23]. The later step involves development of executive consensus on the need of the BPR, identifying the
strengths and weaknesses of the organization, identifying the processes to be reengineered, defining the ul-
timate benefit, and clarifying that is needed and what will be their role [24]. The third step is designing the
new (To-Be) process based on the data obtained from the As-Is mapping, thereby implementing the To-Be

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process. The implementation phase requires initiating culture change program, developing a transition plan
and piloting the new process, providing training for the implementers, and executing the new process in
full scale [25,26]. Once BPR is implemented, it requires monitoring the progress of action by measuring
how much more informed the people feel, how much more commitment the management shows and how
well the new teams are accepted in the broader perspective of the organization [27].
Although the present study is limited to Ethiopia, there are studies in other countries which reported a
dramatic improvement of health care services due to implementation of health care reform using BPR as
a tool. For instance, in Singapore, the second largest hospital in the country was able to eliminate the
waiting time of patients with BPR oriented health care reform [28]. In Italy, a study of the use of BPR in
the surgical ward of a hospital was able to identify areas for improvement such as the number of operat-
ing sessions, preparation of the operating rooms for each operation, and availability of specific surgical
instruments [29]. Juxtapose this, some countries failed implementing health care reforms when using
BPR as a tool [30] because implementation of BPR requires adequate financial resources [31] and knowl-
edge about BPR concepts [32] for making changes.
Though health care reform relies on a good design, its success ultimately depends on careful attention to
the complex details of implementation [33]. Healthcare reform is complex as it needs high investment in
facilities, technologies, sufficient supply of pharmaceuticals, training of health workers, and a system for
quality improvement [34]. The gap between health care reform framework and the support made avail-
able for implementation creates pressure for policy and decision makers, managers, and health profes-
sionals [35]. Long-term political commitment of the local governments [36] and the sense of belonging
of the health care team [37] are shown to affect health care reform strategies.
In Ethiopia, despite the fact that the Ethiopian government began implementing health care reform
through BPR in 2009, there is limited evidence demonstrating its success or failure. Understanding the
way health care reforms have succeeded or failed thus far would help policy makers cater continued re-
form efforts in the future and provide insight into possible levels of improvement in the health care sys-
tem. Thus, this work aims to assess and describe the implications of health care reform on the perfor-
mance of public hospitals in central Ethiopia.

METHODS
Theoretical framework
The theoretical framework of this study was the dimensions of “health system performance” [38]. This
approach presents indicators for five key dimensions of health system performance which map the link-
ages between health sector reform, changes in health system performance, and changes in health status;
namely, quality, access, equity, efficiency, and sustainability. In the same way, the current study has taken
those requirements as the major criteria that should be achieved in public hospitals of Ethiopia following
the implementation of the BPR health care reform. These five key dimensions and their constructs which
determine the effectiveness of the reform are explained with application to the results of this study.

Setting and participants

A facility based, cross-sectional study was conducted in quantitative methods in major and highly com-
plex public hospitals in Addis Ababa, Ethiopia, between January to June 2015. Addis Ababa was selected
among the 11 administrative divisions of Ethiopia considering its status as the largest and city capital of
Ethiopia. The Addis Ababa Health Bureau has been implementing the health care reform designed in six
public hospitals. The bureau administers these public hospitals, which deliver advanced preventive and
curative health services, from which five have been implementing the BPR health care reform since its

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 Manyazewal et al.

inception in 2009. The five hospitals were purposively included as the study sites to maximize the scope
of the study thereby ensure external validity.
The study population was all health care providers that were working in the study sites at the time of data
collection (n = 1681). Of this, those who were employed at least one year before the inception of the re-
form (n = 476, 28%) were purposively selected to include respondents who knew the performances of
the hospitals before implementation of the reform and who could better analyse the changes that occurred
due to the reform. The health care providers included medical doctors, laboratory professionals, nurses,
health officers, pharmacists, dentists and sanitarians.
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Data collection instrument

