Analysis

40 years after Alma-Ata, is building new

BMJ Glob Health: first published as 10.1136/bmjgh-2018-001293 on 22 April 2019. Downloaded from http://gh.bmj.com/ on November 8, 2021 by guest. Protected by copyright.
hospitals in low-income and lower-
middle-income countries beneficial?
Fanny Chabrol,‍ ‍1
Lucien Albert,2 Valéry Ridde‍ ‍1

To cite: Chabrol F, Albert L, Abstract

Ridde V. 40 years after Alma- Summary box
Public hospitals in low-income and lower-middle-income
Ata, is building new hospitals countries face acute material and financial constraints, and
in low-income and lower- ►► 40 years after Alma-Ata, hospitals in low-income
there is a trend towards building new hospitals to contend
middle-income countries and lower-middle-income countries continue to play
beneficial?BMJ Glob Health with growing population health needs. Three cases of new a central role in relation to lower levels of the health-
2019;3:e001293. doi:10.1136/ hospital construction are used to explore issues in relation care system.
bmjgh-2018-001293 to their funding, maintenance and sustainability. While ►► Building new hospitals is an attractive project for
hospitals are recognised as a key component of healthcare international and bilateral funders and for national
Handling editor Seye Abimbola systems, their role, organisation, funding and other aspects governments.
have been largely neglected in health policies and debates ►► Significant challenges are identified that affect
Received 8 November 2018 since the Alma Ata Declaration. Building new hospitals these new hospitals’ ability to function smoothly and
Revised 22 February 2019 is politically more attractive for both national decision- efficiently.
Accepted 25 February 2019 makers and donors because they symbolise progress, ►► There is a crucial need for further research on hospi-
better services and nation-building. To avoid the ‘white tals’ integration within healthcare systems to foster
elephant’ syndrome, the deepening of within-country transformative, resilient and sustainable hospitals.
socioeconomic and geographical inequalities (especially
urban–rural), and the exacerbation of hospital-centrism,
there is an urgent need to investigate in greater depth
how these hospitals are integrated into health systems A new hospital is desirable, in that it manifests
and to discuss their long-term economic, social and the promise of emergency care and specialised
environmental sustainability. tertiary treatments in the context of a growing
burden of non-communicable diseases in
LMICs. It is intended to bridge the ‘infrastruc-
ture gap’ to safely provide emergency and
surgical care.2 3 In this paper, we call attention to
Introduction
several risks inherent in building new hospitals
The celebration of the 40th anniversary of the
in the absence of broader health system reform
Alma Ata Declaration and the call for primary
and sustainability plans. We begin with a review
healthcare1 is an opportune time to reconsider
of current and longstanding challenges facing
the role of public hospitals and specialised care
hospital health services delivery in LMICs. We
in relation to the primary healthcare system.
then consider three newly built hospitals, as
© Author(s) (or their This topic did not generate many debates in
examples, and draw from these cases to iden-
employer(s)) 2019. Re-use the Global conference on Primary Health Care
permitted under CC BY-NC. No
tify key issues for future policy and research.
in Astana in October 2018, yet public hospi-
commercial re-use. See rights Finally, we consider hospitals’ role and how
tals in low-income and middle-income coun-
and permissions. Published by their integration into robust healthcare systems
tries (LMICs) continue to face acute material
BMJ. can foster their transformative potential,4 and
1
Centre Population et and financial constraints. Meanwhile, recent
we emphasise the need for strong infrastruc-
Développement (CEPED), years have seen an intensification of hospital ture to ensure health system resilience.5
French Institute for Research on construction projects, such as in sub-Saharan
Sustainable Development (IRD) Africa and Haiti. The majority of these projects Existing tertiary hospitals face huge
and Université de Paris, INSERM
SAGESUD, Paris, France
are built as part of bilateral cooperation, often constraints
2
École de santé publique, as gifts from Western partners (eg, Canada, In numerous countries, public hospitals
Université de Montréal, France) and emerging powers (eg, China, struggle to fulfil their missions adequately.
Montréal, Québec, Canada India, Turkey) or built through public–private They suffer from insufficient domestic funding
Correspondence to
partnerships (PPPs). Building hospitals is a and incomplete integration in a network of
Dr Fanny Chabrol; fashionable cooperation tool and a high-visi- dispensaries and clinics dedicated to primary
​fanny.​chabrol@​ird.​fr bility political action for national governments. healthcare provision. These lower levels of care

