Teaching Hospitals Shoulder the Burden While Administrators Count the Beans

Jul 26 , 2025.

Teaching hospitals everywhere juggle three jobs at once: teaching, curing, and discovering. But, few do so on a tighter rope than those in Ethiopia.

Around the world, these institutions shape medical minds while pushing the frontiers of science. In Addis Abeba, Gondar, Jimma, Hawassa, and Mekelle, they have taken on an additional role. They are compelled to rescue an overstretched public health system.

That extra duty has turned them into the country’s most critical clinical anchors even as their funding and management remain trapped inside university bureaucracies built for lecture halls, not operating theatres.

Take Tikur Anbessa, Addis Abeba University’s flagship hospital. Measured by patient load, it is the country’s busiest referral centre, yet only seven percent of the university’s budget reaches its wards.

Jimma University Medical Centre, vital for the entire southwest area of the country, manages on 10pc. Mekelle University scrapes by on 10.5pc. Hawassa, the best of the bunch, pulls in 16pc.

Ironically, these sums barely pay their bills. Hospital managers say supplies alone swallow 30pc to 40pc of what little they receive, forcing difficult choices between stocking antibiotics and repairing ventilators.

The mismatch between mission and money is only one symptom of a deeper malaise. There is also a blurred governance issue. Because teaching hospitals are departments within public universities, their chief executives hold impressive titles but feeble purse strings. They have to plead with academic accountants before hiring a nurse, let alone installing an MRI scanner.

Salaries are pegged to academic pay scales, so the country’s best surgeons drift to private clinics or board flights to the Gulf, as well as to Rwanda and Botswana. Those who remain face clogged wards, ageing equipment, and stalled research programmes.

There is an understandable concern that severing hospitals from universities would undermine medical education. Yet, evidence abroad shows the opposite. Where academic medical centres (AMCs) gain their own boards, budgets, and balance sheets, patient care and teaching often improve together.

A comparative study of leading AMCs discovered that teaching hospitals with robust governance and autonomous financing deliver better survival rates for complex cases.

However, the debate mirrors a wider ideological struggle. Market-minded reformers tout autonomy and efficiency, while public health traditionalists worry about equity. Ethiopia adds another twist: its university hospitals answer to the Education Ministry, while ordinary hospitals report to the Ministry of Health, breeding rivalries, duplicated paperwork, and incentives that collide.

Sadly, the price of this fragmentation is counted not only in Birr but in avoidable deaths.

A cure begins with clarity, though. Policymakers could establish joint boards drawing representatives from both ministries, alongside clinicians and community voices. Such bodies would give hospitals a single point of direction and scrutiny.

Financially, they would transition to a mission-based budgeting approach, allocating funds according to measurable clinical results, research output, and teaching quality, rather than historical line items. Hospitals could retain some revenue from paying patients and specialised procedures, cross-subsidising research and free care without undermining universal-coverage goals.

That, in turn, would let hospitals invest. Tikur Anbessa could replace geriatric radiology gear; Jimma could upgrade its laboratories; and Mekelle could rebuild war-damaged wards. The freedom to top up pay packets would help lure talent back home. Shared professorial appointments would preserve academic links, while students would gain richer bedside training in institutions no longer mired in crisis management.

Reform need not stop at the hospital gate. Ethiopia’s geography and patchy roads make regional health networks essential. Specialised centres should act as hubs, supporting district clinics through referral pathways and outreach.

Telemedicine pilots in Amhara and Oromia regional states already show promise. A consultant in Addis Abeba can guide a rural medic through a tricky caesarean section via video link. Scaling such schemes would spread scarce expertise more effectively and efficiently than building new tertiary hospitals in every province.

A unified health information system would let planners track disease trends, drug stocks, and workforce gaps in real time, matching resources with needs.

Community based health insurance (CBHI) is spreading; a national social health insurance (SHI) scheme is on the drawing board. Linking both to teaching hospitals would shield poor households from the shock of high-tech care and reassure policymakers that autonomy will not price out the vulnerable.

Satellite clinics, rotating surgical camps, and mobile diagnostic units could carry university know-how to remote districts.

Mandatory rotations would send junior doctors from university wards to rural health centres and back, fusing academic rigour with the gritty realities of primary care. Nurses, midwives, and technologists could join interprofessional programmes that blend campus learning with community postings. Such schemes would ease urban-rural divides and enrich curricula with practical experience.

Ethiopia faces the familiar double burden of infectious diseases and a surge in non-communicable health issues, such as diabetes, hypertension, and cancers. Teaching hospitals are natural laboratories for developing solutions, creating low-cost diagnostic kits, trialling treatment protocols tailored to local genetics, and conducting implementation science studies that demonstrate what works in resource-constrained settings.

Innovation funds embedded within autonomous hospital budgets would spur such work, with intellectual property returns shared between researchers and institutions.

The cost of doing nothing is clearer still. Starved of resources and shackled by bureaucracy, university hospitals will continue to haemorrhage staff and reputation. Patients who can afford to pay will flock to private facilities; the rest will languish in queues that stretch from the corridor to the courtyard.

Research output will wither, leaving Ethiopia to import medical advances instead of shaping them. Trust in public health institutions will erode, making it harder to rally society in future crises.

Two decades ago, Thailand granted its teaching hospitals semiautonomous status, coupling global budgets with strict quality metrics. Survival rates for neonatal emergencies and cardiac operations improved; faculty members no longer needed to hold second jobs. Kenya allowed Kenyatta National Hospital to set its own fees and pay scales in 2013, while retaining public oversight; brain drain slowed, and equipment downtime fell.

Ethiopia can adapt such models to its own federal structure and fiscal realities.

Suppose Tikur Anbessa Hospital controlled even half of Addis Abeba University’s budget instead of seven percent, and channelled half of that increase into staff remuneration. A modest pay rise of 30pc could retain senior specialists whose departure would cost the state far more in lost expertise and patient referrals.

Jimma’s budget share could rise to 20pc, funding a modern oncology ward that spares families a 300Km journey to Addis Abeba. Freed from month-to-month begging, administrators could sign multi-year procurement contracts, thereby trimming drug prices by volume and avoiding last-minute emergency purchases that inflate costs.

Hospitals can manage themselves within guardrails that keep them public-spirited. Autonomy is not an ideological luxury. It is a practical necessity if Ethiopia is to meet its ambitious targets for universal health coverage by 2030. The alternative is a slow slide into irrelevance for institutions that should be leading the charge against disease.

Ethiopia’s teaching hospitals began as classrooms with beds. They have grown into the backbone of tertiary care, yet their skeleton remains academic. Disconnecting their budgets and governance from academia would let them walk tall. That, in turn, would strengthen the wider healthcare service on which more than 100 million citizens depend.

PUBLISHED ON Jul 26,2025 [ VOL 26 , NO 1317]