RESUMO
The aim of this study was to determine the key organizational dimensions that influence the autonomy of university hospitals and the level of granted autonomy in each dimension. Six hospitals were randomly selected from those affiliated with three medical universities of Tehran, Iran and Shahid Beheshti. In this qualitative study, we interviewed 27 hospital managers [response rate of 82%]. The semi-structured interview guide was developed based on the results of four initial in-depth interviews and the organizational reform model of the World Bank. We used the framework method for the analysis of qualitative data. Nine themes were identified as the key factors influencing hospital autonomy: decision right in strategic management, decision right in human resources management, decision right in financial management, decision right in physical resources management, product market exposure, procurement market exposure, financial residual claim, governance arrangements and accountability mechanisms, and social functions of the hospitals. Limited decision rights in strategic, human resources, and physical resources management were granted to hospitals. Hospitals were not the financial residual claimant, but were exposed to competitive product market. Autonomy was limited regarding the procurement market. Governance systems were hierarchical and accountability mechanisms were supervisor-supervisee oriented. Some of the social functions of the hospitals were defined, but the expenses of these functions were not totally reimbursed by the government and the insurance industry. The autonomy granted to the hospitals is unbalanced and paradoxical. More decision rights should be granted for management of strategic, human resources and physical resources as well as hospitals entry to the procurement market. Hospitals need to be the financial residual claimant. The hierarchical administrative systems should be transformed to cooperative ones. Instead of supervisor-supervisee oriented control measures, Ministry of Health and Medical Education needs more regulatory mechanisms for controlling hospitals' performance and social functions