Understanding autonomy and performance in the public sector: Lessons from autonomous public hospitals in Pakistan

There is an increasing trend worldwide of granting autonomy to public hospitals to improve their performance. This trend is adopted in public hospitals in Pakistan as well. A comparative case study is conducted of three public hospitals in two provinces, Punjab and Khyber Pakhtunkhwa (KPK). The study systematically compares multiple dimensions of autonomy in the three public hospitals - including legal, structural, HR and financial autonomy - as well as the perceived departmental and organisational performance. Besides documents, data are collected from top and middle management through semi-structured interviews and a survey questionnaire. The findings of the study highlight that the public hospital in KPK province has a higher level of autonomy on all dimensions studied compared to both hospitals in Punjab province. However, performance is perceived as high across the three hospitals suggesting that the linkage between autonomy and organisational performance is not straightforward. The article relies on perceptual measures that may be subject to the risk of socially desirable responses. Despite this limitation, the study provides implications for future research by raising the critical question if different levels and dimensions of autonomy have an effect on hospital performance. Practical implications are highlighted regarding hospital autonomy reforms.