Benjamin Loevinsohn

Contracting-in management to strengthen publicly financed primary health services—The experience of Punjab, Pakistan

OBJECTIVES In response to low utilization of primary health services in rural areas, the Government of Punjab contracted with a local non-governmental organization (NGO) to manage the basic health units in one district. METHODS To evaluate the performance of the contractor, health facility surveys, household surveys, and routinely collected information were used to compare the experimental district (Rahim Yar Khan, RYK) with a contiguous and equally poor district (Bahawalpur, BWP). RESULTS The evaluation found that contracting led to more than a 50% increase in out-patient visits in RYK compared to BWP. There was also increased satisfaction of the community with health services. Technical quality of care was equally poor in both districts and contracting also had little effect on the coverage of preventive services. The latter was likely the result of the NGO not being given managerial responsibility over vaccinators and other community health workers. CONCLUSIONS Despite methodological limitations, this study found that contracting in management achieved important goals at the same cost to the Government, implying a large increase in efficiency. Contracting in management worked reasonably well in this context and has now been significantly expanded. The approach provides a plausible means for large-scale improvements of poorly performing primary health care systems.

Contracting urban primary healthcare services in Bangladesh – effect on use, efficiency, equity and quality of care

To evaluate a large, ongoing effort to improve urban primary health care (PHC) in Bangladesh through expansion of publicly funded urban health facilities and contracting with partner non‐governmental organisations (NGOs).

Aid effectiveness in rebuilding the Afghan health system: A reflection

The Paris Declaration defined five components of aid effectiveness: ownership, alignment, harmonisation, managing for results and mutual accountability. Afghanistan, which has received a high level of donor aid for health since 2002, has seen significant improvements in health indicators, expanded access to health services and an increased range of services. Do the impressive health outcomes in this fragile state mean that aid has been effectively utilised? The factors that contributed to the success of the Ministry of Public Health (MOPH)-donor partnership include as follows: Ownership: a realistic role for the MOPH as the steward of the health sector that was clearly articulated to all stakeholders; Donor alignment: donor coordination and collaboration initiated by the MOPH; Joint decisions: participatory decision-making by the MOPH and donors, such as the major decision to use contracts with nongovernmental organisations for health service delivery; Managing for results: basing programmes on available evidence, supplementing that evidence where possible and performance monitoring of health-sector activities using multiple data sources; Reliable aid flows: the availability of sufficient donor funding for more than 10 years for MOPH priorities, such as the Basic Package of Health Services, and other programmes that boosted system development and capacity building; Human factors: these include a critical mass of individuals with the right experience and expertise being deployed at the right time and able to look beyond agency mandates and priorities to support sector reform and results. These factors, which made aid to Afghanistan effective, can be applied in other countries.