Delphine Boulenger - Contracting experiences Between FBOs and MoHs in SSA : final results of an MMI...

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PBF Workshop – ITM, December 18th, 2008

Contracting experiencesBetween FBOs and MoHs in SSA

Final results of an MMI study

Delphine BOULENGER & Bart CRIELDepartment of Public health

Institute of Tropical Medicine, Antwerp

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ITM, December 18th, 2008

Department of Public H ea lth Ins titute of Tropic a l M edic ine, A ntw erp

Background & objectives

• 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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Methodology

• 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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Cases description

• 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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Cameroon : Tokombéré private district hospital

Catholic hospital founded 1960 PHC pilot site since 1978 and standing as model for the national PHC policySole hospital of the areaPlaying the role of DH since 1993 (informal)Contract signed between the owning diocese and the MoH in 2002

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Tanzania: Nyakahanga DDH

• 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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Chad: management of Moïssala district by the Sarh BELACD

• Beboro-Moïssala Transfer 1992• 1995

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Uganda: St Joseph Hospital (Kitgum)

• 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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Uganda: Kabarole Hospital

• 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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Where do we stand?

• 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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Answers to primary research questions:Do contracting experiences work? (1)

• 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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Answers to primary research questions:Do contracting experiences work? (2)

• 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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Answers to primary research questions:Whom do contracting experiences benefit to, if they do?

• 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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Answers to the primary research questions:What makes contracting experiences work, or not?

• 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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Cross-cutting conclusions

• 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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Cross-cutting recommendations

• 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

Delphine Boulenger - Contracting experiences Between FBOs and MoHs in SSA : final results of an MMI...

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