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

Lebanon
belong to the Ministry of Social Affairs, 20 to the Ministry of Public Health and the rest belong
to local or international nongovernmental organizations. Another 50 primary care centres are
about to join soon. The target is to include 150–160 centres by the end of 2005, which is
expected to fill the primary care needs for the uninsured in all of Lebanon.
The Ministry of Public Health uses a standard contract with the primary care centre which
describes responsibilities and expectations. Responsibilities of the Ministry of Public Health
include provision of essential drugs, health information system, and continuing education and
training for staff of the centre. The responsibilities of the centre include commitment to provision
of preventive and health promotion services, emphasis on essential drug list, use of health
information system, and adequate staffing of the centre (in terms of physicians, non-physician
health staff and administration). The contract duration is 5 years, (with 6-months’ notice required
for the centre to break the contract without incurring penalties). The contract is non-monetary,
i.e. it does not involve exchange of cash flow. Supporting this network, including underwriting
the operations of its centres, accounts for about 2%–3% of Ministry of Public Health budget. For
primary care centres owned by the Ministry of Public Health and operated by either
nongovernmental organizations or local municipalities, the Ministry pays basic expenses
(including water and electricity) while the centre is responsible for other operating expenses
(such as telephone). Contracting is not based on competitive bidding. The Ministry of Public
Health chooses primary care centres based on need in geographical areas, centre facilities, and
anticipated success of contracting based on engagement and quality of staff.
The Ministry of Public Health has recently contracted out an independent evaluation of the
Ministry–nongovernmental organization contractual arrangements. Review of this evaluation is
beyond the scope of this report, but the following points are relevant.
• Centres belonging to different parties, whether the Ministry of Public Health, Ministry of
Social Affairs, or nongovernmental organizations, have widely differing allegiances,
agendas, capacities and resources. Contracting with such diverse groups requires emphasis
on the minimum common denominator. This limits the usefulness of the contracting
mechanism as a means to introducing drastic changes in the functions of the contracted
parties.
• The performance of primary care centres belonging to nongovernmental organizations
depends on the agendas, resources and commitments of nongovernmental organizations. For
example, for some nongovernmental organizations with local political affiliations, primary
care centres serve mainly as vote-maximizers and thus the emphasis has been on delivery of
services that impress the public.
• The contractual arrangements are mostly about “organizing” the relationships between the
two parties, since many primary care centres are not under the influence of the Ministry of
Public Health (having long existed), and thus the Ministry of Public Health does not have
great leverage over them. Nevertheless, the organizing aspect of the contract allows
reasonable manoeuvring by the Ministry of Public Health to introduce some change.
Expectedly, this change has been slow.
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