PBF Workshop – ITM, December 18th, 2008




                Contracting experiences
          Between FBOs and MoHs in SSA...
ITM, December 18th, 2008




Background & objectives
                                                                     ...
ITM, December 18th, 2008




Methodology
                                                                             D e ...
ITM, December 18th, 2008




Cases description
                                                           D e pa rtm e nt ...
ITM, December 18th, 2008




Cameroon : Tokombéré private district hospital
                                              ...
ITM, December 18th, 2008


Tanzania: Nyakahanga DDH
                                                            D e pa rtm...
ITM, December 18th, 2008

Chad: management of Moïssala district
by the Sarh BELACD
                                       ...
ITM, December 18th, 2008




Uganda: St Joseph Hospital (Kitgum)
                                                         ...
ITM, December 18th, 2008




Uganda: Kabarole Hospital
                                                               D e ...
ITM, December 18th, 2008




Where do we stand?
                                                            D e pa rtm e n...
ITM, December 18th, 2008


Answers to primary research questions:
Do contracting experiences work? (1)
                   ...
ITM, December 18th, 2008

Answers to primary research questions:
Do contracting experiences work? (2)
                    ...
ITM, December 18th, 2008


Answers to primary research questions:
Whom do contracting experiences benefit to, if they do?
...
ITM, December 18th, 2008

Answers to the primary research questions:
What makes contracting experiences work, or not?
    ...
ITM, December 18th, 2008




Cross-cutting conclusions
                                                                   ...
ITM, December 18th, 2008




Cross-cutting recommendations
                                                               ...
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Delphine Boulenger - Contracting experiences Between FBOs and MoHs in SSA : final results of an MMI study

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Delphine Boulenger - Contracting experiences Between FBOs and MoHs in SSA : final results of an MMI study

