Non-state Providers Research Articles

Contracting-out primary health care services in Tanzania towards UHC: how policy processes and context influence policy design and implementation

BackgroundGovernments increasingly recognize the need to engage non-state providers (NSPs) in health systems in order to move successfully towards Universal Health Coverage (UHC). One common approach to engaging NSPs is to contract-out the delivery of primary health care services. Research on contracting arrangements has typically focused on their impact on health service delivery; less is known about the actual processes underlying the development and implementation of interventions and the contextual factors that influence these. This paper reports on the design and implementation of service agreements (SAs) between local governments and NSPs for the provision of primary health care services in Tanzania. It examines the actors, policy process, context and policy content that influenced how the SAs were designed and implemented.MethodsWe used qualitative analytical methods to study the Tanzanian experience with contracting- out. Data were drawn from document reviews and in-depth interviews with 39 key informants, including six interviews at the national and regional levels and 33 interviews at the district level. All interviews were audiotaped, transcribed and translated into English. Data were managed in NVivo (version 10.0) and analyzed thematically.ResultsThe institutional frameworks shaping the engagement of the government with NSPs are rooted in Tanzania’s long history of public-private partnerships in the health sector. Demand for contractual arrangements emerged from both the government and the faith-based organizations that manage NSP facilities. Development partners provided significant technical and financial support, signaling their approval of the approach. Although districts gained the mandate and power to make contractual agreements with NSPs, financing the contracts remained largely dependent on donor funds via central government budget support. Delays in reimbursements, limited financial and technical capacity of local government authorities and lack of trust between the government and private partners affected the implementation of the contractual arrangements.ConclusionsTanzania’s central government needs to further develop the technical and financial capacity necessary to better support districts in establishing and financing contractual agreements with NSPs for primary health care services. Furthermore, forums for continuous dialogue between the government and contracted NSPs should be fostered in order to clarify the expectations of all parties and resolve any misunderstandings.

Factors influencing performance by contracted non-state providers implementing a basic package of health services in Afghanistan

BackgroundIn 2002 Afghanistan’s Ministry of Public Health (MoPH) and its development partners initiated a new paradigm for the health sector by electing to Contract-Out (CO) the Basic Package of Health Services (BPHS) to non-state providers (NSPs). This model is generally regarded as successful, but literature is scarce that examines the motivations underlying implementation and factors influencing program success. This paper uses relevant theories and qualitative data to describe how and why contracting out delivery of primary health care services to NSPs has been effective.The main aim of this study was to assess the contextual, institutional, and contractual factors that influenced the performance of NSPs delivering the BPHS in Afghanistan.MethodsThe qualitative study design involved individual in-depth interviews and focus group discussions conducted in six provinces of Afghanistan, as well as a desk review. The framework for assessing key factors of the contracting mechanism proposed by Liu et al. was utilized in the design, data collection and data analysis.ResultsWhile some contextual factors facilitated the CO (e.g. MoPH leadership, NSP innovation and community participation), harsh geography, political interference and insecurity in some provinces had negative effects. Contractual factors, such as effective input and output management, guided health service delivery. Institutional factors were important; management capacity of contracted NSPs affects their ability to deliver outcomes. Effective human resources and pharmaceutical management were notable elements that contributed to the successful delivery of the BPHS. The contextual, contractual and institutional factors interacted with each other.ConclusionThree sets of factors influenced the implementation of the BPHS: contextual, contractual and institutional. The MoPH should consider all of these factors when contracting out the BPHS and other functions to NSPs. Other fragile states and countries emerging from a period of conflict could learn from Afghanistan’s example in contracting out primary health care services, keeping in mind that generic or universal contracting policies might not work in all geographical areas within a country or between countries.

