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

Document Type: Original Article

Author

Institute of Development Studies, University of Dar es Salaam, Dar es Salaam, Tanzania

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.

Keywords

Main Subjects


  1. WHO. The world health report 2013: research for universal health coverage. Geneva: World Health Organization; 2013.
  2. Moran D. Comparing services: a survey of leading issues in the sectoral literatures. Public Adm Dev. 2006;26(3):197-206.
  3. Palmer N, Strong L, Wali A, Sondorp E. Contracting out health services in fragile states. BMJ. 2006;332(7543):718-721. doi:10.1136/bmj.332.7543.718
  4. Palmer N. The use of private-sector contracts for primary health care: theory, evidence and lessons for low-income and middle-income countries. Bull World Health Organ. 2000;78(6):821-829.
  5. Berman PA. Rethinking health care systems: Private health care provision in India. World Dev. 1998;26(8):1463-1479. doi:10.1016/S0305-750X(98)00059-X
  6. International Finance Corporation. The Business of Health in Africa: Partnering with the Private Sector to Improve People’s Lives. The World Bank; 2007.
  7. Yoong J, Burger N, Spreng C, Sood N. Private sector participation and health system performance in sub-Saharan Africa. PLoS One. 2010;5(10):e13243. doi:10.1371/journal.pone.0013243
  8. Oxfam International. Blind Optimism: Challenging the myths about private health care in poor countries. Oxfam Briefing Paper. Oxford: Oxfam International; 2009:25.
  9. Mills A, Brugha R, Hanson K, McPake B. What can be done about the private health sector in low-income countries? Bull World Health Organ. 2002;80(4):325-330.
  10. Dahlgren G, Whitehead M. A framework for assessing health systems from the public’s perspective: the ALPS approach. Int J Health Serv. 2007;37(2):363-378. doi:10.2190/u814-6x80-n787-807j
  11. 11.   Ministry of Health and Social Welfare. Health Sector Strategic Plan III July 2009 – June 2015:“Partnership for Delivering the MDGs”. Dar es Salaam: Ministry of Health and Social Welfare;2009.
  12. Boulenger D, Criel B. The difficult relationship between faith-based health care Organizations and the public sector in sub-Saharan Africa: The case of contracting experiences in Cameroon, Tanzania, Chad and Uganda. In: Kegels G, De Brouwere, Criel B, eds. Studies in Health Services Organization & Policy. Antwerp: ITGPress; 2012.
  13. Kisanga OME. Tanzania Takes a new look into PPP: The recently developed Public Private Partnership Policy and the PPP Act will encourage Partnerships healthcare investments. Africa Health Tanzania; 2012.
  14. Mills A. To contract or not to contract? Issues for low and middle income countries. Health Policy Plan. 1998;13(1):32-40.
  15. England R. Contracting and performance management in the health sector: Some pointers on how to do it. London: DFID Health Systems Resource Centre; 2000.
  16. Loevinsohn B, Harding A. Buying results? Contracting for health service delivery in developing countries. Lancet. 2005;366(9486):676-681. doi:10.1016/s0140-6736(05)67140-1
  17. Liu X, Hotchkiss DR, Bose S. The impact of contracting-out on health system performance: a conceptual framework. Health Policy. 2007;82(2):200-211. doi:10.1016/j.healthpol.2006.09.012
  18. Liu X, Hotchkiss DR, Bose S. The effectiveness of contracting-out primary health care services in developing countries: a review of the evidence. Health Policy Plan. 2008;23(1):1-13. doi:10.1093/heapol/czm042
  19. Tibandebage P, Mackintosh M, Kida T. The Public-Private interface in public service reforms: Analysis and Illustrative evidence from the health sector. Draft Paper: REPOA; 2012.
  20. Itika J, Mashindano O, Kessy F. Success and constraints for improving public private partnership in health service delivery in Tanzania. ESRF Discussion Paper; 2011:3.
  21. Yin RK. Case Study Research: Design and Methods (Applied Social Research Methods). SAGE Publications Inc; 2009:5.
  22. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa
  23. La Forgia GM. Health System Innovations in Central America: Lessons and Impact of New Approaches. World Bank Working Paper; 2005:57.
  24. Grepin KA. The role of the private sector in delivering maternal and child health services in low-income and middle-income countries: an observational, longitudinal analysis. Lancet. 2014;384(suppl 1):S7. doi:10.1016/S0140-6736(14)61870-5
  25. Shaikh BT, Rabbani F, Safi N, Dawar Z. Contracting of primary health care services in Pakistan: is up-scaling a pragmatic thinking? J Pak Med Assoc. 2010;60(5):387-389.
  26. Tanzania National Audit Office. Performance audit report on management of hospital agreements between the government and private hospitals. Dar es Salaam: National Audit Office; 2017.