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The role of contractual arrangements in improving health sector performance lower wages and financial incentives and lower productivity in the public sector. Opportunistic behaviour, lack of relevant experience among health cooperatives, delays in payment, restrictive laws and regulations, and providers’ “playing on both sides of the fence” (public and private sectors) are considered the disadvantages of outsourcing. There is no consensus on financial risk sharing among contracting parties. There is belief among some universities that they benefit from a more powerful negotiating position in contracting out health services. On balance it is difficult to determine clearly the impact of contracting out of health care services in the absence of a comprehensive evaluation. Jordan The Ministry of Health in Jordan has been contracting out health services to the private sector and other autonomous public sector organizations over the past three decades. Contracts are mostly given by the Health Insurance Directorate of the Ministry of Health for the provision of hospital services. Of the 8 formal contracts for purchase of services by the Ministry, 5 are with private hospitals and 3 with autonomous public providers. Of these, 6 are reimbursed according to fee-for-service while 2 receive a fixed payment against leasing a specific number of hospital beds. Currently, the Ministry of Health with the support of Partnership for Health Reform Plus is implementing a health insurance pilot project to enhance the capacity of the Ministry in contract design, monitoring and enforcement. There is some evidence that contracting has contributed to improving access and promoting equity through extension of subsidized Ministry of Health activities to the poor and vulnerable. In terms of efficiency, the cost per admission in some autonomous hospitals reduced to less than US$ 424 as compared to over US$ 706 in private hospitals without contracts. There was no evidence, however, that it contributed to improving the quality of services. Lebanon Lebanon has a large private health sector and uses contractual arrangements extensively to provide health care and other services to its citizens. Over 80% of Lebanese receive health care based on one form or another of contractual arrangements. The Ministry of Public Health uses contracting as one of the main tools at its disposal to perform its functions. This includes contracting with primary care centres and hospitals to provide care for the uninsured and with local nongovernmental organizations to support social welfare. There are many limitations to the current contractual arrangements. Some of these include fragmentation of contracting mechanisms, lack of public capacity for monitoring of performance and outcomes, the limited leverage of the public sector as compared with the private sector, and the inability of current arrangements to contain escalating health 16
The role of contractual arrangements in improving health sector performance care costs. Many perceive current arrangements as providing public–private “cash transfers” which do not serve the government or the Lebanese citizen in the long term. Considering that recent large-scale health sector reform projects have not been evidently successful, contracting can be used an entry point to gradual reform. Several recommendations for improving performance of current arrangements can be made, that include creation of a central contracting body, linking inpatient and outpatient care, and unifying tariffs across financing agencies. Morocco The Ministry of Health of Morocco recognizes the competencies and innovative management procedures of private providers and encourages contracting with them. Morocco follows contractual arrangements in a broad sense of the term, which includes purchasing, delegation of services to lower levels, and cooperation among partners. Purchasing has involved the traditional contracting of a private provider on a regular salary to work within a public health institution and provide health services that are not well covered. Such arrangements have been on the decline with the expansion of public health services. More recent experience in Morocco relates to its policy of hospital autonomy and decentralization of district services and entering into a contractual arrangement with them. The Ministry of Health and the Ministry of Finance and privatization concluded what have been called workplan contracts with two university hospitals to meet their statutory responsibilities, namely care, training and education and research. The idea underlying this twin intervention of decentralization and contracting is that these institutions will improve management, optimize use of resources, be more accountable and improve overall performance. The terms and conditions of the contract include a global budget and set of agreed-upon performance monitoring indicators. A similar arrangement called programme contracts has been made with the decentralized facilities of the Ministry of Health that are responsible for providing district health services. Another form contractual arrangement based on cooperation exists between the public sector and the nongovernmental organizations covering such activities as contact tracing for infectious diseases, family planning and diagnostic and treatment services. The public contribution to these organizations comes not only through formal contractual payments but also through annual subsidies, provision of medicines and supplies, and sharing of infrastructure and human resources. Such agreements usually do not anticipate the means and tools necessary to control, monitor and follow up the input of nongovernmental organizations. 17
Page 1 and 2: Morocco Draft The role of contractu
Page 3 and 4: CONTENTS FOREWORD..................