Towards universal health coverage: a mixed-method study mapping the development of the faith-based non-profit sector in the Ghanaian health system

BackgroundFaith-based non-profit (FBNP) providers have had a long-standing role as non-state, non-profit providers in the Ghanaian health system. They have historically been considered to be important in addressing the inequitable geographical distribution of health services and towards the achievement of universal health coverage (UHC), but in changing contexts, this contribution is being questioned. However, any assessment of contribution is hampered by the lack of basic information about their comparative presence and coverage in the Ghanaian health system. In response, since the 1950s, there have been repeated calls for the ‘mapping’ of faith-based health assets.MethodsA historically-focused mixed-methods study was conducted, collecting qualitative and quantitative data and combining geospatial mapping with varied documentary resources (secondary and primary, current and archival). Geospatial maps were developed, providing a visual representation of changes in the spatial footprint of the Ghanaian FBNP health sector.ResultsThe geospatial maps show that FBNPs were originally located in rural remote areas of the country but that this service footprint has evolved over time, in line with changing social, political and economic contexts.ConclusionFBNPs have had a long-standing role in the provision of health services and remain a valuable asset within national health systems in Ghana and sub-Saharan Africa more broadly. Collaboration between the public sector and such non-state providers, drawing on the comparative strengths and resources of FBNPs and focusing on whole system strengthening, is essential for the achievement of UHC.

Contracting-out urban primary health care in Bangladesh: a qualitative exploration of implementation processes and experience

BackgroundContracting-out (CO) to non-state providers is used widely to increase access to health care, but it entails many implementation challenges. Using Bangladesh’s two decades of experience with contracting out Urban Primary Health Care (UPHC), this paper identifies contextual, contractual, and actor-related factors that require consideration when implementing CO in Low- and Middle- Income Countries.MethodsThis qualitative case-study is based on 42 in-depth interviews with past and present stakeholders working with the government and the UPHC project, as well as a desk review of key project documents. The Health Policy Triangle framework is utilized to differentiate among multiple intersecting contextual, contractual and actor-related factors that characterize and influence complex implementation processes.ResultsIn Bangladesh, the contextual factors, both intrinsic and extrinsic to the health system, deeply impacted the CO process. These included competition with other health projects, public sector reforms, and the broader national level political and bureaucratic environment. Providing free services to the poor and a target to recover cost were two contradictory conditions set out in the contract and were difficult for providers to achieve. In relation to actors, the choice of the executing body led to complications, functionally disempowering local government institutions (cities and municipalities) from managing CO processes, and discouraging integration of CO arrangements into the broader national health system. Politics and power dynamics undermined the ethical selection of project areas. Ultimately, these and other factors weakened the project’s ability to achieve one of its original objectives: to decentralize management responsibilities and develop municipal capacity in managing contracts.ConclusionsThis study calls attention to factors that need to be addressed to successfully implement CO projects, both in Bangladesh and similar countries. Country ownership is crucial for adapting and integrating CO in national health systems. Concurrent processes must be ensured to develop local CO capacity. CO modalities must be adaptable and responsive to changing context, while operating within an agreed-upon and appropriate legal framework with a strong ethical foundation.

The Golden Age of Tax Expenditures: Fiscal Welfare and Inequality in Portugal (1989–2011)

ABSTRACTThis paper studies social tax expenditures as an instrument of social policy, considering its broader social and political ramifications, particularly regressive distributive impacts, the targeting of social protection and making markets for non-state providers. Using OECD data and government budgets, we look at ‘tax breaks for social purposes’ in Portugal since the 1980s, with a focus on healthcare, educational and mortgage loan expenses. Portugal presents a comparatively high level of TBSP before the Great Recession. Why? Using Portugal as a theory-developing case, the paper argues that in the critical juncture following the late, double transition to democracy and structural economic reform, tax and welfare state developments combined to create social tax expenditures as a modality of targeted social expenditure favouring middle and higher strata. Once in place, a combination of powerful vested interests, obscure policy-making, regressive income distribution and high take-up rate across taxpaying groups obtained a path-dependent outcome, keeping inegalitarian and costly fiscal welfare growing during adverse fiscal conditions. Such a resilient outcome was curbed only in 2011 by the harsh conditionality of the economic and financial adjustment programme of the Portuguese bailout, an instance of how deep crises provide opportunities for path-shifting reconfigurations of social policy.

Contracting Out Non-State Providers to Provide Primary Healthcare Services in Tanzania: Perceptions of Stakeholders.

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.

