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

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services Overcome budget constraints for capital projects Pakistan Enhance implementation of planned activities Improve access to services Expand service provision for culturally sensitive issues, e.g. HIV/AIDS Syrian Arab Republic Public provision of services, clinical services not contracted out Tunisia Reduce cost of foreign treatment by contracting with national providers The role of contractual arrangements in improving health sector performance partnering with public sector Enhanced recognition of NGOs by population Expansion of programme activities Access to government funds Most contracts between MASS or MOH and private facilities are only adherent to the agreements Political commitment for public–private partnerships exists Bureaucratic support is ambivalent Legal framework is being adapted No bureaucratic and political support for contracting clinical services Only non-clinical contracts Political and legal framework supportive MOH: Ministry of Health; MASS: Ministry of Social Affairs and Solidarity arrangements with public sector No dedicated contracting unit in MOH Limited experience of contracting Experience limited to specific national programmes Major provider of care Expanding service infrastructure Social Security Fund has long experience with contracting Contracts not directly given to private facilities 24 Limited experience in contracting of clinical services Different providers (NGOs, private practitioners) Technical, financial capacities vary widely Advanced diagnostic and therapeutic services Advanced diagnostic and therapeutic services Payments are normally block payments concerned with only quantity Delay in release of payments adversely affects contracts Difficulty in ensuring quality of services Reimbursements made on flat rate determined by MOH and no co-payment can be charged information system not in place Information system has limited capacity to assist in monitoring contracts Most programmes use separate reporting systems not used to monitor quality of services Information system has limited capacity to assist in monitoring contracts Medical inspection for assessing condition of hospitals and treatment facilities
The role of contractual arrangements in improving health sector performance The capacity of private sector providers also varies among countries of the Region. Nongovernmental organizations are more actively involved in the delivery of primary health services in some countries, especially Afghanistan and Pakistan. Other countries such as Egypt are piloting internal contracts with the reformed district provider organizations, as well as external contracts with private providers. There is abundant experience with contracting out of secondary and tertiary services to private providers in Jordan, Lebanon, Morocco and Tunisia. There are several issues with the private providers. The most important of these are the quality of services provided, and the accreditation of the providers. This is especially the case in Afghanistan, Egypt, Lebanon Morocco, Pakistan and Tunisia. Skilled managerial capacity is lacking among private providers, and their technical and financial capacities also vary widely. Private providers in Egypt, Jordan, Lebanon, Morocco and Tunisia have access to advanced medical technologies that make them attractive to contract with for secondary and tertiary care services. There are a number of risks inherent in the contracting process. These include delayed payments; differing interpretations of loosely-worded contracts; limited number of providers in rural areas; capture of contracting process by vested interests; and limited capacity for monitoring and evaluation. Of these, monitoring and evaluation is especially problematic, as the capacity to monitor contracts effectively is weak in most countries. With the exception of Egypt, performance indicators are not adequately included in the design of contract and, if included, often are not used. Management information systems, especially those covering private providers, are largely inadequate to meet the requirements for monitoring of performance and evaluation. Payment methods for most contractual arrangements are in the form of fee-for-service or block grants. Afghanistan has experience with payment based on capitation for a specified package of health services. Interventions with contracting as the implementation strategy Table 3 gives a summary of the specific interventions with contractual arrangements. All countries have experience with contracting out of non-clinical services; however, Bahrain, Morocco and Syrian Arab Republic purchase mainly non-clinical support services. Morocco also has experience with purchase of clinical services. Afghanistan, Egypt, Islamic Republic of Iran, Lebanon and Pakistan have experience with contracting out primary health care services, and Jordan, Lebanon and Tunisia extensively contract out hospital and ambulatory care services to private as well as public providers. 25
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 23: 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
Page 67 and 68: Egypt are governed by their own set
Page 69 and 70: Egypt One of the key objectives of
Page 71 and 72: Egypt Is the legal framework robust
Page 73 and 74: 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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