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
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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
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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
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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.
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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
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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
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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
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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/…)
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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)
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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.
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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
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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
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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.)
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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
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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
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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
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