Факторы развития негосударственных поставщиков социальных услуг: мотивация труда специалистов

Факторы развития негосударственных поставщиков социальных услуг: мотивация труда специалистов

State, Market and Social Inequalities: A Study of Primary Education in the Indian Punjab

The article, using the National Sample Survey (henceforth NSS) data, establishes that the non-state providers, particularly the private-unaided sub-sector, have predominantly captured the primary school education market in Punjab. The predominance of these schools in the state has made the primary education a tradable commodity, catering to the demands based on the ability of the households to pay. In such a situation, the type of school (government or private) the households in the state are able to choose for their wards, particularly at rural level, is largely contingent on their caste and gender, which clearly shows that a new form of social inequality has emerged in Punjab (given not only that the learning environment in the government schools is perceived to be of formidable concern, but these schools are also non-English medium). The article suggests that without a properly functional state-financed school education system, the market forces will continue to strengthen the prevailing social inequalities.

CHANCE DEVELOPMENTS: BINGO REGULATION IN BRAZIL

Throughout the neoliberalism era states have adopted policies that are often – and aptly — analysed and critiqued by reference to gambling metaphors. But the ways that states have turned to gambling industries to generate income, support community projects and promote economic and social development have received much less attention in critical political economy and policy discussion. This oversight is striking because many non-Islamic states have overturned (or greatly attenuated) historic prohibitions on the provision of games of chance over the past couple of decades, and some have sponsored gambling industries and products to foster community regeneration and sustainable development. Brazil, a country known for strong competitive traditions in sports and gaming, creative approaches to community economic development, and an urgent need to strengthen its public finances, is a notable exception to this liberalisation trend. This stance is interesting because Brazil liberalised its gambling regime in 1993 to allow non-state providers to operate bingo games. Drawing on the case of bingo regulation this paper critically analyses challenges that the Brazilian state encountered when it sought to create an economy of non-state provision of gambling products in aid of social development and the conflicts that have ensued as it has re-imposed repression of bingos. The paper reports on desk research and interviews conducted for the Bingo Project, an ESRC-funded comparative research project that critically examines bingo regulation in different parts of the world.

Plural policing and public opinion in Brazil

The article explores public opinion about the public and private security sectors in Sao Paulo state, Brazil, based on data obtained from a survey. The analysis finds evidence that state providers were viewed more favourably than non-state providers. The respondents considered the police and police officers in Sao Paulo state to be more important, more trustworthy, and better prepared than private security companies and professionals. About two-thirds of the respondents also expressed a preference for police officers providing security services in large venues/events. The implications of these findings for the policing system are discussed.

Models of engagement between the state and the faith sector in sub-Saharan Africa – a systematic review

ABSTRACTIn sub-Saharan Africa many individuals rely on non-state health providers, and engagement between state and non-state providers is increasingly common. Little analytic work has been done on the varied models of engagement, resulting in a lack of clarity about the promises and challenges of public–private engagement (PPE) for health. Despite their prevalence, PPEs often fail. Faith-based health providers (FBHPs) form a significant proportion of the non-state health sector in sub-Saharan Africa, and the number of partnerships with FBHPs is increasing. Building on a prior systematic review project that developed a typology of organisational models for PPE for health, this article reports on a secondary analysis, highlighting PPE initiatives with FBHPs.

Neoliberal democratisation, colonial legacies and the rise of the non-state provision of social welfare in West Africa

ABSTRACTThis article explores the rise of the non-state provision of social welfare in West Africa. Over the past three decades, a range of non-state actors, including secular non-governmental organisations, faith-based organisations, for-profit businesses and informal networks have provided access to basic social services such as education and health care even more extensively than states. The article asks: why has the number of non-state providers increased so markedly across Africa, and why do the predominant types of non-state providers vary in different countries? The author argues that neoliberal democratisation during the 1980s and 1990s created new opportunities and spaces for non-state providers. Yet, an analysis of Ghana, Côte d’Ivoire and Liberia shows that colonial legacies have mediated the numbers and types of non-state actors on the ground. The conclusion highlights how this growth in non-state provision has significant negative consequences for citizens’ ability to obtain equitable access to and accountability for social welfare services.

Free Schools in England: ‘Not Unlike other Schools’?

AbstractThe aim of this article is to investigate the argument that choice and competition will unleash entrepreneurial innovation in free schools. Free schools were introduced as a subset of the Academies by the Conservative–Liberal Democrat Coalition government, following the general election in 2010. The government made it possible for non-state providers to set up their own independent, state-funded schools in order to create more choice, competition and innovation. We conclude that a higher level of substantive innovation is taking place in regards to management practices than in respect of curriculum and pedagogical practices. Innovation in curriculum and pedagogical practices is very limited. Creating a free school offer that seems to differ from other schools appears to be done through marketing and branding rather than innovation. We argue that parents, OFSTED, and the relative isolation of free schools constrain innovation from taking place.