The reform documents as well as previous health care reform initiatives in the country were reviewed to
assess the nature and targets of the reform for interpretive analysis. In order to develop a quality ques-
tionnaire, we reviewed secondary data; assessed related studies conducted previously, determined the
target population and their educational levels, and considered the advice of experts before designing the
questionnaire. Additionally, an in-depth review of literature was conducted to identify critical factors that
could influence the success of BPR programs. Finally, six BPR critical success factors were identified;
namely, financial resources, top management commitment and support, training, collaborative working
environment, flatter structure, and information technology [31,39-43].
A self-designed structured, close-ended questionnaire with 82-items and close-ended 5-level scale [44]
was used to collect data. The layout of the questionnaire was divided in logical order into six contents of
the health system performance dimensions indicated above; namely, quality, access, equity, efficiency and
sustainability, along with demographics.
In the “quality” component of the questionnaire, 32 items (Cronbach’s alpha = 0.960) were included to
analyse the reform’s implication on quality of health care services. The quality investigation was guided
by three health care quality dimensions: structure-process-outcome, as proposed in the Donabedian qual-
ity-of-care framework [45]. We included 22 items to measure the “outcome” quality (Cronbach’s al-
pha = 0.958); eight items focusing on patient-provider interaction; four items on documentation, and
monitoring and evaluation; and nine items on provider-management interactions constructed from the
targets depicted by the Ethiopian government in its reform document [4]. For “process”, we included
eight items (Cronbach’s alpha = 0.921) to assess appropriateness of the methods and procedures followed
in the implementation of the reform. “Structure” had two items aimed at assessing improvements of the
overall structure of the hospitals to meet the daily workflow.
“Access” was examined using 25 items (Cronbach’s alpha = 0.960) in the questionnaire; based on the five
dimensions of health care access; namely, physical, economic, temporal, cultural, and approachability
dimensions. The “physical” dimension assessed availability of work space, furniture, equipment, supplies,
medications, reagents, communication materials, and other supplies in the hospitals after implementa-
tion of the reform. The “economic” dimension assessed the overall effect of the reform on financing and
financial management system, and “temporal” dimension assessed the effect of the reform on improving
turn-around-time of the hospitals’ health care services. “Cultural” dimension assessed acceptability of the
hospitals’ services, and “approachability” dimension assessed the effect of the reform on improving aware-
ness of the community that some form of health services exists, can be reached, and have an impact on
their health.
The “equity” section included four items in the questionnaire to assess availability of resources and systems
in the hospitals that would benefit every citizen. “Efficiency” component used twelve items to assess the
technical, economic and allocative processes related to how and which services are produced in the reform
process. “Sustainability” of hospitals’ services was assessed using nine relevant items in the questionnaire.
The respondents received and completed the study questionnaire in paper-based form while they were
on their working area. Each of the five responses in the questionnaire had a numerical value (1-5), in
which the highest two scoring answers (4 and 5) were perceived as positive response answers, the lowest
two scoring answers (1 and 2) were considered negative response answers, and the middle response an-
swer (3) was perceived neutral. As the questions’ items were grouped into health care performance di-
mensions, a scale score was computed as the mean of the scales’ item scores.
The six BPR critical success factors identified in our literature review were used as a guide in identifying and
analysing the factors that influence implementation of the BPR health care reform. From the study’s ques-

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 Implementing healthcare reform

tionnaire, the item stating “the hospital becomes a better treatment facility” was taken as the outcome vari-
able to indicate whether there was hospital service improvement. This item had original responses classified
in five level scale. The responses were dichotomized into “Good” or “Poor” answers by taking the “Strongly
agree” and “Agree” responses as a “Good” value while “Strongly disagree”, “Disagree”, and “Neutral” as “Poor”
value for feasibility of analysis and interpretation. The six BPR critical success factors were taken as the ex-
planatory variables. For each of the six success factors, three items which best describe the factor were pooled
from the questionnaire and the responses given to the items analysed as a cumulative effect. Responses were
valued as “Good” if at least two of the three items had a “Strongly agree” or “Agree” response in the original
scale questionnaire, while the remaining responses were taken as “Poor” value. Associations of health ser-

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vice improvement with the six explanatory variables were tested independently using bivariate analysis.
Based on the results, the independent variables were selected for the logistic regression analysis. Subsequent-
ly, multivariate logistic regression analysis was conducted to exclude confounders.
Reliability of the data collection instruments was ensured by running Cronbach’s alpha test [46] for each
category of items, and the results were found satisfactory. The questionnaire included close-ended ques-
tions to ensure a rational reproducibility of the study. The questionnaire was pre-tested at the study sites
to ensure reliability of the instrument. Internal validity was increased through reviewing and analysing
previous questionnaires and crosschecking the collected data. The inclusion of all five public hospitals
that participated in the reform from inception as the study sites maximized the scope of the study to the
target population. We emphatically believe that public health care providers, who are the ultimate re-
sources of health systems, were the best candidates to validate the success or failure rate of the BPR health
care reform implemented in Ethiopia. We employed the perceptions of health care providers to assess and
describe the implications of the health care reform due to multiple reasons. The exclusion of patients was
based on the fact that there are unwanted variations in health care practice and outcomes that cannot be
explained by patients [47] and health care improvements resulting from patients’ feedback is limited [48],
while providers feedback and involvement is critical as providers can realize the overall implications of
health care reforms [49-52]. We also believe that the major reform the Ethiopian government designed
and implemented to date to enhance the health care service delivery system in the country is the BPR
health care reform. In this manner, this reform, which we assessed, is responsible for major public health
care services’ gains or losses.
The study was granted ethical clearance from the Higher Degrees Committee of the Department of Health
Studies, University of South Africa and the Research and Technology Transfer Core-process of the Addis
Ababa City Administration Health Bureau. Written informed consents were obtained from each respon-
dent before completing the questionnaire.
Data analysis was done through calculation of several statistical procedures on IBM SPSS version 20 (IBM
Corp, Armonk, NY, USA) and on Excel 2010 (Microsoft Corp, Seattle, WA, USA). The variables were
re-coded and dichotomized where appropriate on SPSS. Descriptive statistical analysis [46] was conduct-
ed to describe the means, standard deviations, medians and frequencies of items aimed at measuring
quality, access, equity, efficiency, and sustainability of health care services. The weighted median scores
[53] were used to demark cut-off points and categorize the perceived health service improvements.
Non-parametric analysis, namely Mann-Whitney test and Kruskal-Wallis test [54], were conducted to
statistically test if there was a significant difference in answering tendencies of respondents with different
groups. 2 test [46] was used to evaluate association of different variables, and P < 0.05 at 95% CI was
taken as mark for statistical significance. The association between health service improvement and BPR
critical success factors were tested independently using bivariate analysis. Variables with significant asso-
ciations were analysed further with logistic regression analysis [55].

