Department of Community Health Sciences and Women & Child Health Division, Aga Khan University, Stadium Road, Karachi, Pakistan.
Health Policy Plan. 2012 Oct;27(7):570-81. doi: 10.1093/heapol/czr081. Epub 2012 Jan 27.
Contracting non-governmental organizations (NGOs) for health service provision is gaining increasing importance in low- and middle-income countries. However, the role of the wider context in influencing the effectiveness of contracting is not well studied and is of relevance given that contracting has produced mixed results so far. This paper applies a policy analysis approach to examine the influence of policy and political factors on contracting origin, design and implementation. Evidence is drawn from a country case study of Pakistan involving extensive NGO contracting for human immunodeficiency virus (HIV) prevention services supported by international donor agencies. A multilevel study was conducted using 84 in-depth interviews, 22 semi-structured interviews, document review and direct observation to examine the national policy design, provincial management of contracting and local contract implementation. There were three main findings. First, contracting origin and implementation was an inherently political process affected by the wider policy context. Although in Pakistan a combination of situational events successfully managed to introduce extensive and sophisticated contracting, it ran into difficulties during implementation due to ownership and capacity issues within government. Second, wide-scale contracting was mis-matched with the capacity of local NGOs, which resulted in sub-optimal contract implementation challenging the reliance on market simulation through contracting. Third, we found that contracting can have unintended knock-on effects on both providers and purchasers. As a result of public sector contracts, NGOs became more distanced from their grounded attributes. Effects on government purchasers were more unpredictable, with greater identification with contracting in supportive governance contexts and further distancing in unsupportive contexts. A careful approach is needed in government contracting of NGOs, taking into account acceptance of contracting NGOs, local NGO capacities and potential distancing of NGOs from their traditional attributes under contracts. Political factors and knock-on effects are likely to be heightened in the sudden and aggressive use of contracting in unprepared settings.
在中低收入国家，委托非政府组织（NGO）提供卫生服务变得越来越重要。然而，广泛的背景因素对委托的有效性的影响尚未得到充分研究，鉴于委托至今为止产生了好坏参半的结果，这一点很重要。本文应用政策分析方法来考察政策和政治因素对委托起源、设计和实施的影响。该证据来自于巴基斯坦的一个国家案例研究，该研究涉及在国际捐助机构的支持下，广泛委托 NGO 提供艾滋病毒（HIV）预防服务。采用多层次研究方法，对国家政策设计、省级合同管理和地方合同实施进行了 84 次深入访谈、22 次半结构化访谈、文件审查和直接观察。主要有三个发现。首先，委托的起源和实施是一个固有的政治过程，受更广泛的政策背景的影响。尽管在巴基斯坦，一系列情况事件成功地引入了广泛而复杂的委托，但由于政府内部的所有权和能力问题，在实施过程中遇到了困难。其次，大规模的委托与当地 NGO 的能力不匹配，导致合同实施不理想，从而对通过委托模拟市场的做法提出了挑战。第三，我们发现委托可能对供应商和采购商都产生意想不到的连锁反应。由于公共部门合同，非政府组织与其基层属性的联系变得更加疏远。政府采购商的影响则更加不可预测，在支持性治理环境中，他们更加认同委托，而在不支持的环境中，则更加疏远。在政府委托 NGO 时需要谨慎，要考虑到对委托 NGO 的接受程度、当地 NGO 的能力以及合同下 NGO 与其传统属性可能产生的疏远。在准备不足的情况下，突然和激进地使用委托可能会加剧政治因素和连锁反应。