Chabrol F, et al. BMJ Glob Health 2019;3:e001293. doi:10.1136/bmjgh-2018-001293  1

BMJ Global Health

provision are too dysfunctional to provide timely and robust controversy for its inability to guarantee access for all citi-

BMJ Glob Health: first published as 10.1136/bmjgh-2018-001293 on 22 April 2019. Downloaded from http://gh.bmj.com/ on November 8, 2021 by guest. Protected by copyright.
responses to patients’ most basic needs. Patients usually zens (due to high fees) and for exacerbating an inequitable
bypass them, consulting directly in hospitals through focus on tertiary care. This new hospital absorbed nearly
self-referral, including for complaints that would be more half of the Ministry of Health’s budget in 2013/2014.17 18
appropriately managed in local hospital clinics.6 Most Like Lesotho, several countries have run the risk of incur-
hospitals continue to charge user fees. It is unclear what ring serious debt even when they were not themselves
share of this cost recovery system is directed to the overall financing the building works, while others have had to
functioning of hospitals. However, in most cases these transfer the management of these hospitals to the private
expensive fees lead to catastrophic health expenditures for sector.19 Often, crucial measures needed to support these
patients and their families.7 In too many countries, patients investments—maintenance, human resources, training,
are detained until they can pay their bills.8 9 Moreover, the management—are ignored. Constructing and opening
safety of hospital care is not guaranteed, due to high rates new hospitals could deepen within-country socioeconomic
of unsafe injections,10 and ensuring the overall quality of and geographical inequalities (especially urban–rural) and
care remains a huge challenge.11 exacerbate hospital-centrism.
Overcrowding, lack of emergency and surgical services
and astronomical user fees have all led to serious dysfunc- Haiti: ‘white elephant’ syndrome?
tions, poor quality of care and very negative reputations Haiti is an interesting case of a health system highly
for public hospitals,12 13 decried by citizens, who sometimes dependent on external funding, where there has been
fear visiting them. The loss of motivation among health strong longstanding support for community health
workers, physical deterioration of buildings and lack of workers20 and, at the same time, recent construction of
material equipment and medicines contribute to the high-tech hospitals. Following the devastating hurricane
public’s distrust of hospital care. The role of hospitals in in January 2010, several new hospitals were built and/or
health systems has received little attention in health policy operated by international partners (eg, Canada, France,
debates and was largely absent from the recent Alma Ata Brazil, Cuba) and NGOs, such as Partners in Health. These
celebrations, with only one session on hospital reforms hospitals are dependent on international aid and medical
in Astana14 and a short report on the ‘transformative role missions from abroad.
of hospitals’ published after the conference.4 In a time The Hôpital Universitaire de Mirebalais, built 50 km
of consensual call for universal health coverage (UHC) outside Port-au-Prince for US$ 25 million by Partners
and ‘high quality health systems’,11 we thus ask whether in Health, opened in 2013. The government struggles
building new hospitals is inherently good for creating resil- to contribute its portion of the operating costs of this
ient—and sustainable—health systems. 900-employee hospital, while the progressive withdrawal
of Partners in Health—and other international donors—
threatens the quality of care.(Ministère de la Santé
Is building new hospitals an appropriate response? Publique et de la Population, unpublished data, 2018)
The WHO Global Health Observatory provides no signif- The same concern applies to another hospital built with
icant evidence regarding an increase in the number of Canadian cooperation funds and inaugurated in 2014,
hospitals and the density of hospital beds in sub-Saharan Hôpital La Providence des Gonaïves, since dubbed a ‘white
Africa and Haiti (it only provides data for 2010 and 2013). elephant’ because of its difficult geographical accessibility,
Nonetheless, in the course of our fieldwork, we have high medical fees, corruption scandals and lack of human
observed the trend of building new hospitals as part of resources, among other things. It has also experienced
bilateral cooperation. We examine below three typical dramatic water supply problems. At the same time, the
cases of new hospital construction and identify some of the French Development Agency (Agence française de dével-
questions they raise in relation to funding, maintenance oppement–AFD) helped renovate the Hôpital de l’Uni-
and sustainability. versité d’État d’Haïti (HUEH) in Port-au-Prince, which
was plagued by major dysfunctions when it reopened in
Lesotho: the public–private partnership hospital August 2018 and also experienced water management
During the 2000s, PPPs were promoted as a new model in issues. However, the AFD was not engaged in supporting
various areas of global health.15 16 This new alliance between the hospital after the renovation.
for-profit and not-for-profit organisations was endorsed The State of Haiti is currently unable to support these
by the World Bank and the International Finance Corpo- hospitals’ functioning without international aid. In fact,
ration (IFC), its private arm, as a relevant health delivery in recent years the State has devoted only 3.9% of its
model. In Lesotho, the IFC provided US$ 120 million annual budget to the health sector.21 This case demon-
to build the new Queen Mamohato Memorial Hospital strates the country’s deep dependence on external donor
in Maseru, the capital city, in 2009. The hospital, which funding, exacerbated by these new hospitals that increase
opened in 2011, operates under an 18 year contract of a total spending. In a recent report on health spending in
PPP (called Tsepong) between the government of Lesotho Haiti, the World Bank acknowledged that ‘the ongoing
and a consortium led by the South African private hospital externally financed wave of hospital construction was not
operator Netcare. From its start, the new hospital generated accompanied by plans to sustain hospitals’ operational

