Contracting out of health services improves service utilization and satisfaction: evidence from rural districts of Pakistan

Abstract

Background Contracting out of health services to non-state providers has been widely used in developing countries including Pakistan. Based on three years’ experience of contracting out primary and secondary health services, this paper presents findings of third party evaluation of health services from two rural districts of Sindh Pakistan. Methods This was a baseline vs end-line cross sectional assessment of thirteen primary and secondary healthcare facilities from two rural districts (Thatta and Sujawal) of Sindh province that were contracted out in 2016 to a national non-governmental organization. Healthcare facilities included: 8 rural health centres, 4 taluka headquarter hospitals and 1 district headquarter hospital. District health information system was used to extract three years (2016 – 2019) data on key performance indicators (KPIs) as agreed in contract. We conducted record review related to human resource and budget and in-depth interviews with health managers. Health facility assessment survey and client satisfaction exit interviews were also conducted. Results KPIs showed significant improvement in service provision from baseline. General outpatient department (OPD) (33%), specialist OPD (91%), accident/emergency consultations (106%), in-patient admissions (≥100%) alongside diagnostic/laboratory service utilization (86%) increased substantially. Facility based deliveries (37%), and major (99%) and minor (172%) surgeries also showed significant increase. Preventive services (maternal tetanus toxoid, child vaccination) showed modest improvement (4-19%) in the district (overall) but slight decline in some healthcare facilities. Slight improvement in specialist workforce care was noticed, however challenges related to staff retention persisted. Adequate supplies and equipment were available except radiology services. Most healthcare facilities were also in need of repair. Delayed and partial release of funds by government was a major barrier. Lack of coordination among different stakeholders delivering healthcare in the district was also noted. Majority of clients (60%) were satisfied with service delivery but unavailability of medicine was their main concern. Conclusions Contracting out has the potential to improve service utilization. Autonomy over budget allocation and utilization, appointment of all cadre of staff, and improved coordination among all stakeholders is required to improve service delivery. Quality of care and the longer term health outcomes need further evaluation.