Interrogating the ‘artificial’ divide between health and education for children aged 0–3 years in urban poor locales in Kenya

Holistic integrated early childhood policies foster child well-being in the first 3 years of life. The normative framing of Early Childhood Care and Education (ECCE) entrenches segmentation and creates artificial divides between education and health. This segmentation persists yet development processes for children are intertwined and mutually reinforcing. We trouble this artificial divide by drawing on findings from a study which examined the discursive care spaces in an urban poor locale in Kenya. Data were produced through in-depth interviews; participant observation and focus group discussions with caregivers and both state and non-state care providers. Using a socio-ecological lens to analyse intra- and inter-household interactions among caregivers, our analysis exposes the assumptions and silences in ECCE health and education and presents caregivers’ rich nuanced experiences and counter accounts. We conclude by calling for the imperative of bridging the divide between and within early childhood health and education to support integrated, adaptive and contextualised policy and practice.

Sectarianism and the Ambiguities of Welfare in Lebanon

Nonstate providers are often more important in the everyday lives of the poor than outposts of the state. In this essay, I focus on one type of provider, sectarian organizations, which are an integral component of politics and welfare regimes in parts of the Middle East and other developing regions. Focusing on Lebanon, I describe how sectarian welfare providers emerge from and help to constitute political sectarianism while tracing what is at stake for the poor. First, by holding public offices and dominating informal channels that mediate access to public benefits, these actors mediate the experience of accessing the “rights” of citizenship. Second, while they provide benefits and services that might not otherwise be available, the modes of allocating welfare by sectarian parties can be discriminatory, notably along partisan and religious lines. Third, sectarian groups politicize the process of accessing social benefits while undercutting the political voice of the poor by weakening alternative channels...

Human resources for health in six healthcare arenas under stress: a qualitative study.

BackgroundResearch on “human resources for health” (HRH) typically focuses on the public health subsector, despite the World Health Organization’s inclusive definition to the contrary. This qualitative research examines the profile of HRH in six conflict-affected contexts where the public health subsector does not dominate healthcare service provision and HRH is a less coherent and cohesive entity: Afghanistan, the Central African Republic (CAR), the Democratic Republic of Congo (DR Congo), Haiti, the Occupied Palestinian Territories and Somalia.MethodsThe study uses a multiple-country qualitative research design including documentary analysis and key informant interviews undertaken between 2010 and 2012. The documentary analysis included peer-reviewed articles, books, unpublished research and evaluations and donor and non-government organisation reviews. A common thematic guide, informed by this analysis, was used to undertake key informant interviews. Informants thought able to provide some insight into the research questions were identified from ministry of health organograms, and from listings of donors and non-government organisations. Local informants outside the familiar structures were also contacted. In CAR, 74 were interviewed; in Somalia 25; . in Haiti, 45; in Afghanistan, 41; in DR Congo, 32; and in the Occupied Palestinian Territories, 30. In addition, peer review was sought on the initial country reports.ResultsThe study discovered, in each healthcare arena investigated, a crowded HRH space with a wide range of public, private, formal and informal providers of varying levels of competence and a diverse richness of initiatives, shaped by the easy commodification of health and an unregulated market. The weak regulatory framework and capacity to regulate, combined with limited information regarding those not on the state payroll, allowed non-state providers to flourish, if not materially then at least numerically.ConclusionWhen examining HRH, a reliance on information provided by the state health sector can only provide a partial and inadequate representation of reality. For policy-makers and planners in disrupted contexts to begin to appreciate fully current and potential HRH, there is a need to study the workforce using conceptual tools that reflect the situation on the ground, rather than idealised patterns generated by incomplete inventories and unrealistic standards.

