Contracting for primary health services : evidence on its effects and a framework for evaluation

These reforms include the contracting out of primary health care services, which typically involves government agencies contracting out specific health care services either to the private sector or to autonomized public providers. Advocates of the contracting of primary health care services claim that it will improve service delivery by stimulating competition among providers and by providing economic incentives for improved performance. Unfortunately, there is a paucity of evaluation research that has investigated whether contracting-out interventions have led to their desired objectives. To encourage more research on the impact of contracting out and to stimulate the discussion on its long-term impacts, this paper presents a conceptual framework and a set of indicators for monitoring and evaluating contracting-out interventions at both the program and system levels. The framework focuses on four types of factors: the attributes of the contracting-out intervention, the external environment, responses of providers and purchasers both within and outside the intervention, and health system performance. The report also includes a literature review of studies that have investigated the impact contracting out has had on program and health system performance, and recommendations regarding the design and implementation of evaluation research studies on this topic. (Author abstract)