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

Pakistan
There may be a potential conflict between efficiency requirements of the market
environment and equity goals, which may act to undermine equity goals. This may include
loss of comprehensiveness of local service provision and potential loss of consumer choice.
Equity may also be threatened through the practice of provider or purchaser selection of low
risk patients where payment does not adequately compensate for the level of risk of specific
patients or types of patient.
Selective contracting may also have substantial impact on the wider health system.
Introduction of contracted providers may lead to fragmentation or lack of coordination within
the broader public health system. Contracting could also lead to competition between
contractors and public providers for staff resources, leading to increased salaries and to public
hospitals being drained of key personnel, or suffering from increased staff turnover. Contracts
can lock scarce resources into a particular allocation, even when changed circumstances
dictate a reallocation.
SCOPE, OBJECTIVES AND METHODOLOGY
The scope of this study is to undertake situation analysis, including exploratory case
studies, and document experiences as well as recommendations for outsourcing of publicly
financed health services to private sector organizations in Pakistan. The study in Pakistan is
part of a regional initiative to develop an evidence-based regional strategy on public–private
partnership in health in the Eastern Mediterranean Region.
The objectives of the study are to review the arrangements and experiences of
“contracting out” and provide recommendations for future programming by:
assessing the environment and overall capacity of providers and purchasers in terms of
contracting out health services to the private sector, its implementation as well as
evaluation;
assessing the arrangements and experiences of a project/programme in health that has taken up
contractual arrangements as an implementation modality; and
discussing findings on contractual arrangements with the key stakeholders to inform the study
recommendations.
The qualitative study uses a mix of methods to address the multiplicity and complexity
of dimensions of the contractual arrangements for health services. The methods used in the
study are: a) literature review; b) focus group discussion; c) key informant interview; d) case
study; and e) a consensus-building workshop.
a) Literature review
The relevant international and national literature was identified through library and
internet searches. The literature was screened and relevant material was selected for in-depth
review by the researcher. The documented arrangements and experiences in the countries
were reviewed to identify key areas of information about various dimensions of contractual
arrangements. The guidelines and schedule for focus group discussion and key informant
interviews were developed, in the light of literature review.
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