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The Implications of Contracting out Health Care Provision to Private Not-For View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Queen Margaret University eResearch THE IMPLICATIO1S OF CO1TRACTI1G OUT HEALTH CARE PROVISIO1 TO PRIVATE 1OT-FOR- PROFIT HEALTH CARE PROVIDERS: THE CASE OF SERVICE LEVEL AGREEME1TS I1 MALAWI ELVIS SITITHA1A MPAKATI GAMA Thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy in Health economics QUEE1 MARGARET U1IVERSITY 2013 1 Declaration I have read and understood the school’s definition of plagiarism and cheating given in the research degrees handbook. I hereby declare that this thesis is my own work and that, to the best of my knowledge, it contains no previously published or written by another person nor material which to a substantial extent has been accepted for the award of any other degree of the university or other institute of higher learning, except where due acknowledgment has been made in the text. Signed.........Elvis Mpakati Gama.......................Date......18 December 2013.......................... Elvis Sitithana Mpakati Gama 2 “The primary determinants of disease are mainly economic and social, and therefore its remedies must also be economic and social. Medicine and politics cannot and should not be kept apart” (Geoffrey Rose- The strategy of preventive medicine, Oxford, Oxford University Press, 1992, page 129) 3 ABSTRACT Background: The Malawi government in 2002 embarked on an innovative health care financing mechanism called Service Level Agreement (SLA) with Christian Health Association of Malawi (CHAM) institutions that are located in areas where people with low incomes reside. The rationale of SLA was to increase access, equity and quality of health care services as well as to reduce the financial burden of health expenditure faced by poor and rural communities. This thesis evaluates the implications of SLA contracting out mechanism on access, utilization and financial risk protection, and determines factors that might have affected the performance of SLAs in relation to their objectives. Methods: The study adopted a triangulation approach using qualitative and quantitative methods and case studies to investigate the implications of contracting out in Malawi. Data sources included documentary review, in-depth, semi-structured interviews and questionnaire survey. The principal agent model guided the conceptual framework of the study. Results: We find positive impact on overall access to health care services, qualitative evidence of perverse incentives for both parties to the contracting out programme and that some intended beneficiaries are still exposed to financial risk. Conclusion: An important conclusion of this study is that contracting out has succeeded in improving access to maternal and child health care as well as provided financial risk protection associated with out of pocket expenditure. However, despite this improvement in access and reduction in financial risk, we observe little evidence of meaningful improvement in quality and efficiency, perhaps because SLA focused on demand side factors, and paid little attention to supply factors: resources, materials and infrastructure continued to be inadequate. 4 Acknowledgements My first and special thanks go to Professor Barbara Isobel McPake and David Newlands, for their kindness, commitment advice and dedication in supervising me throughout my research project. Their continuous awareness and encouragement over the whole period of my research was crucial to the completion of this thesis. Their emphasis on the evidence and authority of the informants throughout the analysis and write up stages of the research advanced my analytical and critical skills. My appreciation also goes to Dr Maureen Chirwa for her wonderful supervision during the field work. She was committed to my research by helping me through the jungle of ethical approval process, introducing me to policy makers in the Malawi health sector and providing me with some resources required for fieldwork. I am indebted to friend Dr Jimmy-Gama of the College of Medicine in Malawi for introducing me to various Ministry of Health officials and his assistance with transport during the data collection stage of the research as well as his advice on analysing qualitative data. My thanks also go to staff and fellow students at the institute for international health and development –IIHD for the enduring support and encouragement along the path. No less gratitude’s goes to Kyoko Jardine and Janice, administrative staff at IIHD. I am also very grateful to Effie, my wife, friend and fellow scholar for providing ubiquitous support and without whom practically, emotionally and spiritually this thesis would never have been completed, and my daughter Alinafe and son Ngwazi for their endurance during the time we were living on low incomes and spending less time with them. I appreciate it was hard for you guys... 5 Acronyms and abbreviations ACB Ant corruption bureau AFDB African development Bank AIDS Acquired immune deficiency syndrome ART Anti-Retroviral therapy ANC Ante Natal care ARV Antiretroviral drug CABS Common approach to budget support CAS Country assistance strategy CHAM Christian hospital Association of Malawi CPI consumer price index DFID Department for international development DHO District health officer DHMT District health Management team DIP District implementation plan DP Development partner EHRP Emergency Human resource program EHP Essential health package FGD Focus Group Discussion GDP Gross domestic product GIZ Deutsche Gesellschaft Fur international zusammenarbeit GoM Government of Malawi GTZ Gesellschaft Fur Technische Zusammenarbeit HIV Human immune virus HMIS Health Management Information systems HSSP Health sector strategic plan HRH Human resource for health LGA Local government act MAM Muslim association of Malawi MDG Millennium development goals 6 MDHS Malawi Demographic health survey MDGS Malawi development and growth strategy MPRS Malawi poverty reduction strategy MoH Ministry of Health MOU Memorandum of understanding NAO National Audit Office NCA Norwegian church council NGO Non governmental organisation NHA National health accounts NORAD Norwegian agency for development cooperation ODA Official development assistance OECD Organisation for economic co-operation and development PHAM Private Hospital association of Malawi POW Program of works SLA Service level agreement SWAp Sector wide approach USAID United states agency for international development TCE Transaction cost economics WHO World health organisation VHF Vertical health funds VDRL Venereal disease research laboratory ZHA Zone health administration 7 Table of contents Declaration Abstract Acknowledgments Dedication Acronyms and abbreviations List of Figures List of Tables List of appendixes Table of Contents Declaration....................................................................................................................................... 2 Acknowledgements ......................................................................................................................... 5 Acronyms and abbreviations ........................................................................................................... 6 Chapter 1: Background to the study .............................................................................................. 14 1.0 Introduction ............................................................................................................................. 14 1.2 Rationale for the Study ............................................................................................................ 15 1.3 Significance of the study ......................................................................................................... 16 1.4 Structure of the thesis .............................................................................................................. 16 Chapter 2: Developments in the health sector in Malawi .............................................................. 19 2.0 Introduction ............................................................................................................................. 19 2.1 Background information .......................................................................................................... 19 2.2 Health care financing ............................................................................................................... 20 2.3 Delivery of health care ............................................................................................................ 22 2.4 Private sector involvement in healthcare provision ................................................................. 24 2.5 Health sector policies............................................................................................................... 26 2.5.1 Sector Wide Approach - SWAp ................................................................................... 26 2.5.2 Programme of works (POW) ........................................................................................ 28 2.5.3 Essential health package (EHP) .................................................................................... 29 2.5.4 Emergency Human Resource Programme (EHRP) ...................................................... 30 2.5.5 Decentralisation process ............................................................................................... 32 2.6 CHAM development ..............................................................................................................
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