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

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.
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