This paper examines the recent trends in public hospital autonomy as an integral part of health systems reforms. It reviews literature produced on the subject across a range of developing countries and explores varying viewpoints, arguments, and rationale for hospital autonomy developed over the past two decades. It then leads onto a discussion of two experiences of autonomy reforms in Pakistan: the provinces of Punjab and NWFP. Derived from the lessons learned from these initiatives, a set of guidelines is suggested as sustainable frameworks for reviewing the current measures and for designing future autonomy initiatives in Pakistan.