Reform by Design presents an evidence-informed account of the transformation of the University of Benin Teaching Hospital (UBTH), one of Nigeria’s flagship teaching hospitals, over the period 2017 to 2025. The book provides a practical, context-driven blueprint for institutional reform, grounded in strategic planning, digital innovation, and resilient systems thinking. It captures the critical leadership choices, operational frameworks, and performance metrics that repositioned UBTH as one of Nigeria’s most effective tertiary healthcare institutions. Drawing on real-time implementation, institutional data, and lived executive experience, Reform by Design provides actionable insights for policymakers, hospital managers, development partners, and academics. This book is both a technical roadmap and a legacy text for health systems strengthening in resource-constrained settings.