Perceived Barriers to Utilizing Maternal and Neonatal Health Services in Contracted-Out Versus Government-Managed Health Facilities in the Rural Districts of Pakistan

Document Type : Original Article


1 Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan

2 Women and Child Health Division, Aga Khan University, Karachi, Pakistan


A number of developing countries have contracted out public health facilities to the Non-Government Organizations (NGOs) in order to improve service utilization. However, there is a paucity of in-depth qualitative information on barriers to access services as a result of contracting from service users’ perspective. The objective of this study was to explore perceived barriers to utilizing Maternal and Neonatal Health (MNH) services, in health facilities contracted out by government to NGO for service provision versus in those which are managed by government (non-contracted).
A community-based qualitative exploratory study was conducted between April to September 2012 at two contracted-out and four matched non-contracted primary healthcare facilities in Thatta and Chitral, rural districts of Pakistan. Using semi-structured guide, the data were collected through thirty-six Focus Group Discussions (FGDs) conducted with mothers and their spouses in the catchment areas of selected facilities. Thematic analysis was performed using NVivo version 10.0 in which themes and sub-themes emerged.
Key barriers reported in contracted sites included physical distance, user charges and familial influences. Whereas, poor functionality of health centres was the main barrier for non-contracted sites with other issues being comparatively less salient. Decision-making patterns for participants of both catchments were largely similar. Spouses and mother-in-laws particularly influenced the decision to utilize health facilities.
Contracting out of health facility reduces supply side barriers to MNH services for the community served but distance, user charges and low awareness remain significant barriers. Contracting needs to be accompanied by measures for transportation in remote settings, oversight on user fee charges by contractor, and strong communitybased behavior change strategies.


