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

Pakistan
The block payment seems to be an appropriate payment mode under the current
circumstances. In block payment, the data requirements and management efforts are relatively
limited compared with other payment modes such as indemnification and fee-for-service.
Block payment may be more suitable for ensuring timely and uninterrupted availability of
required inputs, which in turn can affect the quality of services.
Indemnification relies on the provider’s financial input for service delivery, which is
then reimbursed. Organizations with a strong reserve of resources are likely to qualify;
however organizations that are potentially able but have limited resources in reserve may opt
not to compete for the contract. This has potential equity and quality implications.
The fee-for-service payment made relies on more elaborate record-keeping as well as
advanced accounting and financial management arrangements. There are also potential
difficulties in rationalizing the provision of services and limiting its administrative cost.
Public sector managers are aware of but have a relatively limited ability to undertake
cost and pricing analysis. The national programmes have tried to carry out unit costing for
various sub-components, and these unit costs have been used in the contracting process. Only
few larger private sector organizations have the capacity to conduct full cost and price
analysis for contracting purposes.
Monitoring and evaluation systems
The Federal Ministry of Health has an information system in place for nationwide
collection and analysis of health care delivery data from public sector facilities. This general
system is also supplemented by disease-specific data collected by respective programmes, e.g.
tuberculosis, malaria. The data are focused mainly on disease reporting and on service input
and output monitoring. These core data are supplemented by periodic community and health
surveys, e.g. integrated household survey. Some of the available information can be helpful
during the contracting and implementation, in particular service delivery through government
health facilities. Each contract also defines specific information needs as well as arrangements
to monitor the performance and the outcomes by collecting and extracting the required
information. However, the quality of performance indicators and data vary across projects.
There are tools for recording financial data, and generally the records are adequate for
periodic financial audits.
The Ministry does have arrangements to evaluate the ongoing projects through peer
review (i.e. internal), external review (i.e. third-party review and international missions), and
scientific research studies. A mix of these approaches is used in the projects, according to the
situation.
The Federal Ministry of Health does not maintain a database of private sector partners
according to their areas of expertise, including working experience. The Ministry also lacks
reliable data on which to base the costing and pricing analysis for contracting. There is no
regular arrangement for collecting data on care delivery activities or outputs of the private
sector partners.
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