  1. 1. PBF Workshop – ITM, December 18th, 2008 Contracting experiences Between FBOs and MoHs in SSA Final results of an MMI study Delphine BOULENGER & Bart CRIEL Department of Public health Institute of Tropical Medicine, Antwerp 1
  2. 2. ITM, December 18th, 2008 Background & objectives D e pa rtm e nt o f P ublic H e a lth I ns titute o f T ro pic a l M e dic ine , A ntw e rp • Medicus Mundi International & contracting in health: • Advocacy, lobbying, publications • Field experience of member organisations • Relative FBOs focus ⇒ Need for updated knowledge and insight on the issue of contracting between African Church-based district hospitals or organizations and public health authorities ⇒ feed and steer future policies of MMI and its member organizations ⇒ Learning potential for local stakeholders and policy makers 2
  3. 3. ITM, December 18th, 2008 Methodology D e pa rtm e nt o f P ublic H e a lth I ns titute o f T ro pic a l M e dic ine , A ntw e rp Backbone: case-study analysis • Selection of purposeful countries and cases: mix of francophone/ • anglophone countries, variety of context and types of experiences Mix of desk research and field visits • 4 country cases, 5 case-studies :Cameroon (1), Tanzania (1), Chad (1), • Uganda (2) Descriptive and inductive method drawing from • • Detailed semi-structured interviews with key-informants: all levels in both Public and FB sectors • Shorter, more informal interviews (historical witnesses; specific resources) • Documentary analysis including policy and contracting documents, progress reports, routine health information system data, etc. => triangulation 3
  4. 4. ITM, December 18th, 2008 Cases description D e pa rtm e nt o f P ublic H e a lth I ns titute o f T ro pic a l M e dic ine , A ntw e rp • 3 ‘classical’ contracting arrangements: Cameroon (FBH as district hospital) , Tanzania (DDH), Chad (delegation of district management) • No ‘PBF’ contracts as the lion share of direct line contracting between FBHs/ FBOs and MoHs still relies on traditional contracting forms • Counterpoint study of upcoming contracting forms : FBHs with PEPFAR recipients; 2 case-studies in Uganda. 4
  5. 5. ITM, December 18th, 2008 Cameroon : Tokombéré private district hospital D e pa rtm e nt o f P ublic H e a lth I ns titute o f T ro pic a l M e dic ine , A ntw e rp Catholic hospital founded 1960 PHC pilot site since 1978 and standing as model for the national PHC policy Sole hospital of the area Playing the role of DH since 1993 (informal) Contract signed between the owning diocese and the MoH in 2002 5
  6. 6. ITM, December 18th, 2008 Tanzania: Nyakahanga DDH D e pa rtm e nt o f P ublic H e a lth I ns titute o f T ro pic a l M e dic ine , A ntw e rp • Lutheran hospital founded 1912 as a rural aid-post, became an hospital in 1953 • Located in a particular setting: Kagera region with a vast majority of church owned hospitals (10/13) and the total of district reference hospitals • Informally operates as a DDH from 1972 • Contract first signed in 2002 6
  7. 7. ITM, December 18th, 2008 Chad: management of Moïssala district by the Sarh BELACD D e pa rtm e nt o f P ublic H e a lth I ns titute o f T ro pic a l M e dic ine , A ntw e rp • Beboro-Moïssala Transfer 1992 • 1995 7
  8. 8. ITM, December 18th, 2008 Uganda: St Joseph Hospital (Kitgum) D e pa rtm e nt o f P ublic H e a lth I ns titute o f T ro pic a l M e dic ine , A ntw e rp • Founded 1942: an ‘institution’ in the area • Located next to Kitgum district hospital but attracts the majority of patients in the catchment area • The hospital receives a grant from the MoH but can also rely on important donors (AVSI, EU, WFP) and user fees • 3 contracts with PEPFAR recipients (CRS, TASO and UPHOLD) • UPHOLD (2003-2007) • TASO (2005/…) • CRS (2005/…) 8
  9. 9. ITM, December 18th, 2008 Uganda: Kabarole Hospital D e pa rtm e nt o f P ublic H e a lth I ns titute o f T ro pic a l M e dic ine , A ntw e rp • Founded 1903 but revived only in 2001 after a period of difficulties • Located next to 2 other hospitals: a public, regional referral hospital (Buhinga) and a Catholic hospital (Virika) • A relatively small facility in a growing faze; relies entirely on user fees and the Public grant for its all- round activities • 1 contract with CRS (ART + VCT) 9
  10. 10. ITM, December 18th, 2008 Where do we stand? D e pa rtm e nt o f P ublic H e a lth I ns titute o f T ro pic a l M e dic ine , A ntw e rp • Intermediary report of results : • A methodological introduction • 4 case studies including summary of key-findings and case-specific recommendations • Cross-cutting and general recommendations to MMI • Annexes including analytical summary of the MMI Guidelines questionnaire results • Final report to be completed by the end of January 2009: fine-tuning, full data and further completion of analysis, inclusion of internal and external peer-review comments. 10
  11. 11. ITM, December 18th, 2008 Answers to primary research questions: Do contracting experiences work? (1) D e pa rtm e nt o f P ublic H e a lth I ns titute o f T ro pic a l M e dic ine , A ntw e rp • The analysis of ‘classical’ experiences shows deceiving results on the whole, regardless of the type of relationship and context: • Regulatory frameworks show different stages and levels of development • They rarely or insufficiently apply to all experiences, especially older ones • Hospitals or districts operate in a difficult context, lacking adequate resources • Some contracts are under pressure or even being overhauled • Partnership theory and materialization concentrates at central level 11
  12. 12. ITM, December 18th, 2008 Answers to primary research questions: Do contracting experiences work? (2) D e pa rtm e nt o f P ublic H e a lth I ns titute o f T ro pic a l M e dic ine , A ntw e rp • The analysis of upcoming bilateral, performance-based contracts (PEPFAR) calls for balanced appreciation: • Risky, but depends on the beneficiaries’ capacity, maturity and resilience • The combination of factors intrinsic to this type of contracts (focus, rigidity, results-oriented, often exogenous priorities) and lack of transparency/ visibility carries the risk of impairing integration and generating gaps (public/ faith-based sector; facilities/ coordinating organs) • However, contractual relationships are valued by beneficiaries as efficient, supportive and predictable (“what is promised is what you get”): • They form a kind of mirror image of ‘classical’ relationships: • The focus is on district rather than central level • What makes these contracts work is precisely what lacks in the contractual relationships between public and faith-based sector 12
  13. 13. ITM, December 18th, 2008 Answers to primary research questions: Whom do contracting experiences benefit to, if they do? D e pa rtm e nt o f P ublic H e a lth I ns titute o f T ro pic a l M e dic ine , A ntw e rp • Signed agreements materialize the recognition of the FBO’s role in the health sector • They may improve the public sector’s support to the facilities in terms of financial and/ or human resources • But this support remains unreliable and insufficient in terms of resources • On the whole, relations appear unbalanced, at best formalizing an existing situation and mainly benefiting the public sector (service delivery, respect of national policy, inclusion in referral/ counter-referral system, etc.) 13
  14. 14. ITM, December 18th, 2008 Answers to the primary research questions: What makes contracting experiences work, or not? D e pa rtm e nt o f P ublic H e a lth I ns titute o f T ro pic a l M e dic ine , A ntw e rp • The public sector’s failure to fulfil its contractual obligations nurtures the crisis affecting faith-based facilities: lack of resources, instability of human resources . At worst, contracts may come with factual disengagement of the public sector, leaving the financial weight of healthcare delivery to FBO’s without empowering them to fulfil their mission (Chad) • Lack and unequal distribution of knowledge, poor communication lines and contradictions between central and peripheral level show how unachieved decentralization may affect contracting relationships and the quality of partnership • Classical contracts lack ambition and vision • Overall lack of provision for M&E mechanisms and poor supervision/ follow-up affect the quality of relationships on the long run and reduce possibilities of improvement • Insufficient capitalization of past experiences creates a multilayered and multiform contractual landscape 14
  15. 15. ITM, December 18th, 2008 Cross-cutting conclusions D e pa rtm e nt o f P ublic H e a lth I ns titute o f T ro pic a l M e dic ine , A ntw e rp • A silent crisis • The state insufficiently respects its obligations • Monitoring & evaluation mechanisms are widely lacking or disfunctionning • Limited and badly distributed knowledge • Insufficient capitalization of (past) experiences • Balkanized contractual landscape and overal failure of experiences stands as a mirror for imperfect decentralization processes • The specific case of Uganda/ PEPFAR contracts offer an interesting counterpoint for the analysis of classical contracts • Classical contracts rather acknowledge a pre-existing situation than form a base for future, innovative developments • Current situation stands as a risk indicator for the future of FBO/ Public partnerships 15
  16. 16. ITM, December 18th, 2008 Cross-cutting recommendations D e pa rtm e nt o f P ublic H e a lth I ns titute o f T ro pic a l M e dic ine , A ntw e rp • The situation requests a dramatically revised strategy: • Taking specific needs and characteristics into account: providing tailored and contextualized support rather than focusing on overall theory dissemination. • Supporting the mandatory professionalization of the faith- based health sector by moving (MMI’s) focus from moral authorities (bishops) to technical specialists (coordination organs; facility managers) • Taking new developments into account, especially the current move towards PBF contracting forms • Helping countries to build an institutional memory on health partnerships and contracting, including a data-base 16

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