2 Chabrol F, et al. BMJ Glob Health 2019;3:e001293. doi:10.1136/bmjgh-2018-001293

 BMJ Global Health

costs and maintain service delivery’ and that the Ministry system reform,25 especially in the context of global prioriti-

BMJ Glob Health: first published as 10.1136/bmjgh-2018-001293 on 22 April 2019. Downloaded from http://gh.bmj.com/ on November 8, 2021 by guest. Protected by copyright.
of Health ‘does not have enough financing to meet the sation of quality and equity in access to UHC.
increasing operational costs, thereby affecting its capacity
to ensure staff recruitment, training, and the provision of Alma Ata: hospitals to complement, not replace, primary
medical equipment and commodities’.22 The report called healthcare
for a ‘moratorium on new hospital construction until Along with comparative studies of reform attempts,26 a
the existing infrastructure can be mapped and a hospital critical and retrospective analysis of previous debates and
licensing program has been developed’ and also empha- reform attempts would be enlightening.27 What organisa-
sised the need to prioritise ‘wise spending’ on hospitals, tional models were promoted? Why were they generally
consistent with a reprioritisation of primary healthcare and not successful?
preventive health services. Specialised university hospitals In 1978, the WHO conference in Alma Ata promoted
are pivotal to any health system, but they require a strong primary healthcare as the best way to achieve health for all
sustainability plan—in terms of financial, material and in 2000. That conference positioned community health
human resources—to ensure their long-term functionality. workers as the backbone of health systems and empha-
sised the need for community participation, adequate
Chinese-built hospitals in sub-Saharan Africa financing and national and international support for the
Among the most visible projects in recent years are strategy.28 Less was said on the role of hospitals, but the
Chinese-built hospitals being constructed and progressively Alma Ata report insisted that their primary function was
starting to operate in Africa. China has long been present to support—not replace—primary healthcare. Indeed,
in Africa’s health sector and has become its pre-eminent Halfdan Mahler, then Director-General of WHO, was
infrastructure builder. The Chinese government is offering reported to have said, ‘A health system based on primary
the building of district, regional or tertiary hospitals to its care cannot be realised without support from a network
African partners. In 2006, president Hu Jintao announced of hospitals’.4 The concept of ‘appropriate technology’
China’s wish to build 30 hospitals there, and during the was invoked to justify the concentration of resources
Africa-China Cooperation summit in 2015, president in urban hospitals for the provision of secondary and
Xi Jinping confirmed that 100 more hospitals would be tertiary care.29
built in the near future. Presented as a ‘win-win’ scenario To compensate for the inconsistent implementation
for African development, these Chinese-built hospitals and disappointing results of primary healthcare strate-
operate under various modalities. In most cases, Chinese gies in the 1980s, international agencies tried to promote
medical missions are involved for several years in medical the district hospital level as a key component in an effi-
care and training. Equipment and training are part of the cient referral system,30 less costly and more advantageous
package. It is not clear, however, how these hospitals fit for the population than big national or regional urban
within the local and national healthcare systems. In Niger, hospitals, and more in line with the PHC strategy.31 In
for instance, a large and highly specialised hospital was the 1990s, the international community acknowledged
entirely funded and built by China in 2016 at a cost of 68 that big public hospitals in LMICs were too costly and
million euros, but many uncertainties remain about how inefficient and defended the necessity of granting more
it will be staffed, equipped, funded and maintained over autonomy to hospitals and even privatising them to
the long term. Our preliminary field study in June 2018 ensure their efficiency.32 33 It was believed—a belief still
showed that health actors there have many concerns about dominant—that financial and administrative autonomy
how this new hospital will be able to function smoothly of public hospitals would produce better health
and in close complementarity with other hospitals and in outcomes.34 This inspired a wave of national hospital
a context of national health policies such as free health- reforms and the transformation of public hospitals into
care for children and indigents. Nigerien health authori- public autonomous hospitals.26 35 Most of the intended
ties have raised concerns about financial accessibility for results (in terms of quality, satisfaction, equity and so on)
the treatment of complicated and highly specialised care, did not materialise.36
which they endeavour to provide to all of their population. This makes the wave of reforms in recent years based on
In other countries, such as Angola,23 Chinese-built hospital New Public Management (NPM),16 a business-oriented
infrastructures have shown early signs of deterioration. approach to public services, all the more surprising.
Equally disconcerting are the occasional attempts at
performance-based financing in hospitals—an approach
generally implemented at the PHC level—without
Further research is needed on hospitals within any strong evidence of its effectiveness.34 The interest
healthcare systems in PPPs (whether for building infrastructures or for
In many countries, as in Haiti, hospitals have been built or private management of hospitals) remains intense. Even
reconstructed without any reform or even prior reflection though PPPs offer some potential (availability of finan-
on the feasibility and sustainability of their functioning and cial resources, advanced technologies), they also present
financing.24 More research is needed to better understand serious limitations (costs, risks, corruption). Tertiary or
how hospital reform can be integrated into broader health ‘reference’ hospitals are seen as profitable investments

