Contracting for Health: When Does It Work? Why Does It Work?

Can contracting with private health providers increase coverage of basic health services among poor populations? According to April Harding of the World Bank, who spoke today at a packed CGD seminar today, the answer is a resounding “yes.” April presented work that she and colleague Benjamin Loevinsohn have done to examine 10 experiences in contracting for health in the developing world, including the cases of Cambodia, Pakistan, Haiti and other countries. Their findings (PDF) strongly suggest that when governments or donor agencies have contracted NGOs to deliver a specific set of services, like immunization and prenatal care, for particular populations, those NGOs have performed – more efficiently than the public sector. These results are compelling and provocative, and make a real contribution to the often murky world of “health systems strengthening.” But the findings lead directly to a new set of questions: Is contracting an approach that can work in a broad range of environments, and be sustained? What are the key factors that would lead to successful contracting? Does contracting in post-conflict environments support or undermine long-term health sector development? Is there something about how contracting results in better outcomes – a focus on monitoring results? incentives for good performers? – that can help us find solutions to the big problems of dysfunctional health systems?