1) Introduction

Hospital reform is a priority in the health sector strategic 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 hospitals identified the following priority thematic areas to
strengthen hospital management: (i) human resource management; (ii) governing boards; (iii)
global budgeting and financial management; (iv) patient flow; (v) medical records management;
(vi) pharmaceutical inventory and warehouse management; (vii) nursing standards 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 government 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 availability and
implementation of team charter, the ability to conduct customers’ satisfaction surveys, the
measurement of performance against the BPR objectives and the number of monthly meetings
conducted to discuss BPR issues. 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 materials, 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, hygienic 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.

2.3) Adama Hospital

2.3.1) Background
Adama Hospital Medical College (AHMC) is over 100 km east of Addis Ababa and has a
capacity of 444 beds. Currently the hospital provides services for more than 4.6 million
populations 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 712. It has 65
specialist physicians with 4 expatriate medical volunteers, 16 general practitioners, 146 nurses
and mid wife, 28 laboratory staff, 34 pharmacy technicians and 5 X-Ray technicians, with 218
administration staff on permanent and contractual basis. Under the hospital health service
provision core process there are 20 case teams. AHMC provides medical, surgical,
gynecology/obstetrics, pediatrics, ophthalmology, psychiatry and dental services. In addition, it
provides private wing OPD services. AHMC 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). 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 employees’ representative.

2.3.2) Performance
Areas of success were revenue generation and utilization and improvement in volume and
quality of services. The annual recurrent budget in 2009/10 was 18.2 million, of which 25.9%
was for salary and the rest for operating cost. Out of the total budget, 60% was from retained
revenues, while 40% was allocated from the government. AHMC has implemented major
hospital reforms including BPR, HCF, Health Management Information System (HMIS) and
FMOH Standards for Ethiopian Hospitals (FMOH, 2010). In addition, it has implemented
Income Budget Expenditure Software (IBEX) for its financial management and Human Resource
Information System (HRIS) for human resource management. 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, diagnostic 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 holidays 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 private
wing are being met: (i) staff retention and motivation; (ii) choice of treatment for clients who are
willing to pay the additional price; (iii) increased hospital revenue to improve the quality of
services; and (iv) increased 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 collectors at different
payment points; (iii) assigning collectors at point of service provision; (iv) supplying all reagents
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
consultants. This is expected to be implemented over the next few years together with the
Oromia RHB and key stakeholders. Local partners, such as the Oromia Development
Association, have recognized 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 AHMC Governing Board has been essential in promoting this Endeavour. International
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 million. 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 Administration; (vi) in-service
training for nurses and a training plan for all staff; (vii) gold awards for the top 16 hospital staff
performers; (viii) pharmacy warehouse management; (ix) emergency care management; (x) a
new 35 bed surgical ward under construction; (xi) research 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 investment 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 anti-
retro viral 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 tolerance to change resistance”.