Contracts with non-governmental organisations (NGOs) are seen as an effective way to expand services quickly in fragile states. NGOs currently provide most of Afghanistan’s health services. Researchers from the London School of Hygiene and Tropical Medicine, UK, discuss the benefits, pitfalls and long-term implications of this approach.

‘Fragile states’ include some 40 countries affected by or emerging from conflict or otherwise unable to implement pro-poor policies. A successful pilot programme in Cambodia has encouraged the promotion of contracting out to NGOs in other weak health systems. In Afghanistan, the removal of the Taliban regime in 2001/2 created new chances to tackle the country's poor health indicators. A joint mission of donors, largely influenced by the World Bank, proposed the use of non-state organisations as the main providers for a basic package of health services in Afghanistan.

Donors now fund contracts with NGOs worth over US$140 million. Nominally, these cover around three quarters of the population, although not all people may have access to a facility. The remainder are under recent calls for proposals. Twenty-seven NGOs have contracts (17 international and 10 Afghan) lasting 12 to 36 months. They provide a basic package of care, including maternal and newborn health, child health and immunisation, public nutrition, communicable diseases and supply of essential drugs.

The researchers identify several advantages of contracting, such as:

• NGOs were already running most facilities and are experienced in the difficulties of delivering health services in unstable environments.
• The bulk of public health expertise in Afghanistan is within NGOs.
• NGOs may have financial and logistical backing from large international organisations.
• Their motivation is thought to be closer to public providers than the for-profit private sector, but with greater flexibility.

They also highlight some areas of concern:

• Competition for contracts, which could improve efficiency and quality, is often lacking in remote areas. In addition, it may not be desirable to replace providers once they have built up local knowledge and networks.
• Contracts may be difficult to specify and monitor. However, in the Afghan case, performance is taken seriously, with different donors monitoring input, process or output indicators and providing different incentives.
• Management costs may wipe out efficiency gains. Extra costs from contracting include expatriate technical assistance and the need for external monitoring.
• Decentralisation to non-state providers means that health system fragmentation is very likely. There is no standard practice for user fees, drug supply systems and use of community health workers. Variation between providers may lead to advances in service delivery, but also has implications for equity and efficiency.
• The capacity of NGOs to continue to scale-up and sustain quality services is unclear. NGOs may develop the same weaknesses as government delivery mechanisms if they grow bigger.
• Governments in fragile states often struggle to maintain legitimacy. Delivering health services and controlling health workers are seen as key state functions. As a government becomes better established, it may wish to resume control.

Source(s):
‘Contracting out health services in fragile states’, British Medical Journal 332, pages 718-721, by Natasha Palmer, Lesley Strong, Abdul Wali and Egbert Sondorp, 2006 Full document.

Funded by: UK Department for International Development (DFID) via the EC-PREP programme

id21 Research Highlight: 29 September 2006

Further Information:
Natasha Palmer
Health Policy Unit
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT
UK

Tel: +44 (0) 20 7927 2271
Fax: +44 (0) 20 7637 5391
Contact the contributor: natasha.palmer@lshtm.ac.uk

Conflict and Health Programme, London School of Hygiene and Tropical Medicine, UK

European Commission Poverty Reduction Effectiveness Programme (EC-PREP) supported by the UK Department for International Development (DFID)

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'The benefits contracting health services in Afghanistan'

'Grim picture: improving the health service in Chad'

'Unsafe haven? The risk of malaria in refugee camps'

'Frequently unasked questions - reproductive health needs during war'

'Running battle - international intervention in post-conflict healthcare'

'Health policy in Afghanistan: two years of rapid change (a review of the process from 2001 to 2003)', Conflict and Health Programme, London School of Hygiene and Tropical Medicine, 2005