RESULTS
Socio-demographic profiles
Of the total participants who were eligible as they have worked in the hospitals for at least a year before
the inception of the reform (n = 476), the questionnaire was distributed to those who consented (n = 465).
The questionnaires returned (n = 410, 88%) were rechecked for completeness and those completed
(n = 406) presented for analysis. Majority of the respondents were nurses (n = 304, 74.9%) followed by
medical doctors (n = 35, 8.6%), and medical laboratory professionals (n = 24, 5.9%). The demographic
profiles are represented in detail in Table 1.

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 Manyazewal et al.

Table 1. Socio-demographic characteristics of respondents

Item Count (n = 406) % Cumulative %
Gender:
Male 124 30.5 30.5
Female 282 69.5 100.0
Age (years):
20-29 93 22.9 22.9
30-39 195 48.0 70.9
40-49 92 22.7 93.6
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50-59 26 6.4 100.0

Duration of work as health professional (years):
6-9 146 36.0 36.0
10-19 202 49.8 85.7
20-29 55 13.5 99.3
30-39 03 0.7 100.0
Duration of work as staff in this hospital (years):
6-9 247 60.8 60.8
10-19 136 33.5 94.3
20-29 21 5.2 99.5
30-39 02 0.5 100.0
Profession:
Medical Doctor 35 8.6 8.6
Laboratory 24 5.9 14.5
Pharmacy 16 3.9 18.5
Nurse 304 74.9 93.3
Health Officer 14 3.4 96.8
x-ray technician 11 2.7 99.5
Sanitarian 2 0.5 100.0
Level of education:
Certificate 2 0.5 0.5
Diploma 37 9.1 9.6
Degree 342 84.2 93.8
MSc/MA or MPH 7 1.7 95.6
Medical Doctor Degree + Specialty 18 4.4 100.0
Total 406 100 100

Quality
Quality was explained by three dimensions. For the outcome, 42% responses indicated that the reform
did not meet the perceived patients-provider interaction. The lowest score in patient-provider interaction
was for bed appointments, where 341 (84%) of respondents claimed that the perceived time limit of 10
minutes allotted in the reform document for patients getting beds has not been met (Table 2). For docu-
mentation, 102 (25.1%) respondents agreed that the reform allowed reporting systems of the hospitals
to be easy and time-efficient. Additionally, 130 (32%) respondents agreed that hospital guidelines and
protocols are up to date and appropriate. For providers-hospital management interaction, respondents’
feedback showed that the hospital staff were not promoted to a relatively higher position (n = 246, 60.6%)
or got recognition of their outstanding performance (n = 255, 62.8%). Besides, the reform did not allow
for increases in salaries of staff (n = 256, 63.1%) nor did it create a better feeling of overall job satisfaction
among staff (n = 228, 56.2%). The relatively positive input of the reform was on work relationship, in that
the reform created better working relationship among staff (n = 204, 50.2).
The overall analysis of findings indicates that provider-management system interaction of the hospitals is
still weak. The weighted median descriptive statistics made on outcomes of quality from visual binning
of the variables, suggest that 207 (51%) of the respondents argued that the BPR health care reform has
brought improvements on hospital quality outcomes, while 199 (49%) indicated that there are no im-
provements. For process, among the major gaps in the health care reform implementation process was
training, and 246 (60.6%) of the respondents explained that adequate training had not been provided to
all staff throughout the BPR implementation process. Additionally, only 68 (16.7%) of respondents agreed
that the reform process involved stakeholders on the new design and received their feedback (Table 2).

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 Implementing healthcare reform

Table 2. Descriptive analysis of health care quality

Agree frequency Neutral frequency Disagree frequency
Perceived service quality (%) (%) (%)
Outcome
Due to the BPR health care reform:
1.1.1. Out patients are completing treatment services within 2 hours 144 (35.5) 42 (10.3) 220 (54.2)
1.1.2. Emergency patients are receiving treatment immediately 232 (57.1) 67 (16.5) 107 (26.4)
1.1.3. Patients are getting beds within 10 min 27 (6.7) 38 (9.4) 341 (84)
1.1.4. Patients are receiving specialized services within 72 hours 199 (49) 63 (15.5) 144 (35.5)
1.1.5. Customers are receiving medical certificate within 1 hour 237 (58.4) 85 (20.9) 84 (20.7)