Chabrol F, et al. BMJ Glob Health 2019;3:e001293. doi:10.1136/bmjgh-2018-001293 3

BMJ Global Health

offering good market opportunities. Promotion of the Many research organisations and international agen-

BMJ Glob Health: first published as 10.1136/bmjgh-2018-001293 on 22 April 2019. Downloaded from http://gh.bmj.com/ on November 8, 2021 by guest. Protected by copyright.
private sector and the ‘business of health’ in Africa37 has cies can play a role in collecting and monitoring data on
not resolved issues of accessibility and equity. On the access to hospital care, bed occupancy, quality of care
contrary, these investments often go to high-end urban and—of course—patients’ satisfaction, of which we know
hospitals, benefitting wealthier citizens, and as such, they very little. Useful tools are being developed, such as the
do not expand the population’s access to healthcare.38 service readiness index, constructed with data from the
Service Provision Assessment.44 In addition to creating
How can hospitals be transformative? Infrastructure for a resilience index,40 41 there should be a call for estab-
resilient, high quality health systems lishing a citizens’ observatory of healthcare equity and
quality in hospitals that would help to create patient-cen-
Published after the 2018 conference in Astana, the
tred and transformative hospitals, with a view to transi-
WHO report titled The Transformative Role of Hospitals in
tioning towards UHC.
the Future of Primary Health Care4 called for ending the
dichotomy between hospitals and the rest of the health
system and dissolving the walls, to create a ‘networked and Conclusion
people-centred hospital’ with a view towards achieving There is a crucial need for safe, equitable, effective and
UHC. Hospitals, whether new or renovated, can play a good-quality hospital care in LMICs, for specialised and
transformative role if they are closely integrated within emergency care (maternity, paediatrics, surgery) as well
strengthened healthcare systems in a way that is consistent as for good accessibility of these services,2 3 in combina-
with national priorities and that acknowledges the role of tion with a strong primary healthcare network. Govern-
infrastructures. ments might find it difficult to refuse offers from bilateral
Hospital projects need to be understood in the context partners, especially when these new hospitals symbolise
of larger and more intense socioeconomic and demo- progress, better services and nation-building. However,
graphic changes within dynamic, mobile, urban societies every hospital infrastructure must be funded, maintained
and fast-growing economies. There is an urgent need to and equipped over the long run and, as such, runs the
address the growing burden of non-communicable and risk of becoming a ‘white elephant’—a building project,
chronic diseases, the long-neglected cancer epidemic scheme or facility that the owner cannot dispose of
and mental health—in short, a need for curative and because the cost, particularly of maintenance, is out of
preventive medicine. proportion to its usefulness, as has been pointed out both
Hospitals’ transformative role and the development of by experts and by the population.45 It is urgent, indeed,
patient-centred hospitals will be a ‘trickle-down’ effect to investigate in greater depth how these hospitals are
of infrastructure development, because healthcare integrated into health systems. The current and long-
staff need, first of all, to be supported by a functioning term costs of these new facilities appear to have been
infrastructure in which equipment is smoothly main- underestimated. What resources are required for their
tained, and where water, power and waste are securely maintenance, beyond human and material resources,
managed.39 Local governments and international donors training and so on, to guarantee safe and affordable
need to dedicate resources to the maintenance of ‘resil- services? Who will pay to maintain the equipment, ensure
