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

Pakistan
GFATM support, and a National Fortification Alliance for nutrition. The early experience with
these multi-partner forums seems encouraging.
Bureaucratic support for the contracting process has been increasing gradually during
the past few years. Multiple factors may have contributed to the change in bureaucrats’
attitude including political commitment at the highest level, repeated failure of the
government-only approach to health care delivery, enhanced abilities of private sector,
international initiatives such as GFATM, GAIN, and GAVI. However, the bureaucratic
commitment is more individual-based than institutionalized, which makes its future prospects
uncertain. There is a need for expediting the development of standardized guidelines and tools
for transparent management of various health interventions through contracting arrangements.
The general legal framework is workable and adaptable for guiding and safeguarding
the private as well as the public sector contracting partners in health. The finance as well as
law and justice ministries do assist the Ministry of Health in the contracting process, by
technically assessing and vetting their contracts. The agreed mechanisms for resolving any
dispute, if arises, are generally documented in the contract. However, the description of
arrangements is not always detailed enough to cover all the important dimensions of potential
dispute between the partners. Multiple factors that might contribute to inadequate description
of dispute resolution arrangements include inadequate understanding and experience of
partners, influence of private and public partners, and deficiencies in current legal and
bureaucratic framework.
Contracting is meant to promote an optimal use of available resources by the private
sector as a supplement, rather than a substitute, for public sector efforts. The contracting
implies enhanced capacity of the public sector to deliver its own set of services effectively as
well as to support the private sector in supplementing public sector efforts in certain defined
geographic or service areas. The success of contracting and the efficiency gains depend on the
government capacity to act as an efficient purchaser, and more specifically to decide on the
need for contracting, prepare contract related documents, support the implementation, and
monitor the performance. The enabling process of public sector purchasers requires
comprehensive analysis, planning, preparation and operationalization of efforts, which in turn
means investment of time, energy and resources. Timely arrangement of the required inputs
for building the purchaser capacity of public sector is a challenge with no simple answer. The
public sector organizational development plans need to address the purchaser capacity
challenges at various levels by giving attention to areas such as planning, cost and price
analysis, contract design and negotiation, regulatory capacity including licensing and
accreditation.
There is wide variation in the technical, managerial and financial capacity of private
sector providers. Based on the very limited information available, the number of capable
private sector providers, i.e. with the right mix of strengths required for various types of
activities, seems relatively limited. The capacity limitation of providers can adversely affect
the performance as well as the future prospects of the contractual arrangements. One key
requisite for building private sector capacity is an “enabled public sector” for coordinating the
219