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1.1.6. Patients satisfied with the hospital services 184 (45.3) 114 (28.1) 108 (26.6)
1.1.7. Treatment & respect of patients improved 213 (52.5) 79 (19.5) 114 (28.1)
1.1.8. Missing patients’ medical records is rare 107 (26.4) 66 (16.3) 233 (57.4)
% Patient-provider interaction 41% 17% 42%
1.1.9. Reporting systems are easy and not time consuming 102 (25.1) 76 (18.7) 228 (56.2)
1.1.10. Guidelines & protocols are up-to-date & appropriate 130 (32) 87 (21.4) 189 (46.6)
1.1.11. Opportunities to learn from successes/challenges created 190 (29.6) 96 (23.6) 120 (46.8)
1.1.12. Up-to-date technologies for patient diagnosis are in use 150 (36.9) 92 (22.7) 164 (40.4)
1.1.13. Monitoring & evaluation systems are established 181 (44.6) 94 (23.2) 131 (32.3)
% Documentation & progress monitoring 37% 22% 41%
1.1.14. Staff developed good working relationship with each other 204 (50.2) 82 (20.2) 120 (29.6)
1.1.15. Staff receive appropriate & timely performance feedback 131 (32.3) 78 (19.2) 197 (48.5)
1.1.16. Staff have clear job description 188 (46.3) 96 (23.6) 122 (30)
1.1.17. Staff get a better feeling of overall job satisfaction 111 (27.3) 67 (16.5) 228 (56.2)
1.1.18. Staff are highly motivated to their work 96 (57.4) 77 (19) 233 (23.6)
1.1.19. Staff salary increases 93 (22.9) 57 (14) 256 (63.1)
1.1.20. Staff promoted to a relatively higher position 92 (22.7) 68 (16.7) 246 (60.6)
1.1.21. Staff with outstanding performance are getting recognition 93 (22.9) 58 (14.3) 255 (62.8)
1.1.22. Staff use their working hours appropriately 166 (40.9) 59 (14.5) 181 (44.6)
% Staff-hospital management system interaction: 32% 18% 50%
% Outcome 37% 18% 45%
Process:
In the BPR implementation process:
1.2.1. Staff are able to clearly know the mission and vision of the hospital 218 (53.7) 130 (32) 58 (14.3)
1.2.2. Supervisors were coming from health bureau to monitor the reform effort 119 (29.3) 156 (38.4) 131 (32.3)
1.2.3. Hospital quality improvement goals were known throughout case teams 199 (49) 109 (26.8) 98 (24.1)
1.2.4. Hospital employees were involved in developing plans 165 (40.6) 78 (19.2) 163 (40.1)
1.2.5. Adequate training has been provided to all staff 109 (26.8) 51 (12.6) 246 (60.6)
1.2.6. Stakeholders communicated on the new design and feedbacks received 68 (16.7) 144 (35.5) 194 (47.8)
1.2.7. Feedbacks from patients and data from pilot test were incorporated 90 (22.2) 114 (28.1) 202 (49.8)
1.2.8. The right team members have been prepared to process the reform 117 (28.8) 123 (30.3) 166 (40.9)
% Process: 33% 28% 39%
Structure:
Due to implementation of BPR health care reform:
1.3.1. The way the hospital is structured is conducive to the daily work flow 161 (39.7) 110 (27.1) 135 (33.3)
1.3.2. The hospital becomes a better treatment facility 202 (49.8) 136 (33.5) 68 (16.7)
% Structure 45% 30% 25%
BPR – business process reengineering

Overall, 211 (52%) of respondents indicated that appropriate procedures have not been followed in the
processing of the reform. For structure, 52.5% of respondents argued that there is no improvement in the
structure of the hospitals, while 322 (65%) of participants agreed that the hospitals became conducive to
the daily workflow.
From the analysis of the weighted median score from visual binning of the variables, 211 (52%) of re-
spondents indicated that there are no improvements in quality of health care services due to implemen-
tation of the BPR health care reform.

Access
Access was explained by five dimensions, with which, 206 (50.7%) of respondents indicated that the re-
form enabled the hospitals organized with case teams that have well-defined rooms or spaces adequate

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 Manyazewal et al.

to the daily work flow (Table 3). However, according to the respondents, there were other physical bar-
riers which were compromising their day-to-day activities. The respondents claimed that after implemen-
tation of the reform, the hospitals still have insufficient office furniture (n = 227, 55.9%), stationery ma-
terials (n = 238 58.6%), and reagents and drugs (n = 215 53%). Additionally, the hospitals lack conducive
staff rest rooms (n = 266 65.5%) and clean work areas (n = 192 47.3%). Implementation of the reform did
not empower the hospitals to get equipped with internet services (n = 332, 81.8%), functioning comput-
ers (n = 343 56%) and a functioning landline telephone to call within and outside the hospitals (n = 239
58.9%). Preventive and curative maintenance of diagnostic equipment were also described as ineffective.
The overall finding indicated that implementation of the reform did not address the shortages or absence
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of critical physical dimensions that are needed for the hospitals’ day-to-day services.

