Abstract
BackgroundThe case of contracting out government health services to non-governmental organizations (NGOs) has been weak for maternal, newborn, and child health (MNCH) services, with documented gains being mainly in curative services. We present an in-depth assessment of the comparative advantages of contracting out on MNCH access, quality, and equity, using a case study from Pakistan.MethodsAn end-line, cross-sectional assessment was conducted of government facilities contracted out to a large national NGO and government-managed centres serving as controls, in two remote rural districts of Pakistan. Contracting out was specific for augmenting MNCH services but without contractual performance incentives. A household survey, a health facility survey, and focus group discussions with client and spouses were used for assessment.ResultsContracted out facilities had a significantly higher utilization as compared to control facilities for antenatal care, delivery, postnatal care, emergency obstetric care, and neonatal illness. Contracted facilities had comparatively better quality of MNCH services but not in all aspects. Better household practices were also seen in the district where contracting involved administrative control over outreach programs. Contracting was also faced with certain drawbacks. Facility utilization was inequitably higher amongst more educated and affluent clients. Contracted out catchments had higher out-of-pocket expenses on MNCH services, driven by steeper transport costs and user charges for additional diagnostics. Contracting out did not influence higher MNCH service coverage rates across the catchment. Physical distances, inadequate transport, and low demand for facility-based care in non-emergency settings were key client-reported barriers.ConclusionContracting out MNCH services at government health facilities can improve facility utilization and bring some improvement in quality of services. However, contracting out of health facilities is insufficient to increase service access across the catchment in remote rural contexts and requires accompanying measures for demand enhancement, transportation access, and targeting of the more disadvantaged clientele.
Highlights
The case of contracting out government health services to non-governmental organizations (NGOs) has been weak for maternal, newborn, and child health (MNCH) services, with documented gains being mainly in curative services
Formal controls brought in by the contract included (1) posted government staff made available to the NGO but without transfer and termination authority; (2) additional NGO- supported staff hired with incentivised salary; (3) introduction of an expanded number of essential drug categories and diagnostic tests; (4) authority over maintenance of building and equipment related to MNCH services; (5) introduction of user charges for additional diagnostics that were not covered by Rural Health Centres (RHCs) budget; and (6) introduction of user charges for antenatal and delivery registration
Utilization of MNCH services Results from the household survey showed that the utilization of contracted RHCs was significantly higher than control RHCs for facility-based births, antenatal care (ANC) 3+ visits, postnatal care (PNC), and care for newborn illness
Summary
The case of contracting out government health services to non-governmental organizations (NGOs) has been weak for maternal, newborn, and child health (MNCH) services, with documented gains being mainly in curative services. Contracting out of government-provided health services to NGOs is an increasingly popular means to increase access to health services in remote areas where there is little government capacity to provide such services and is based on a stipulated contract agreement and targets. It has been applied in fragile states, such as Afghanistan and Cambodia, for quick roll out of service delivery as well as more stable states, such as Bangladesh, India, and Pakistan, for improved delivery of health services [3]. There is little evidence on client-perceived barriers to using contracted facilities as available evidence tends to focus on quantitative assessments, neglecting community perspectives
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