The purpose of this research was to explore and describe the effectiveness of the health care reform implemented in Ethiopia in the form of Business Process Reengineering (BPR) and develop strategies to strengthen its implementation. The research was conducted in two phases. In phase I, the effectiveness of the BPR health care reform was explored and described through gathering quantitative information from health care providers (n=406) using a structured questionnaire. All public hospitals of Addis Ababa, Ethiopia which have been implementing the reform from its inception (n=5) were included. In Phase II, in-depth strategies aimed at strengthening implementation of the reform were developed. Two-rounds of Delphi study were conducted to seek the opinions of senior health policy experts (n=10) and arrive at consensus on the developed strategies. Cronbach's alpha, descriptive statistics, Chi-square, logistic regression analysis, principal component analysis, weighted median score, adjusted and standard satisfaction scores, Mann-Whitney U test, and Kruskal-Wallis test were conducted for data analysis. The BPR health care reform was able to restructure the hospitals’ departments into case teams, with the goal of adopting a “one-stop shopping” approach. However, 50% of the health care providers reported that the reform was not effective to satisfy the perceived health service needs. Limited effects were reported in favour of health care quality (48%), access (50%), efficiency (51%), sustainability (53%), and equity (61%). While poor effects were reported in patient-provider (41%) and provider-management (32%) interactions. The most important predictors that influenced implementation of the reform were financial resources (AOR=3.54, 95%CI: 1.97, 6.33), top management commitment 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). The overall job satisfaction in the public health sectors remained poor, with only 25% job-satisfied providers engaged. Moral satisfaction (AOR=177.654, 95%CI: 59.539, 530.08), management style (AOR=4.017, 95%CI: 1.490, 10.828), workload (AOR=2.422, 95%CI: 0.925, 6.342), and task (AOR=5.491, 95%CI: 2.307, 13.069) were the most significant factors. Job satisfaction results were significantly different among the study hospitals (2 = 30.557, p < 0.001). The current health care delivery performance of the public hospitals was 60% when weighed against the World Health Organization’s health system framework which required a minimum of 80% score. However, there existed a significant difference in performance at least between two hospitals (2 = 571.902, p < 0.001). Five strategies that could disrupt the status quo and strengthen the BPR health care reform are proposed based on their strategic priority, which were: reinforce patient-centred quality of care services; foster a healthy and respectful workforce environment; efficient and accountable leadership and governance; efficient use of hospital financing; and maximize innovations and the use of health technologies. The strategies could be used to enrich the quality of health care interventions through continuous review, refinement and adjustment of the reform as required. Key words: Health care reform; Business Process Reengineering; quality; access; equity; efficiency; sustainability; job satisfaction; health system; patient-centred care; workforce; leadership and governance; hospital financing; health technologies; Ethiopia. / Health Studies / D. Litt. et Phil. (Health Studies)

The purpose of this research was to explore and describe the effectiveness of the health care reform implemented in Ethiopia in the form of Business Process Reengineering (BPR) and develop strategies to strengthen its implementation. The research was conducted in two phases. In phase I, the effectiveness of the BPR health care reform was explored and described through gathering quantitative information from health care providers (n=406) using a structured questionnaire. All public hospitals of Addis Ababa, Ethiopia which have been implementing the reform from its inception (n=5) were included. In Phase II, in-depth strategies aimed at strengthening implementation of the reform were developed. Two-rounds of Delphi study were conducted to seek the opinions of senior health policy experts (n=10) and arrive at consensus on the developed strategies. Cronbach's alpha, descriptive statistics, Chi-square, logistic regression analysis, principal component analysis, weighted median score, adjusted and standard satisfaction scores, Mann-Whitney U test, and Kruskal-Wallis test were conducted for data analysis. The BPR health care reform was able to restructure the hospitals’ departments into case teams, with the goal of adopting a “one-stop shopping” approach. However, 50% of the health care providers reported that the reform was not effective to satisfy the perceived health service needs. Limited effects were reported in favour of health care quality (48%), access (50%), efficiency (51%), sustainability (53%), and equity (61%). While poor effects were reported in patient-provider (41%) and provider-management (32%) interactions. The most important predictors that influenced implementation of the reform were financial resources (AOR=3.54, 95%CI: 1.97, 6.33), top management commitment 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). The overall job satisfaction in the public health sectors remained poor, with only 25% job-satisfied providers engaged. Moral satisfaction (AOR=177.654, 95%CI: 59.539, 530.08), management style (AOR=4.017, 95%CI: 1.490, 10.828), workload (AOR=2.422, 95%CI: 0.925, 6.342), and task (AOR=5.491, 95%CI: 2.307, 13.069) were the most significant factors. Job satisfaction results were significantly different among the study hospitals (2 = 30.557, p < 0.001). The current health care delivery performance of the public hospitals was 60% when weighed against the World Health Organization’s health system framework which required a minimum of 80% score. However, there existed a significant difference in performance at least between two hospitals (2 = 571.902, p < 0.001). Five strategies that could disrupt the status quo and strengthen the BPR health care reform are proposed based on their strategic priority, which were: reinforce patient-centred quality of care services; foster a healthy and respectful workforce environment; efficient and accountable leadership and governance; efficient use of hospital financing; and maximize innovations and the use of health technologies. The strategies could be used to enrich the quality of health care interventions through continuous review, refinement and adjustment of the reform as required. Key words: Health care reform; Business Process Reengineering; quality; access; equity; efficiency; sustainability; job satisfaction; health system; patient-centred care; workforce; leadership and governance; hospital financing; health technologies; Ethiopia. / Health Studies / D. Litt. et Phil. (Health Studies)

The main focus of the thesis is the multilayered view of regional hospitals on their contractual relationship with health insurance companies. The thesis draws information from two case studies of regional hospitals in Central Bohemia. These case studies have allowed me to map the whole process of establishing a contractual relationship with health insurance companies from the first contact to the final conclusion of the contract for a particular year. Through mapping the process I have identified a number of problematic areas that are encountered when concluding contracts. Thesis has also concentrated on the establishment and content of the payment regulation which, to a large extent, determines the final form of the contractual relationship. One of the goals of the thesis is the identification of key problems stemming from the parameters of the contractual relationship and payment mechanism. These problems are analyzed on the level of hospitals, individual specialized units, and in relation to the provision of health care to patients.