ient hospitals’, beyond disaster preparedness, to nurture constant provision of water and electricity and manage
day-to-day resilience and ensure the safety and quality of waste? Lessons can be drawn from the past decades that
care.40 41 could foster reflection on the structure and the regula-
How can international cooperation support local and tion of hospital supply. It is also urgent to consider hospi-
national dynamics in ways other than building hospi- tals’ environmental impact (water consumption, power)
tals that are not sustainable? The different typologies and—in the spirit of the Sustainable Development
of hospital cooperation actors and programmes, some Goals— to think together about the path towards UHC
of which have been mentioned in this paper, need to and other development goals, such as infrastructure
be systematically analysed. Other partnerships are of development, equitable and safe access to water, good
interest, especially those giving preference to training, hygiene and attention to the environmental impacts of
such as the hospital partnerships or ‘jumelages hospi- existing and new infrastructures.
taliers’ (hospital twinning) initiated by French hospitals Acknowledgements We wish to thank Ludovic Queuille for insightful input
for AIDS research and treatment.42 India, Brazil and Cuba and Donna Riley for her editing support. The comments from three anonymous
also have their own—more or less outmoded— cooper- reviewers were very helpful in improving our arguments.
ation tools that may or may not help transform hospi- Contributors VR had the initial idea for this paper with FC. FC coordinated the
writing of the article, VR and LA wrote the section on Haiti. All authors contributed
tals from inside, either by supporting capacity-building
to the development of ideas and the writing of the manuscript, commented on
and medical training, or by local drug production, as in drafts and approved the final version.
the case of Brazil.43 Medical training remains a crucial Funding Fanny Chabrol has received funding by Agence Nationale de la
issue, and large urban university hospitals should not be Recherche (http://​dx.​doi.​org/​10.​13039/​501100001665) and grant number:
the unique sites for clinical training: clinics and district ANR-17-CE36-0006-01.
hospitals should also be given larger roles in this area. Competing interests None declared.

4 Chabrol F, et al. BMJ Glob Health 2019;3:e001293. doi:10.1136/bmjgh-2018-001293

 BMJ Global Health

Patient consent for publication Not required. Note d’information stratégique - Septembre 2017. Port-au-Prince:

BMJ Glob Health: first published as 10.1136/bmjgh-2018-001293 on 22 April 2019. Downloaded from http://gh.bmj.com/ on November 8, 2021 by guest. Protected by copyright.
PAHO, 2017: 4.
Provenance and peer review Not commissioned; externally peer reviewed. 22. Cavagnero EDV, Cros MJ, Dunworth AJ, et al. Better spending,
Data sharing statement No additional data are available. better care : a look at Haiti’s health financing [Internet]. The World
Bank; 2017:1–104. Report No: 116682. Available: http://​documents.​
Open access This is an open access article distributed in accordance with the worldbank.​org/​curated/​en/​790331522095815549/​Better-​spending-​
Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which better-​care-​a-​look-​at-​Haitis-​health-​financing
permits others to distribute, remix, adapt, build upon this work non-commercially, 23. Mthembu P. China and India’s development cooperation in
and license their derivative works on different terms, provided the original work is Africa: the rise of Southern powers. Cham, Switzerland: Springer
properly cited, appropriate credit is given, any changes made indicated, and the International Publishing, 2018.
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use is non-commercial. See: http://​creativecommons.​org/​licenses/​by-​nc/​4.​0/.
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public hospitals: an agenda for reform in Asia and the Pacific. BMJ
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