Informal Networks and Access to Power to Obtain Housing in Urban Slums in Ghana

Scholarship that examines obtaining housing in urban Ghana focuses on the role of state planning or access to financial markets, yet most housing in Ghana is provided outside these official channels, often in urban slums, where residents turn to nonstate providers (NSPs) to find housing. NSPs are local social networks led by political entrepreneurs motivated by informal norms and incentives, which shape the quality of housing and security of tenure. Their logic is best represented by treating the governance of housing as a collective action problem. This article introduces a typology of slums based on settlement patterns, including extralegal, indigenous, and purchased settlements. Ethnographic research and survey data illustrate the governance of housing across these types of Ghanaian informal settlements.

The "empty void" is a crowded space: health service provision at the margins of fragile and conflict affected states.

BackgroundDefinitions of fragile states focus on state willingness and capacity to ensure security and provide essential services, including health. Conventional analyses and subsequent policies that focus on state-delivered essential services miss many developments in severely disrupted healthcare arenas. The research seeks to gain insights about the large sections of the health field left to evolve spontaneously by the absent or diminished state.MethodsThe study examined six diverse case studies: Afghanistan, Central African Republic, Democratic Republic of the Congo, Haïti, Palestine, and Somalia. A comprehensive documentary analysis was complemented by site visits in 2011–2012 and interviews with key informants.ResultsDespite differing histories, countries shared chronic disruption of health services, with limited state service provision, and low community expectations of quality of care. The space left by compromised or absent state-provided services is filled by multiple diverse actors. Health is commoditized, health services are heterogeneous and irregular, with public goods such as immunization and preventive services lagging behind curative ones. Health workers with disparate skills, and atypical health facilities proliferate. Health care absorbs large private expenditures, sustained by households, remittances, charitable and solidarity funding, and constitutes a substantial portion of the country economy. Pharmaceutical markets thrive. Trans-border healthcare provision is prominent in most studied settings, conferring regional and sometimes true globalized characteristics to these arenas.ConclusionsWe identify three distortions in the way the global development community has considered health service provision. The first distortion is the assumption that beyond the reach of state- and donor-sponsored services is a “void”, waiting to be filled. Our analysis suggests that the opposite is the case. The second distortion relates to the inadequacy of the usual binary categories structuring conventional health system analyses, when applied to these contexts. The third distortion reflects the failure of the global development community to recognise—or engage—the emergent networks of health providers. To effectively harness the service provision currently available in this crowded space, development actors need to adapt their current approaches, engage non-state providers, and support local capacity and governance, particularly grassroots social institutions with a public-good orientation.

Perspectives on reproductive healthcare delivered through a basic package of health services in Afghanistan: a qualitative study

BackgroundContracting-out non-state providers to deliver a minimum package of essential health services is an increasingly common health service delivery mechanism in conflict-affected settings, where government capacity and resources are particularly constrained. Afghanistan, the longest-running example of Basic Package of Health Services (BPHS) contracting in a conflict-affected setting, enables study of how implementation of a national intervention influences access to prioritised health services. This study explores stakeholder perspectives of sexual and reproductive health (SRH) services delivered through the BPHS in Afghanistan, using Bamyan Province as a case study.MethodsTwenty-six in-depth interviews were conducted with health-system practitioners (e.g. policy/regulatory, middle management, frontline providers) and four focus groups with service-users. Inductive thematic coding used the WHO Health System Framework categories (i.e. service delivery, workforce, medicines, information, financing, stewardship), while allowing for emergent themes.ResultsImprovements were noted by respondents in all health-system components discussed, with significant improvements identified in service coverage and workforce, particularly improved gender balance, numbers, training, and standardisation. Despite improvements, remaining weaknesses included service access and usage - especially in remote areas, staff retention, workload, and community accountability.ConclusionsBy including perspectives on SRH service provision and BPHS contracting across health-system components and levels, this study contributes to broader debates on the effects of contracting on perceptions and experiences among practitioners and service-users in conflict-affected countries.

Historical Origins of Uneven Service Supply in Sub-Saharan Africa. The Role of Non-State Providers

Variations in non-state service provision are a relatively understudied dimension of wellbeing inequality in sub-Saharan Africa. This study from Madagascar documents long-term associations between nineteenth-century missionary education and the availability of private schools today. The article exploits an original data set with unusually detailed information on missionary education and contemporary local private school supply. The results indicate high levels of persistence in non-state schooling at the geographic level. The long tradition of faith-based education appears to contribute to religious differences that overlap only imperfectly with more widely studied ethnic divides.