Table 3. Descriptive analysis of health care access

Agree frequency Neutral frequency Disagree frequency
Perceived access (%) (%) (%)
2.1. Physical dimension
After the BPR health care reform, the hospital has:
2.1.1. Defined room/spaces for each case team 206 (50.7) 94 (23.2) 106 (26.1)
2.1.2. Enough office furniture 140 (34.5) 39 (9.6) 227 (55.9)
2.1.3. Enough stationery materials 128 (31.5) 40 (9.9) 238 (58.6)
2.1.4. Enough reagents/drugs/supplies to perform daily activities 111 (27.3) 80 (19.7) 215 (53.0)
2.1.5. Clean work area 118 (29.1) 96 (23.6) 192 (47.3)
2.1.6. Conducive staff rest room 67 (16.5) 73 (18) 266 (65.5)
2.1.7. Functioning computers as needed 154 (37.9) 62 (15.3) 190 (46.8)
2.1.8. Internet access 46 (11.3) 28 (6.9) 332 (81.8)
2.1.9. Backup generator whenever needed 251 (61.8) 103 (25.4) 52 (12.8)
2.1.10. A functioning and accessible landline 98 (24.1) 69 (17) 239 (58.9)
2.1.11. Adequate maintenance service when a diagnostic machine fails 77 (19) 85 (20.9) 244 (60.1)
2.1.12. A scheduled equipment preventive maintenance services 39 (9.6) 107 (26.4) 260 (64)
% Physical dimension 29% 18% 53%
2.2 Economic dimension
After implementation of BPR health care reform:
2.2.1. Efficient and effective health care financing system has been established 141 (34.7) 184 (45.3) 81 (20)
2.2.2. Financial mobilization is linked with evidence-based plan 123 (30.3) 135 (33.3) 148 (36.5)
2.2.3. Hospital income increased 207 (51) 162 (39.9) 37 (9.1)
2.2.4. Budget consumption becomes effective 142 (35) 151 (37.2) 113 (27.8)
2.2.5. Corruption suspects decreased 144 (35.5) 97 (23.9) 165 (40.6)
% Economic dimension 37% 36% 27%
2.3 Temporal dimension:
After implementation of BPR health care reform:
2.3.1. Patients receive hospital services on time 223 (54.9) 81 (20) 102 (25.1)
2.3.2. Patients’ appointment wait-time is reasonable 216 (53.2) 81 (20) 109 (26.8)
2.3.3. Patients’ time spent while waiting in reception is reasonable 219 (53.9) 72 (17.7) 115 (28.3)
% Temporal dimension 54% 19% 27%
2.4. Cultural dimension:
After implementation of BPR health care reform:
2.4.1. P
 atients receive hospital services using languages and mode of
224 (55.2) 110 (27.1) 72 (17.7)
communication suitable to them
2.4.2. There is no patient discrimination 338 (83.3) 45 (11.1) 23 (5.7)
% Cultural dimension: 69% 19% 0.6%
2.5. Approachability dimension:
After implementation of BPR health care reform:
2.5.1. T
 he hospital establishes a system of advocating its services to the
157 (38.7) 136 (33.5) 113 (27.8)
community
2.5.2. The community is aware of the hospital’s services 213 (52.5) 131 (32.2) 62 (15.3)
2.5.3. The community understands the value of the hospital on their health 204 (50.2) 140 (34.5) 62 (15.3)
% Approachability dimension 47% 33% 20%
BPR – business process reengineering

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 Implementing healthcare reform

For the economic dimension, 141 (34.7%) of respondents agreed that efficient and effective health care
financing systems are in place after implementation of the reform. However, 165 (40.6%) respondents
claimed that corruption in the hospitals still exists. In general, 37% responses agreed that there were im-
provements in economic dimensions of the hospitals, 27% disagreed and 36% were neutral. The overall
result of temporal dimension of access showed reasonable improvement, with 54% level of agreement.
In the cultural dimension, 224 (55.2%) of the respondents agreed that the reform enabled patients to re-
ceive health care services using a mode of communications suitable to them. Additionally, the majority of
respondents (n = 338, 83.3%) agreed that there was no patient discrimination in the hospitals since the
reform was implemented. The overall analysis revealed that the reform was reasonably capable of address-
ing the cultural dimensions of health care performance, with only 95 (0.6%) level of disagreement. Con-

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versely, for the approachability dimension, responses indicated that the reform did not effectively address
the approachability dimensions of health care reform performance.
According to analysis of the total weighted median score of the five dimensions of health care access, 50%
of the respondents revealed that implementation of the BPR health care did not bring improvements on
health care access.

