In 1999, Cambodia contracted out management of government health services to NGOs in five districts that had been randomly made eligible for contracting. The contracts specified targets for maternal and child health service improvement. Targeted outcomes improved by about 0.5 standard deviations relative to comparison districts. Changes in non-targeted outcomes were small. The program increased the availability of 24-hour service, reduced provider absence, and increased supervisory visits. There is some evidence it improved health. The program involved increased public health funding, but led to roughly offsetting reductions in private expenditure as residents in treated districts switched from unlicensed drug sellers and traditional healers to government clinics.
Overall Bangladesh is making good progress toward the Millennium Development Goals, faster than any other country in South Asia. Especially in regard to the first goal, "Halve, between 1990 and 2015, the proportion of people who suffer from hunger," the country may well be successful. However, although the prevalence of malnutrition among children under five years of age is decreasing, it is still very high-about 40 percent of children under five are stunted and 12 percent are wasted, according to the 2004 Bangladesh Demographic and Health Survey. It is therefore extremely important that the country's commitment and the momentum for improving nutrition be sustained. The Bangladesh Integrated Nutrition Programme (BINP) (see report no. 13193) represented the first large-scale government intervention in nutrition. The program began in 1995; it was followed in 2002 by the National Nutrition Programme and is being followed up now with a sector wide health approach. There has been considerable debate in the press and the scientific community and among development partners about the impact of BINP. This study tries to lay that debate to rest by critically reviewing the various evaluations and trying to explain the variation appearing in the results that were obtained.
Bangladesh has experienced rapid fertility decline and reductions in under-five mortality over the last three decades. This impact study unravels the various factors behind these changes. Economic growth has been important, but so have major public sector interventions, notably reproductive health and immunization, supported by external assistance from the World Bank and other agencies. By contrast, nutrition began to improve only in the 1990s and remains high. The Bangladesh Integrated Nutrition Program (BINP) has played a small role, if any, in this progress, which is mainly attributable to higher agricultural productivity.
Despite the emphasis placed during the last two decades on public delivery of comprehensive and equitable primary care (PC) to developing country populations, coverage remains far from universal and the quality often poor. Users frequently patronise private providers, ranging from informal drug sellers to trained professionals. Interest is increasing internationally in the potential for making better use of private providers, including contractual approaches. The research aim was to examine the performance of different models of PC provision, in order to identify their strengths and weaknesses from the perspective of a government wishing to develop an overall strategy for improving PC provision. Models evaluated were: (a) South African general practitioners (district surgeons) providing services under public contracts; (b) clinics provided in Lesotho under a sub-contract between a construction company and a South African health care company; (c) GP services provided through an Independent Practitioner Association to low income insured workers and families; (d) a private clinic chain serving low income insured and uninsured workers and their families; and (e) for comparative purposes, South African public clinics. Performance was analysed in terms of provider cost and quality (of infrastructure, treatment practices, acceptability to patients and communities), allowing for differences in services and case-mix. The diversity of the arrangements made direct comparisons difficult, however, clear differences were identified between the models and conclusions drawn on their relative performance and the influences upon performance. The study findings demonstrate that contextual features strongly influence provider performance, and that a crude public/private comparison is not helpful. Key issues in contract design likely to influence performance are highlighted. Finally, the study argues that there is a need before contracting out service provision to consider how the performance of private providers might change when the context within which they are working changes with the introduction of a contract.
OBJECTIVE: To examine the effects on immunization equity of the large-scale contracting of primary health-care services in rural areas of Cambodia.
METHODS: Data were obtained pre-intervention and post-intervention from a large-scale quasi-experiment in contracting with nongovernmental organizations to provide primary health care in nine rural districts of Cambodia between 1999 and mid-2001. Coverage targets and equity targets for all primary health-care services, including immunization of children, were explicitly included in the contracts awarded in five of nine rural districts which together have a population of over 1.25 million people. The remaining four districts used the traditional government model for providing services and were given identical targets.
FINDINGS: After the 2.5 years of the trial, bivariate and multivariate analyses of the results suggested that although there was a substantial increase in the proportion of children who were fully immunized in all districts, children in the poorest 50% of households in the districts served by contractors were more likely to be fully immunized than poor children living in similar circumstances in districts using the government's model, all other things being equal.
CONCLUSION: The contracting approach described in this paper suggests a means of moving towards a more equitable distribution of immunization services in developing countries.
