The role of contractual arrangements in improving health sector ...

Lebanon
postnatal care, vaccination and other reproductive health services, such as family planning
and infertility services. The centre receives a capitated fee per pregnant woman for antenatal
visits and a capitated fee per delivery. This is the only contract that involves monetary cash
flow with a local nongovernmental organization in Lebanon. It is too early to assess this
contractual project but several aspects invite optimism that it represents a useful model for
other Ministry of Public Health contracts: the clear terms of reference, including
performance indicators, adequate staffing, training of personnel, and the interest within the
Ministry of Public Health in pilot and innovative projects of a limited scope than can be later
expanded.
• Contracts with individuals. The Ministry of Public Health contracts on an as-needed basis
with individuals to deliver certain consultative or operational services. This is done
especially in areas with inadequate staffing, for example in reproductive health. There is no
dedicated reproductive health programme at the Ministry of Public Health, and therefore the
Ministry contracts periodically with public health experts to provide programmatic-like
services in this area. Contracts are typically awarded to known qualified people rather than
based on an open process that involves competitive applications. Payments are typically
based on cash transfers upon meeting the terms of reference for the contract. There has not
been an assessment of the quality of outcomes of these contracts, but the Ministry of Public
Health sees such contracts as allowing it to secure public health expertise, which is abundant
in Lebanon, at reasonable costs without the need to enlarge its professional body.
• Contracts with international organizations. The Ministry of Public Health contracts with
international organizations operating in Lebanon to achieve certain public health goals.
Contracting with UNICEF has already been discussed. The Ministry also contracts with the
country office of WHO to support several programmes such as the national tobacco control,
noncommunicable disease, and AIDS control programmes. Typically, the Ministry of Public
Health provides the bulk of the financial support for these programmes (around 70% if only
cash support is considered but up to 90% if indirect costs are also considered) while WHO
contributes the rest. WHO administers these programmes under a special “trust fund.” The
Ministry of Public Health gets these funds back in the form of expenditures on programme
activities. WHO charges 13% for administering the funds.
The collaborative programmes allow for local expertise to be secured as valued public
health professionals are paid at WHO scale, which is higher than the MOPH pay scale. Thus,
Lebanon is able to both retain these professionals and benefit from their experience. Programme
staff are recruited by the WHO Representative but are usually proposed by the Ministry of
Public Health. However, this is subject to political and other considerations, which limits the
usefulness of the open process of application and appointment. However, most of the staff have
been of high quality and have undergone adequate training by WHO. Therefore, these contracts
have allowed for the building of strong human resource teams. Nevertheless, considering that
Lebanon is a small market that has abundance of qualified health professionals and that many
such professionals have already had a lot of training in public health through the different
programmes, the Ministry of Public Health can probably handle these programmes on its own
with some help from WHO on an as-needed basis.
160