Page 5 and 6: The role of contractual arrangement
Page 15: The role of contractual arrangement
Page 23 and 24: Islamic Republic of Iran care (incr
Page 37 and 38: Afghanistan AFGHANISTAN 37
Page 39 and 40: Current health services delivery Af
Page 41 and 42: Afghanistan with the staff of the M
Page 43 and 44: Afghanistan 3) Greater emphasis cou
Page 45 and 46: Afghanistan Table 2. Implementation
Page 47 and 48: Provider Strengths Afghanistan •
Page 49 and 50: Bahrain BAHRAIN
Page 51 and 52: Bahrain services to be contracted-o
Page 53 and 54: Bahrain claiming under them respect
Page 55 and 56: Financing Bahrain There is a clear
Page 57 and 58: Bahrain receipt of the invoice. The
Page 59 and 60: Bahrain RESULTS AND DISCUSSION: CAS
Page 61 and 62: Bahrain The competitive bidding pro
Page 63 and 64: Bahrain 11. SMC Cleaning Services C
Page 65 and 66: INTRODUCTION Egypt The health secto
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Egypt are governed by their own set
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Egypt One of the key objectives of
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Egypt Is the legal framework robust
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Egypt The opportunity for the HSRP
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Egypt The Research Unit includes Fa
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Egypt How was the nongovernmental o
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Egypt How did the approved list of
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Egypt districts, where private and
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Egypt Annex 1 Contract copy between
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Egypt deposit the fees of opening n
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Islamic Republic of Iran ISLAMIC RE
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INTRODUCTION Islamic Republic of Ir
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Islamic Republic of Iran OVERVIEW O
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Delivery Facility Health House Sour
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Islamic Republic of Iran PBSC invol
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Islamic Republic of Iran authoritie
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Islamic Republic of Iran From an ad
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Islamic Republic of Iran 6. Shieber
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Medical Sciences University Islamic
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Jordan JORDAN
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INTRODUCTION Jordan This study docu
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Jordan hospital beds in Jordan. In
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Jordan health education programmes.
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Jordan Benefits by health subsystem
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Jordan Table 2. Summary of health e
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Jordan ASSESSMENT OF OVERALL CAPACI
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Jordan attract foreign investment,
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Jordan businesses efficiently. The
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Expected risks and incentives Minis
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Jordan Table 4. Profile of contract
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Fee-for-service contracts Royal Med
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Jordan King Abdullah Hospital (KAH)
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Strengths Jordan • Provides acces
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Jordan • The minimum charge scale
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Jordan The main reasons behind the
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Jordan • Interviews with the Mini
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Jordan • This type of contracting
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Jordan CONCLUSIONS AND RECOMMENDATI
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Jordan 3. Prospective payment mecha
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Jordan Annex 1 CONTRACT/AGREEMENT A
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Lebanon LEBANON
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Lebanon at their disposal for regul
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Research methods and data sources L
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Lebanon and local municipalities. E
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Lebanon Table 1. Contractual arrang
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Lebanon Table 3. Costs of contractu
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Lebanon performance or mechanisms f
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Lebanon Overall, the contracts allo
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Lebanon belong to the Ministry of S
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Lebanon Perhaps the more obvious di
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Lebanon quality of care in the cont
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Lebanon Correcting this imbalance b
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Lebanon could be a first step towar
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Lebanon Table 5. Scorecard of contr
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Lebanon support for wide reform and
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Lebanon Sabri B et al. Health secto
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INTRODUCTION Morocco During the pas
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Morocco A contractual arrangement i
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Morocco services, as the administra
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Morocco The programme budget is lik
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Morocco According to his Act, each
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Morocco The number of patients curr
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Morocco facilities and the technica
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Morocco Evaluation of the subcontra
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Morocco Annex 2 EVALUATION OF THE E
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Chefchaouen Reassignment of agents,
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Ain Seb. Hay Moh. S. B. Zenata El F
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Pakistan PAKISTAN
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Pakistan To improve the health stat
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Pakistan the government grants a co
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Pakistan The relevant documents wer
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Pakistan Table 1. Examples of contr
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Pakistan Each contract generally sp
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Pakistan services. The specialized
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Pakistan Case study: contractual ar
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Pakistan used in the project to col
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Pakistan GFATM support, and a Natio
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RECOMMENDATIONS Pakistan 1. Conduct
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Pakistan Annex 1 GUIDELINES FOR DIS
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Pakistan Question Discussion points
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INTRODUCTION Tunisia The health ins
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Tunisia hospital facilities may be
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Tunisia the regulations of the mutu
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Tunisia pocket household expenditur
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Tunisia The Tunisian health strateg
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Table 2. Distribution of agreements
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Tunisia Coverage of MRI procedures
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under the agreements, 1995-2004 Tun
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Tunisia Table 5. Beneficiaries (BEN
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Tunisia The National Pension and So
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Tunisia Table 8 shows an increase i
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Tunisia to the private sector. The
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CONCLUSIONS Tunisia Three closely i
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