Equity
Responses on equity indicated that the hospitals are giving medical services with reasonable prices. The
findings confirmed that the hospitals gave free services for patients who cannot afford. A total of 284 (70%)
of responses indicated that patients with different socio-economic, demographic, ethnic, and/or gender
groups have equal access to the hospitals’ services (Table 4). Overall, 61% of respondents agreed that
health care equity has improved due to implementation of BPR health care reform, while 39% disagree.
Table 4. Descriptive analysis of health care equity, efficiency, and sustainability
Agree frequency Neutral Disagree
3. Perceived equity (%) frequency (%) frequency (%)
After implementation of BPR health care reform:
3.1.1. Amount of money patients pay for getting hospital services is reasonable 281 (69.2) 98 (24.1) 27 (6.7)
3.1.2. The hospital gives free services for patients who cannot afford 343 (84.5) 35 (8.6) 28 (6.9)
3.1.3. The hospital has appropriate infrastructure setup for disabled patients 115 (28.3) 43 (10.6) 248 (61.1)
3.1.4. Patients with different socio-economic, demographic, ethnic, and/or gender
284 (70) 89 (21.9) 33 (8.1)
groups have equal access to the hospital services
% Equity 63% 16% 21%
4. Perceived efficiency
In the BPR health care reform implementation process:
4.1.1. The best use of resources is observed 175 (43.1) 128 (31.5) 103 (25.4)
4.1.2. Wastage reduced and cost-effective interventions enhanced 168 (41.4) 76 (18.7) 162 (39.9)
4.1.3. Enough and competent health care workers and administrators are in place 181 (44.6) 98 (24.1) 127 (31.3)
4.1.4. Sufficient rooms are in place 173 (42.6) 98 (24.1) 135 (33.3)
4.1.5. Enough drugs and medical supplies, medical apparatuses and equipment 146 (36) 104 (25.6) 156 (38.4)
4.1.6. The staff have adequate knowledge on BPR objectives and principles 141 (34.7) 119 (29.3) 146 (36)
4.1.7. The staff is technically competent to implement the BPR reform 141 (34.7) 117 (28.8) 148 (36.5)
4.1.8. Supervisors assigned according to the BPR reform structure are capable and qualified 141 (34.7) 83 (20.4) 182 (44.8)
4.1.9. There is a clear channel of communication at workplace 176 (43.3) 51 (12.6) 179 (44.1)
4.1.10. Top management is competence to support the BPR reform 166 (40.9) 61 (15) 179 (44.1)
4.1.11. Top management involves the technical staff in decision making 153 (37.7) 55 (13.5) 198 (48.8)
4.1.12. Hospital management facilitates job-related training to staffs when necessary 142 (35) 43 (10.6) 221 (54.4)
% Efficiency 39% 21% 40%
5. Perceived sustainability
After implementation of BPR health care reform:
5.1.1. The hospital management is committed to maintain the BPR reform 187 (46.1) 143 (35.2) 76 (18.7)
5.1.2. The hospital is able to continuously improve performance 199 (49) 108 (26.6) 99 (24.4)
5.1.3. The hospital acquires the required financial resources to insure sustainability 181 (44.6) 125 (30.8) 100 (24.6)
5.1.4. The hospital acquires the required qualified staff to ensure sustainability 170 (41.9) 129 (31.8) 107 (26.4)
5.1.5. The hospital networking with external partners is strengthened 122 (30.0) 163 (40.1) 121 (29.8)
5.1.6. The hospital has the capacity to assemble and manage resources 150 (36.9) 130 (32.0) 126 (31.0)
5.1.7. The hospital increases satisfaction of patients and providers with clinical or
170 (41.9) 93 (22.9) 143 (35.2)
administrative services
5.1.8. community-level partnerships are maintained 129 (31.8) 152 (37.4) 125 (30.8)
5.1.9. new organizational practices and policies are sustained 118 (29.1) 165 (40.6) 123 (30.3)
% Sustainability 69% 33% 28%
BPR – business process reengineering

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 Manyazewal et al.

Efficiency
For efficiency, 175 (43.1%) respondents agreed that the best use of economic resources was achieved in
the reform implementation process, and 181 (44.6%) of respondents agree that enough and competent
health care workers were available in the reform implementation process. However, 179 (44%) respon-
dents argued that the role and capacity of the hospitals’ high-level management in the reform implemen-
tation process was insufficient (Table 4). In general, 207 (51%) respondents claimed that there are no
improvements in efficiency of health care services due to implementation of the reform.

Sustainability
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From analysis of weighted median score, 192 (47.3%) respondents agree that the reform improved sus-
tainability, while 214 (52.7%) of respondents disagree that the reform improved sustainability of the pub-
lic hospitals (Table 4). For sustainability, based on the overall weighted median score, 203 (50%) respon-
dents agree that the implemented BPR health care reform was not effective in improving the health care
system performance of public hospitals. A relatively higher level of agreement (n = 199, 49%) was on the
hospitals ability to continuously improve performance, while the rest of responses for this category of
items were neutral.

Overall health care system

Based on the overall weighted median score result, 203 (50%) respondents claimed that the implement-
ed BPR health care reform was not effective in improving the health care system performance of public
hospitals. Analysis with the Kruskal-Wallis test indicates that there were difference in scoring tendency
between respondents with different health profession (P = 0.001) and respondents with different duration
of work in the hospitals (P = 0.026). Meanwhile, there were no differences in the scoring tendency be-
tween respondents with different levels of education (P = 0.539) and between respondents with different
age groups (P = 0.235).