Main Subjects

  1. Babalola S, Fatusi A. Determinants of use of maternal health services in Nigeria-looking beyond individual and household factors. BMC Pregnancy Childbirth 2009; 9: 43. doi: 10.1186/1471-2393-9-43
  2. Griffiths P, Stephenson R. Understanding users' perspectives of barriers to maternal health care use in Maharashtra, India. J Biosoc Sci 2001; 33: 339-59. doi: 10.1017/s002193200100339x
  3. Nanda P. Gender dimensions of user fees: Implications for women's utilization of health care. Reprod Health Matters 2002; 10: 127-34. doi: 10.1016/s0968-8080(02)00083-6
  4. Onah HE, Ikeako LC, Iloabachie GC. Factors associated with the use of maternity services in Enugu, southeastern Nigeria. Soc Sci Med 2006; 63: 1870-8. doi: 10.1016/j.socscimed.2006.04.019
  5. Amooti-Kaguna B, Nuwaha F. Factors influencing choice of delivery sites in Rakai district of Uganda. Soc Sci Med 2000; 50: 203-13. doi: 10.1016/s0277-9536(99)00275-0
  6. McNamee P, Ternent L, Hussein J. Barriers in accessing maternal healthcare: evidence from low-and middle-income countries. Expert Rev Pharmacoecon Outcomes Res 2009; 9: 41-8. doi: 10.1586/14737167.9.1.41
  7. Nabukera SK, Batwala VK, Mulogo EM, Barry S, Salihu HM. Use of postpartum health services in rural Uganda: knowledge, attitudes and barriers. J Community Health 2006; 31: 84-93. doi: 10.1007/s10900-005-9003-3
  8. Fotso JC, Ezeh AC, Essendi H. Maternal health in resource-poor urban settings: how does women's autonomy influence the utilization of obstetric care services? Reprod Health 2009; 6: 9. doi: 10.1186/1742-4755-6-9
  9. Furuta M, Salway S. Women's position within the household as a determinant of maternal health care use in Nepal. Int Fam Plan Perspect 2006; 32: 17-27. doi: 10.1363/3201706
  10. Zaidi S, Salam R, Rizvi SS, Ansari S, Bhutta Z. Public Private Partnerships for Improving Maternal & Neonatal Health Service Delivery. Islamabad: Research and Advocacy Fund, British Council; 2013.
  11. Zaidi S, Bhutta, Z, Shaikh S, Salam R, Rahim A. Landscaping finance support platforms for the improvement of Basic and Emergency obstetric care. WHO; 2012. (Unpublished report)
  12. 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 Plann 2008; 23: 1-13. doi: 10.1093/heapol/czm042
  13. Matsuoka S, Aiga H, Rasmey LC, Rathavy T, Okitsu A. Perceived barriers to utilization of maternal health services in rural Cambodia. Health Policy 2010; 95: 255-63. doi: 10.1016/j.healthpol.2009.12.011
  14. Ministry of Finance (MoF). Health and Nutrition. Economic survey 2006-7. Government of Pakistan. Available from:
  15. Pakistan Bureau of Statistics. Pakistan Social and Living Standards Measurement Survey (PSLM). Islamabad; 2012-3.
  16. Martinez J, Pearson M, England R. Third-Party Evaluation of the PPHI in Pakistan. Technical Resource Facility and Sosec; 2010. (Unpublished document)
  17. Hatcher P, Shaikh S, Fazli H, Zaidi S, Riaz A. Provider cost analysis supports results-based contracting out of maternal and newborn health services: an evidence-based policy perspective. BMC Health Serv Res 2014; 14: 459. doi: 10.1186/1472-6963-14-459
  18. Burr V. Social constructionism. London: Psychology Press; 2003.
  19. Gage AJ. Barriers to the utilization of maternal health care in rural Mali. Soc Sci Med 2007; 65: 1666-82. doi: 10.1016/j.socscimed.2007.06.001
  20. Mrisho M, Obrist B, Schellenberg JA, Haws RA, Mushi AK, Mshinda H, et al. The use of antenatal and postnatal care: perspectives and experiences of women and health care providers in rural southern Tanzania. BMC Pregnancy Childbirth 2009; 9: 10. doi: 10.1186/1471-2393-9-10
  21. Uzma A, Underwood P, Atkinson D, Thackrah R. Postpartum health in a Dhaka slum. Soc Sci Med 1999; 48: 313-20. doi: 10.1016/s0277-9536(98)00319-0
  22. Atkinson S, Ngwengweb A, Macwan'gic M, Ngulubed TJ, Harphame T, O'Connellf A. The referral process and urban health care in sub-Saharan Africa: the case of Lusaka, Zambia. Soc Sci Med 1999; 49: 27-38. doi: 10.1016/s0277-9536(99)00072-6
  23. Shaikh BT, Haran D, Hatcher J. Where do they go, whom do they consult, and why? Health-seeking behaviors in the northern areas of Pakistan. Qual Health Res 2008; 18: 747-55. doi: 10.1177/1049732308317220
  24. Choudhury N, Ahmed SM. Maternal care practices among the ultra poor households in rural Bangladesh: a qualitative exploratory study. BMC Pregnancy Childbirth 2011; 11: 15. doi: 10.1186/1471-2393-11-15
  25. Aboagye E. Access Opportunities, Social Structures and Maternal Health Seeking Behaviour in Bosomtwe District. Norwegian University of Science and Technology; 2010.
  26. Mullany BC, Becker S, Hindin MJ. The impact of including husbands in antenatal health education services on maternal health practices in urban Nepal: results from a randomized controlled trial. Health Educ Res 2007; 22: 166-76.
  27. Zaidi S, Rabbani F, Riaz A, Pradhan N, Hatcher P. Improvement in Access and Equity for Maternal and Newborn Health Services: Comparative Advantages of Contracted out versus Non-Contracted Facilities. Islamabad: Research and Advocacy Fund, British Council; 2013.
  28. Regalia F, Castro L. Performance-Based Incentives for Health: Demand-and Supply-Side Incentives in the Nicaraguan Red de Proteccion Social. Center for Global Development Working Paper; 2007.
  29. Ir P, Horemans D, Souk N, Van Damme W. Using targeted vouchers and health equity funds to improve access to skilled birth attendants for poor women: a case study in three rural health districts in Cambodia. BMC Pregnancy Childbirth 2010; 10: 1. doi: 10.1186/1471-2393-10-1
  30. Nguyen HT, Hatt L, Islam M, Sloan NL, Chowdhury J, Schmidt JO, et al. Encouraging maternal health service utilization: an evaluation of the Bangladesh voucher program. Soc Sci Med  2012; 74: 989-96. doi: 10.1016/j.socscimed.2011.11.030
  31. Essien E, Ifenne D, Sabitu K, Musa A, Alti-Mu'azu M, Adidu V, et al. Community loan funds and transport services for obstetric emergencies in northern Nigeria. Int J Gynaecol Obstet1997; 59: S237-44. doi: 10.1016/s0020-7292(97)00171-9
  32. Baqui AH, El-Arifeen S, Darmstadt GL, Ahmed S, Williams EK, Seraji HR, et al. Effect of community-based newborn-care intervention package implemented through two service-delivery strategies in Sylhet district, Bangladesh: a cluster-randomised controlled trial. Lancet 2008; 371: 1936-44. doi: 10.1016/s0140-6736(08)60835-1
  33. Abdullah S, Tworoger T, Tworoger L. Targeted microfinance and women involvement in household decision-making: evidence from Bangladesh. Allied Academies 2008; 15: 348.
  34. Swain RB, Wallentin FY. Does microfinance empower women? Evidence from self-help groups in India. International Review Applied Economics 2009; 23: 541-56.
  35. Ensor T, Cooper S. Overcoming barriers to health service access: influencing the demand side. Health Policy Plan 2004; 19: 69-79. doi: 10.1093/heapol/czh009