In 1998, Senegal launched an ambitious hospital reform. More than ten years later, despite a massive injection of government funds in hospitals, many of them are now close to bankruptcy. However, this reform clearly had the effect of 'bringing back patients' to hospitals. While hospitals were largely empty (as in many Sub-Saharan African countries), the number of hospital-based outpatient visits has increased by over 20 percent every year since 2000. This increased activity also suggests that hospitals have become more attractive for patients and that the quality of care may have improved. In contrast, equity of access to hospital care (especially for the poorest) has clearly deteriorated. While the proportion of poor is estimated at nearly 51 percent of the Senegalese population, this group constitutes only 3 percent of hospital patients. Last but not least, the hospital reform has resulted in a major deterioration in the technical efficiency of the hospital system. The first reason is the uncontrolled increase of the wage bill, both because of massive recruitment of unqualified staff and because of the creation of numerous and inconsistent staff bonuses. A second reason is the underfunding of several free care programs, especially of the Plan Sesame (that is, free care for the elderly). The mixed results of this hospital reform are due to several factors. The 1998 reform is a textbook case of granting very large management autonomy to hospitals without implementing any serious accountability mechanism. Hospitals have indeed acquired considerable autonomy in all management areas. It might have been possible to avoid the current situation if, in addition to empowering hospitals, some accountability mechanisms had been implemented
however, this did not happen. Among the various remedies proposed, the utmost priority is to restore some government control over hospitals. This can be done by establishing mechanisms for evaluating hospital managers and controlling ex ante their budgets, especially their decisions about recruitments and compensation. A second priority would be to restore the efficiency of hospitals, which would require (i) revision of rates for hospital user fees so that they better reflect actual costs, (ii) reduction of overstaffing with nonqualified workers, and (iii) restructuring of the hospital system in Dakar.