Predictors
With the backward stepwise logistic regression analysis, the important predictors that influenced imple-
mentation of the reform were financial resources (aOR = 3.54, 95%CI = 1.97-6.33), top management com-
mitment and support (aOR = 2.27, 95%CI = 1.15-4.47), collaborative working environment (aOR = 1.77,
95% CI = 1.00-3.11), and information technology (aOR = 3.15, 95% CI = 1.57-6.32) (Table 5).

Table 5. Logistic regression analyses of the relative effect of BPR critical success factors on health service
improvement
Healthcare services
Frequency
Factors df Significance Crude OR (95% CI) Adjusted OR (95% CI)
Improved Not improved

Adequate financial Poor 145 35

1 <0.001 11.72 (7.30-18.83) 3.54 (1.97-6.33)
resources Good 59 167

Top management Poor 162 49

1 0.018 12.04 (7.55-19.22) 2.27 (1.15-4.47)
commitment & support Good 42 153

Collaborative working Poor 155 72

1 0.050 5.71 (3.71-8.79) 1.77 (1.00-3.11)
environment Good 49 130
Poor 169 63
Flatter structure 1 0.092 10.65 (6.66-17.05) 1.80 (0.91-3.55)
Good 35 139
Poor 187 90
Information technology 1 0.001 13.70 (7.75-24.18) 3.15 (1.57-6.32)
Good 17 112
Poor 175 73
Training 1 0.218 10.66 (6.56-17.35) *
Good 29 129
BPR – business process reengineering, CI – confidence interval, OR – odds ratio, df – degrees of freedom
*aOR not calculated as the variable had insignificant association in the bivariate analysis.

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 Implementing healthcare reform

DISCUSSION
Healthcare services that are partly supported by the government were established in Ethiopia in the late
19th century. The health policy of the transitional government of Ethiopia that was approved in 1993 per-
ceived the development of an acceptable standard of health service system as a critical element within the
general health policy. Lately, based on this health policy, BPR health care reform rose and endeavoured to
satisfy health care quality needs of the government and citizens. It was yet to be assessed for its implica-
tions and opportunities to improve.
The findings of this study proved that the implemented BPR health care reform struggles to meet health

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care quality requisites. The majority of the anticipated patient-provider interactions delineated in the re-
form document have not been achieved. According to the reform guideline document, emergency patients
coming to public hospitals at any time ought to get the required services without any delay, whereas out-
patients ought to complete treatment services within two hours and patients’ admissions should be car-
ried out within 10 minutes [4]. Similarly, patients who require specialized health care services need to get
the services within 72 hours of visiting the hospitals. The reform document conjointly urged for the sat-
isfaction of patients with health care services and their rights fully respected. Though we did not calculate
the turn-around-time of care for each patient, we boldly deduced from responses of the health care pro-
viders that there exists a high gap in meeting patients’ needs. Prior to designing and implementing the
reform, the Ethiopian government was able to conduct SWOT analysis and identify major gaps that would
impact patient-provider interactions, and amongst this was longer patients waiting time [4], and this study
revealed that the challenge has not been addressed. Recent studies conducted in Ethiopia also reported
critical gap in patient’s waiting time and patient-provider interactions in public health care facilities where
the studies were conducted [56,57]. A patient-provider trust would generate smooth interaction between
the two parties and further insists the community decide to engage in prevention and control interven-
tions in the general health care systems [58-60].
The implication of the BPR health care reform was found to be poor in improving the interaction between
providers and the hospital management. Appropriate and timely feedback to staff, clear job descriptions,
motivation, job satisfaction, and staff promotion were not improved as providers anticipated. The finding
also concurs with previous studies done in Ethiopia [61-63]. Poor provider-management interaction in
public hospitals would compromise the maximum commitment and engagement providers could exert
to their duties. This in turn leads the hospitals not to function to the best of their abilities. It is crucial to
actually listen and respond to providers’ needs to ensure high levels of engagement throughout the hos-
pitals. If there are factors which are beyond the control of providers, the possibilities that they become
client-oriented, productive, skilled, and competent to perform their duties could lessen [6].
There were severe gaps in the implementation process of the health care reform which contributed neg-
atively to service quality. For instance, high level supervisors had given the implementation process little
attention, and this actually contradicts with BPR reform standards. The management’s support and in-
volvement in all phases of a reform is essential for lifting technical competency of staffs and enhancing
outcomes [32,50,64].
In terms of structure, the reform could not enable the hospital to become a better treatment facility than
it was before, though there were some recognized improvements. As well, the way the hospitals were
re-structured did not match the daily work flow of the hospitals as anticipated. In general, there have
been many service quality gaps identified in the public hospitals that implemented health care reform,
though there were a few improvements as well. The findings were in line with previous findings from
other studies done in Ethiopia [6,58,65] and elsewhere [66,67].
Access to health care services is the other dimension of health system performance that the reform ought
to address. In view of the physical dimension, the reform was able to organize the hospitals into three
core case teams; namely, emergency, outpatient, and inpatient. The outpatient core case team consisted
of eight activity-specific case teams, and inpatient core case team consisted of nine case teams. Though
the case teams existed in the hospitals, those with major furniture, supplies, and infrastructure were con-
sidered a major implementation challenge of the health care reform as providers indicated. This finding
supports other studies conducted in Ethiopia [65,68]. Financial management systems raised another key
concern in the reengineered public hospitals. The result indicated that the reform was able to increase
income of the hospitals to some extent. However, the hospitals’ health care financing system remained
weak. Financial mobilization schemes of the hospitals did not centre on evidence-based plans and their

