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The public sector in developing countries is increasingly contracting with the non-state sector to improve access, efficiency and quality of health services. We conducted a multicountry study to assess the range of health services contracted out, the process of contracting and its influencing factors in ten countries of the Eastern Mediterranean Region: Afghanistan, Bahrain, Egypt, Islamic Republic of Iran, Jordan, Lebanon, Morocco, Pakistan, the Syrian Arab Republic and Tunisia. Our results showed that Afghanistan, Egypt, Islamic Republic of Iran and Pakistan had experience with outsourcing of primary care services; Jordan, Lebanon and Tunisia extensively contracted out hospital and ambulatory care services; while Bahrain, Morocco and the Syrian Arab Republic outsourced mainly non-clinical services. The interest of the non-state sector in contracting was to secure a regular source of revenue and gain enhanced recognition and credibility. While most countries promoted contracting with the private sector, the legal and bureaucratic support in countries varied with the duration of experience with contracting. The inherent risks evident in the contracting process were reliance on donor funds, limited number of providers in rural areas, parties with vested interests gaining control over the contracting process, as well as poor monitoring and evaluation mechanisms. Contracting provides the opportunity to have greater control over private providers in countries with poor regulatory capacity, and if used judiciously can improve health system performance. Voir page 872 le résumé en français. En la página 873 figura un resumen en español.

Assessing trade in health services (TiHS) in developing countries is challenging since the sources of information are diverse, information is not accessible and professionals lack grasp of issues. A multi-country study was conducted in the Eastern Mediterranean Region (EMR)--Egypt, Jordan, Lebanon, Morocco, Oman, Pakistan, Sudan, Syrian Arab Republic, Tunisia, and Yemen. The objective was to estimate the direction, volume, and value of TiHS; analyze country commitments; and assess the challenges and opportunities for health services.Trade liberalization favored an open trade regime and encouraged foreign direct investment. Consumption abroad and movement of natural persons were the two prevalent modes. Yemen and Sudan are net importers, while Jordan promotes health tourism. In 2002, Yemenis spent US$ 80 million out of pocket for treatment abroad, while Jordan generated US$ 620 million. Egypt, Pakistan, Sudan and Tunisia export health workers, while Oman relies on import and 40% of its workforce is non-Omani. There is a general lack of coherence between Ministries of Trade and Health in formulating policies on TiHS.This is the first organized attempt to look at TiHS in the EMR. The systematic approach has helped create greater awareness, and a move towards better policy coherence in the area of trade in health services.

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Healthcare financing is in crisis in mostAfrican countries of the Eastern Mediterranean Region of WHO. In lowincome countries, spending on health is very low and populations are not protected against financial risks. Middle-and high-income countries are suffering from inappropriate use of resources devoted to health and lack of use of economic tools in priority setting. As coverage by insurance is not well developed, concerns over equity in access are voiced in most countries. Planned policy changes or health sector reforms are designed to address these challenges. The approaches used are based on capacity building, institutional development and provision of needed expertise. International agencies are providing technical support to help in setting the reform agenda, in managing the planned changes and in monitoring the impact. Efforts are being made to strengthen national capabilities in developing national health account functions and in promoting the use of economic tools such as cost-effective analysis, costing and cost analysis in health system management. A particular interest is paid to the development and strengthening of health insurance, and particularly microinsurance for uncovered populations. Countries of the subregion are encouraged to make better use of their training and research institutions and to facilitate the development of networks of health professionals dealing with health system development, supported by international agencies and development banks.