• Service delivery

Service delivery

This paper, from the London School of Hygiene and Tropical medicine, discusses the benefits and challenges to contracting out health services to NGOs (non-governmental organisations) in fragile states. Fragile states are defined as countries affected by conflict, emerging from conflict, or otherwise lacking the will or capacity to implement pro-poor policies. The paper uses Afghanistan as a case study, where international and national NGOs have become the main providers of basic health care packages since the removal of the Taliban in 2001-2. The paper identifies several advantages of contracting out: the bulk of public health expertise in Afghanistan is already within NGOs, and they are often more flexible than government in their ability to recruit new staff and set up services rapidly.

The paper also discusses possible problems with contracting out health services. In rural areas of Afghanistan there is little competition for health services to encourage providers to maintain efficiency and quality, and monitoring contracts may be difficult. Furthermore, the capacity of NGOs to continue to scale-up and sustain quality services is unclear - NGOs may develop the same weaknesses as government delivery mechanisms if they grow bigger. The authors conclude that contracts with NGOs are probably the only way to get health systems moving quickly in fragile states, however, there are important issues which need to be taken into consideration including NGO capacity and motivation, equity, politics, and the role of government.

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