Abstract
Background: In the attempt to move towards universal health coverage (UHC), many low- and middle-income countries (LMICs) are actively seeking to contract-out non-state providers (NSPs) to deliver health services to a specified population. Research on contracting-out has focused more on the impact of contracting-out than on the actual processes underlying the intervention and contextual factors that influence its performance. This paper reports on perceptions of stakeholders on contracting-out faith-based hospitals through service agreements (SAs) to provide primary healthcare services in Tanzania. Methods: We adopted a qualitative descriptive case study design. Qualitative research tools included document review and in-depth interviews with key informants, and data were analysed using a thematic approach. Results: Stakeholders reported mixed perceptions on the SA. The government considered the SA as an important mechanism for improving access to primary healthcare services where there were no public hospitals. The faith-based hospitals viewed the SA as a means of overcoming serious budget and human resource constraints as a result of the tightening funding environment. However, constant delays in disbursement of funds, mistrust among partners, and ineffective contract enforcement mechanisms resulted into negative perceptions of the SA. Conclusion: SAs between local governments and faith-based hospitals were perceived to be important by both parties. However, in order to implement SAs effectively, the districts should diversify the sources of financing the contracts. In addition, the government and the faith-based organizations should continually engage in dialogue so as to build more trust between the partners involved in the SA. Furthermore, the central government needs to play a greater role in building the capacity of district and regional level actors in monitoring the implementation of the SA.
Highlights
Global attention has recently converged on the need for countries to achieve universal health coverage (UHC), which aims to guarantee access to healthcare services without facing financial ruin.[1]
Implications for the public This study provides the public with an understanding of the process of contracting-out to faith-based hospitals to provide primary healthcare services in Tanzania, that is yet to be sufficiently evaluated
There is need to continually engage in dialogue involving the central and local governments, service providers and other stakeholders so as to discuss expectations and build more trust between the parties involved in service agreement (SA)
Summary
Global attention has recently converged on the need for countries to achieve universal health coverage (UHC), which aims to guarantee access to healthcare services without facing financial ruin.[1]. Maluka approaches to engage NSPs has been to contract-out the delivery of health services to a specified population on behalf of the government.[3] A contract document usually specifies the responsibilities of the parties to the contract, the precise range of services to be provided, time span, the performance standards to be achieved, procedures for performance monitoring, and terms of payment and costs.[4] Advocates of contracting-out argue that given the resourceconstraints of existing health systems, a more realistic approach to improving access to healthcare is to acknowledge and build upon the opportunities and resources of the NSPs.[4,5,6,7] critics claim that, in the context of many developing countries, contracting-out may be unlikely to achieve its intended objectives for several reasons These include high administrative costs, lack of sufficient providers for meaningful competition in many rural areas and the power of vested interests, which may try to gain control over the contracting process.[4,8] Others are concerned about user fees associated with private health services. Understanding the perceptions of stakeholders is crucial for proper implementation of the SA between the government and NSPs and could, in turn, help to assess the feasibility and sustainability of the SA
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