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

The role of contractual arrangements in improving health sector performance
given the right to collect and retain revenues, but is required to
pay a fee or a percentage to the government for the privilege of
doing so.
a. Contracting-in should not be confused with internal contracts among governmental agencies. Contracting-in, as
used here and in some countries (such as in Cambodia), refers to bringing in outside private management to
operate an internal government service.
b. Subvention is also used as a public finance term in many Eastern European countries for reallocation of financial
flows across geographic regions.
Contracting out health services is an increasingly prevalent phenomenon in
developing countries and governments in all regions contract out some type of health care
service. In developing countries, contracting out has been an element of health system
reform programmes often under the influence of multilateral and bilateral agencies.
These agencies promote a new role for the state in health care provision. Specifically,
they emphasize the state’s role as a catalyst for competition among providers and as a
force that encourages greater utilization of private providers, rather than promoting the
state as the dispenser of services itself.
Contracting out of health services is receiving increasing attention among low- and
middle-income countries, but evidence relating to the benefits and risks of the approach,
while accumulating, is far from conclusive. Despite the growing experience with
contracting out of health services in developing countries, limited evidence exists on the
impact these programmes have had on equity, quality, and efficiency or on health
outcomes.
Resolution WHA56.25 endorsed by the World Health Assembly in 2003 asked
Member States to assess the role of contractual arrangements in improving health system
performance [4]. There is limited experience, and even less documentation, on
contracting out of publicly financed health services among countries of the Eastern
Mediterranean Region, although several are at various stages of implementing health
sector reforms. There is increasing realization within the Region, as elsewhere, of the
importance of awareness creation and capacity-building within ministries of health in
contracting out publicly financed health services to the private sector.
The purpose of this document is to share experience in contracting from among 10
countries of the Region: Afghanistan, Bahrain, Islamic Republic of Iran, Egypt, Jordan,
Lebanon, Morocco, Pakistan, Syrian Arab Republic and Tunisia. The country studies on
contracting of publicly financed services were undertaken between January and
September 2004. Countries were identified representing the Region, based on the size of
the private sector, on anecdotal evidence of experience with contractual arrangements,
and implementation of a programme in which contractual arrangement with the private
sector was the principal strategy.
8