Governments and donors are increasingly contracting non-governmental organisations to provide a basic package of health services in post-conflict situations. In Afghanistan and South Sudan, this is now the principal way to deliver primary care services. This contracting approach could significantly scale up the provision of sexual and reproductive health services in post-conflict settings, but challenges remain.

A paper in the journal Reproductive Health Matters asks if the basic package of health services (BPHS) approach can adequately address sexual and reproductive health (SRH) in post-conflict settings. The need for health services in post-conflict countries often far exceeds the capacity to provide them, and packaging them into service contracts may be a way to rapidly expand delivery.

The content of the BPHS reflects a country’s needs and the cost-effectiveness of health services and is delivered through health posts, health centres and district hospitals. Non-governmental organisations (NGOs) bid for service contracts. The government and international donors review bids, evaluate NGO performance and set national standards. Packages commonly include services related to maternal and newborn health, reproductive health, child health and immunisation, communicable diseases and nutrition.

In theory, the BPHS approach increases the effectiveness and efficiency of health service delivery by strengthening a coordinated nationwide system. NGOs often have experience and capacity and can respond more rapidly and effectively than weak government agencies. The bidding process and focus on results promotes accountability and quality. However, there are doubts about the nature of the cost-effectiveness, the true competitiveness of the contracting process and the impact of NGO dominance on government capacity.

The following factors could affect efforts to expand SRH services when using the BPHS approach:

• Decision makers may overlook less tangible benefits to overall health and wellbeing from SRH services due to the focus on cost-effectiveness.
• The bidding process encourages NGOs to cut costs, potentially at the expense of certain, less tangible SRH services.
• Conservative political, religious and cultural forces may threaten provision of family planning and services to address unsafe abortion, especially if faith-based NGOs win contracts.
• General health NGOs may not have the ability to deliver SRH services to international standards, but funding for specialised NGOs may be limited under the BPHS approach.
• NGOs may feel unable to criticise governments and donors with whom they have or would like to have contracts under the BPHS approach.

The researchers conclude that governments and donors applying the BPHS contracting approach in post-conflict countries should:

• ensure the full range of comprehensive reproductive health services and activities are provided, particularly those currently omitted in BPHS approaches such as sexual and gender-based violence, and SRH services for young people
• monitor contracts and services closely to ensure the full range of SRH services is provided
• ensure NGOs have the skills and resources to deliver SRH services
• support advocacy activities on reproductive rights.

Source(s):
‘A Basic Package of Health Services for Post-Conflict Countries: Implications for Sexual and Reproductive Health Services’, Reproductive Health Matters 16 (31), pages 57 to 64, by Bayard Roberts, Samantha Guy, Egbert Sondorp and Louise Lee-Jones, 2008

id21 Research Highlight: 6 October 2008

Further Information:
Bayard Roberts
Conflict and Health Programme
London School of Hygiene and Tropical Medicine
Keppel Street
London WC1E 7HT, UK

Tel: +44 20 7927 2050
Fax: +44 20 7637 5391
Contact the contributor: bayard.roberts@lshtm.ac.uk

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

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'NGOs take on health services in Afghanistan'

'Grim picture: improving the health service in Chad'

'Ten years on from Cairo: integrating policies on population, gender and development'