Did contracting effect the use of primary health care units in Pakistan?

Abstract

For many years, Pakistan has had a wide network of Basic Health Units spread across the country, but their utilization by the population in rural and peri-urban areas has remained low. As of 2004, in an attempt to improve the utilization and performance of these public primary healthcare facilities, the government has gradually started contracting-in intergovernmental organizations to manage these BHUs. Using five nationally representative household surveys conducted between 2001 and 2012, and exploiting the gradual roll-out of this reform to apply a difference-in-difference approach, we evaluate its impact on BHU utilization. We find that contracting of the BHU management did not have any effect on health care use generally in the population, but it did significantly increase the use of BHU for childhood diarrhoea for the poor (by 4% points) and rural (3% points) households. These increases were accompanied by lower rates of self-treatment and private facilities usage. We do not find any significant effects on the self-reported satisfaction with BHU utilization. Our findings contrast with earlier small-scale studies that reported larger effects of the contracting of primary care in Pakistan. We speculate that the modest additional budget, the limited management authority of the contracting agency and the lack of clear performance indicators are reasons for the small impact of the contracting reform. Apparently critical aspects of services delivery such as location of BHUs, ineffective referral system and medical practice variation in public and private sectors have contributed to the overall low utilization of BHUs, yet these were beyond the scope of the contracting reform.

Stakeholder perspectives on public-private partnership in health service delivery in Sindh province of Pakistan: a qualitative study

“…Participants in our study also perceived the success of existing PPP initiatives as important facilitator for the provincial government to be interested in adopting the PPP policy. Previous studies have also indicated that BHUs under the PPHI management perform better than government run BHUs 12,15,26 . For example, Tanzil et al 12 compared functioning of two BHUs in Sindh, one administered by PPHI and the other was led by government.…”

“…Although PPHI has successfully been established in Sindh, it would appear that the systems for administration of PPP are weak with little emphasis placed on setting up and monitoring of actual performance targets or objectively verifiable outcomes 15 .As per the Management Contracting agreements of secondary hospitals with private organisations adopted by the Sindh provincial government, private sector organisations will be responsible for management and provision of services, ensuring availability of medicines, equipment and upgrading of facility infrastructure as per requirement 18 .Management contracts with NGOs for the provision of primary healthcare services have been reported in other low and middle income countries also. However, the contract arrangements have some variations e.g.…”

An assessment of a performance-based management agreement initiative in Ghana’s health service

“…Since health managers do not have sufficient control over both human and material resources in their jurisdictions and yet are made to sign PMAs to achieve targets with those resources, it raises issues of injustices. Previous studies have documented limited authority of managers to adversely affect the success of PMAs [30]. Efforts should therefore be made to enhance the authority of managers to control both human and material resources within their directorates.…”

Barriers to accessing maternal and newborn care: a qualitative study in district Thatta, Pakistan

“…For example, the closest health facility to a village is the basic health unit (28). Studies from rural Pakistan report that basic health units have limited facilities and are staffed by apathetic healthcare providers (29,30). Therefore, in order to get quality treatment, women either go to a private clinic or travel to the nearest city (29).…”

“…were averse to availing micronutrients and vaccinations citing that both may cause pregnancy complications. Vaccinations for neonatal tetanus is low in Pakistan and according to a national survey, only 48% of rural women were protected against neonatal tetanus in Sindh (29).…”