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

Pakistan
specific indicators and arrangements for monitoring the performance of PRSP. So far the
district officials rely on routine data provided by the programme, and district health officials
have not been regular about visiting the BHUs and providing written feedback, as agreed in
the contract. The evaluation of PRSP performance, to be conducted at the completion of the
first year, was not yet due at the time of study.
Financial management
The administrative and transaction cost is about one tenth of the project cost. The public
sector reimburses the cost. The public sector provides the agreed financial inputs as a block
grant to PRSP. There has been no delay reported in the release of funds.
As a company, the PRSP is required to maintain financial records for audit purposes.
The annual audit of accounts is conducted by a qualified auditing firm, as required under the
corporate law. The PRSP submits a copy of an annual audit report to the district government.
There has been no reported incident of any fiduciary dispute between the PRSP and district
government. However, the agreed process for dispute resolution is considered valid for
fiduciary as well as other issues related to contractual arrangements.
DISCUSSION
The study is meant to focus on the contracting process and experiences of the public
sector purchasers and the private sector providers. The study is based mainly on qualitative
information gathered from interviews, discussions and document reviews. The scope does not
include study of cost or quality comparisons between the services provided by the government
and the private sectors, nor efficiency and equity gains over time.
The rationale given by the public and private sector partners in Pakistan covers most of
the key dimensions observed in other countries. Not all the rationale cited is based on valid
scientific evidence or programme experience. The issue of enhanced effectiveness and
efficiency through the introduction of market mechanisms has not emerged as an important
justification for contracting in health. Furthermore, the lack of resolution of potential equity
issues and the preference for providing a certain set of services require attention.
In contrast to other developing countries, where the contracting experience focuses
more on non-clinical services, Pakistan has focused more on clinical and preventive services
including primary health care.
Political support seems to be reasonable at the higher level of government hierarchy.
There is a need to translate the political commitment into a set of transparent institutional
arrangements which can facilitate the planning, implementation and evaluation of health
interventions through contractual arrangements. In absence of such transparent arrangements,
there is a risk of inappropriate use of political influence in the contracting process.
Recognizing this, Pakistan has already started developing arrangements for optimizing these
political, technical and bureaucratic influences. These arrangements include an Inter-Agency-
Coordinating Committee for tuberculosis and AIDS, Country Coordinating Mechanisms for
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