Creating an Enabling Environment for Contracting Health Services: A Policy Primer

By contracting health or health-related services from both nongovernmental organizations (NGOs) and the private commercial sector, governments can increase health system capacity, efficiency, and accountability, including in the delivery of tuberculosis (TB) services. The US Agency for International Development (USAID)'s Health Systems for Tuberculosis (HS4TB) project conducted a global study that found ample evidence for the importance of government contracting for health. However, guidance is limited on how to establish contracting in the first place, including how to mobilize political will, navigate the legal, policy, and governance environment, and leverage development partner support. To create an enabling environment for contracting health services, seven key actions are necessary. These actions are not meant to be implemented in a specific order, as every country has its unique path to contracting and may have a different starting point. The seven actions are: 1. Identify stakeholders, their incentives, and any perceived risks of contracting. This involves understanding the country context, political economy of contracting, and different audiences that will consider the case for contracting. 2. Develop a clear and compelling rationale for contracting. This requires a succinct and clear explanation of the problem that needs to be solved and how contracting will provide the necessary solution. 3. Mobilize high-level political will for contracting. This involves generating the willingness and commitment of high-level policymakers to move forward with contracting. 4. Navigate the legal, policy, and governance environment. This involves understanding the legal and regulatory framework that governs contracting and ensuring that it is conducive to contracting. 5. Leverage development partner support. This involves working with development partners to access technical assistance, funding, and other forms of support. 6. Develop a contracting strategy. This involves developing a clear and comprehensive plan for contracting, including the scope of services to be contracted, the contracting process, and the monitoring and evaluation framework. 7. Establish a contracting framework. This involves establishing the rules, regulations, and procedures for contracting, including the contracting process, payment mechanisms, and dispute resolution procedures. The Western Cape province of South Africa provides an example of how contracting can be used to improve health service delivery. In this case, regional health officials proactively engaged civil society to better understand their capacity and willingness to provide community-level services and consulted internally within government to understand what functions were not core business and could be more efficiently contracted out. In conclusion, creating an enabling environment for contracting health services requires a comprehensive and multi-faceted approach that involves identifying stakeholders, developing a clear and compelling rationale, mobilizing high-level political will, navigating the legal, policy, and governance environment, leveraging development partner support, developing a contracting strategy, and establishing a contracting framework.