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 Manyazewal et al.

budget consumption system was stagnant, which was in support of previous studies in Ethiopia [57,69,70].
Some hospitals that implemented the reform are suspected of corruption, and this should be further in-
vestigated by the authorized government institution. For the cultural dimension of health care access, it
was indicated that patient discrimination in the hospitals highly decreased since the reform was imple-
mented. With this, the BPR health care reform was capable of addressing the cultural dimensions of health
care reform performance. In general, although the reform was capable of producing meaningful changes
in the cultural dimension and fairly in the approachability dimension of health service systems, it was not
able to achieve the overall access to health care services.
Healthcare equity was studied to analyse the availability of adequate resources and systems in the hospi-
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tals, which would fairly benefit every citizen. The findings of the study indicate that medical care costs of
the hospitals were reasonable. The reform enabled financial procedures of the hospitals to endorse free
services to patients who could not afford them. The reform also allows patients with different socio-eco-
nomic, demographic, ethnic, and/or gender groups to have equal access to the hospitals’ services. How-
ever, the reform was not able to address equity for disabled patients and there has been limited infrastruc-
ture setup for disabled patients. The overall findings of the study show that the implemented BPR health
care reform was relatively fair at meeting the depicted health equity needs.
Efficiency was the other dimension of health system performance assessed in this study. The effect of the
BPR health care reform on improving efficiency of public hospital services was shown to be unsatisfacto-
ry. While enough and competent health care workers were not in place to efficiently implement the re-
form efforts, efforts exerted by the hospitals’ high level management in the reform implementation pro-
cess were insufficient. It was also noticed that management did not enrich knowledge and technical
competency of the staff to enable them to efficiently implement the reform. These challenges, together
with high wastage and inefficient use of resources, led the reform to have a little effect on efficiency. Sim-
ilarly, the reform did not ensure sustainability of public hospitals’ services to continue functioning and
initiate changes in order to continuously improve performance. The commitment of hospitals’ manage-
ments to maintain the BPR reform, readiness of financial resources and qualified staff, existing network
of the hospitals with external partners, and satisfaction of patients and providers with existing hospitals’
clinical and administrative functions were revealed as very weak to ensure sustainability of the hospital
services.
In summary, the health care reform implemented in public hospitals of Ethiopia did not improve quality,
access, efficiency, and sustainability of health services, while a relatively fair improvement was shown on
equity.
This study has some limitations. The study did not solicit the views of administrative staff and we think
their inputs may have further strengthened the study findings, while the possible effect of this has been
mitigated by inclusion of health care providers who also have administrative role. The study bases the
perspectives of the respondents that may increase the likelihood of recall biases. Despite these, the study
generates important findings in the area of health care reform.

CONCLUSIONS
It was acceptable that the Ethiopian government made its level to improve the quality of care through
BPR health care reform. The reform has laid the groundwork for health system improvement but prog-
ress was slow and the health care delivery system was still fragmented. Healthcare reform efforts in such
settings are feasible, but with regular mapping of programmatic outcomes and bringing a common un-
derstanding of the reform among stakeholders. Such efforts in resource-limited settings need concrete
follow-up and supports consistent with national and global needs. Local governments should strengthen
collaborations with global health partners for empirical interventions against the major gaps detracting
their health care system.

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 Implementing healthcare reform

Acknowledgments: The authors would like to thank Prof. MJ Oosthuizen, Rest in Peace, and Dr Shewangizaw
Getahun for their expert guidance.
Ethics: The study had been awarded Ethical Clearance Certificate by the Higher Degrees Committee of the
Department of Health Studies, University of South Africa and the Addis Ababa Research and Technology Trans-
fer Core-process of the Addis Ababa City Administration Health Bureau. Written informed consents developed
for each respondent to read and sign before moving on to filling the questionnaires. The study did not include
details, images, or videos relating to individual participants, thus consent for publications were not required.
Availability of data and materials: The dataset supporting the conclusions of this article is included within

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the article.
Funding: This research project has been supported by the University of South Africa.
Authors’ contributions: TM conceived the study. TM, MCM designed the study. TM implemented the study
under the guidance of MCM. TM wrote the first draft, and MCM critically revised it for important intellectual
content. TM and MCM analysed and interpreted data. Both authors participated in the write-up, review, feed-
back and approval of the manuscript for publication.
Competing interests: The authors have completed the Unified Competing Interest form at
www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author), and declare no conflict
of interest.

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