Foreword

Contracting between faith-based and public health sector in Sub-Saharan Africa: An ongoing crisis? The case of Cameroon, Tanzania, Chad and Uganda

“Contracting NGOs for Health” – This has been more than a slogan, but a strategic priority of the Medicus Mundi International Network (MMI) over the last years: the promotion of the integration of private not for profit health institutions in national health systems. We have been strongly and successfully advocating the development of contractual arrangements between private not for profit facilities and Health Ministries. In order to promote this approach, Medicus Mundi International organized, in 1999, a meeting on “Contracting NGOs for Health” as a side event to the 52nd World Health Assembly. Finally, in May 2003, the World Health Assembly adopted a resolution on “The role of contractual arrangements in improving health systems’ performance” (WHA 56.25).

But when one promotes a technical approach to address a public health issue, one also likes to be ensured whether it works. Therefore we mandated the Institute of Tropical Medicine Antwerp (ITM) to conduct a study on the experiences with contracting in Sub-Saharan Africa, focusing on faith-based institutions. Now we know the results, we publish them in this report - and we are rather concerned with what we learnt. 

Contracting between private not for profit institutions and public health authorities in Africa faces a crisis. This is the main conclusion of the study conducted by the ITM researchers in Cameroon, Chad, Tanzania and Uganda. In spite of the wide variety of contexts and experiences, the different case studies show that contracting between the State and the faith-based district health sector has run into great difficulties. 

To make matters worse, there is no general awareness of the crisis, certainly not among the public sector actors. 

Unless correcting measures are taken, this almost hidden crisis risks to jeopardize in the medium-term the important contribution which the faith-based health institutions – many of them supported by members of the Medicus Mundi International Network – make to the provision of healthcare in Africa.

The dysfunctioning of contractual arrangements is explained in the study by a number of factors: the lack of information and inadequate preparation of the actors, the almost systematic absence of support mechanisms adapted to the reality and needs of the field, the lack of monitoring and evaluation systems for the contracting experiences and the fact that a management culture, that would integrate the lessons of the past in matters of contracting in current policies and tools, is lacking. Last but not least, the State does not always respect its commitments.

A rather unexpected issue is provided by the contracts between the US “Presidential Emergency Plan for Aids Relief“(PEPFAR) and the faith-based hospitals in Uganda. Although the study does not deny the danger of a selective and vertical approach in healthcare provision and the risk of bypassing public and faith-based central government structures in contracting, these contracts obviously offer interesting avenues for improving “classic” contracting relations between the public and faith-based sector. Indeed, these contracts can be considered as benchmarks for contracts characterized by a great extent of specificity and predictability, by the quality and sustainability of the monitoring, steering and evaluation mechanisms, and, last but not least, by the donor’s respect for commitments. The management of the district faith-based hospitals has explicitly voiced its appreciation of these positive aspects.

Now that we know the study’s results and its recommendations – which are shared by ourselves – what are we going to do with them?

Let us be clear: the situations investigated in this study do not question the validity of a support policy to contracting. We believe that contracting remains a most valid option. The study rather emphasizes that the strengthening of such a policy is urgent. The study clearly showed that the different field actors field actors involved in the contracting processes feel the necessity for steady, close and personalized support, adapted to the local context. It is most unlikely that this observation would not hold for other than the countries and cases studied.

The Medicus Mundi International Network intends to play a role here. The experience of our Network’s members - in terms of their support to contracting and knowledge of the faith-based health sector – is an asset to exploit. 

We will start with sharing the results of this study in each of the surveyed countries (Cameroon, Tanzania, Chad, Uganda) aiming to induce relevant and sustainable changes in the field. This dissemination process will take place within the next months and involve actors from all sectors and levels: the public and religious health authorities at central and peripheral level, the care providers and the community representatives.

Regarding the organization of these local restitutions, we decided to leave the lead to the organisations in the countries themselves: their choices and preferences will determine the format as well as Medicus Mundi International’s degree of involvement, taking the Network’s and its members’ capacities into account.

As MMI commissioned the study, we also have a role to play in the further dissemination of its results in order to contribute to the development of a general awareness of the situation and of the urgency of the need for change, and this not only in the countries and cases concerned, but also with international cooperation actors.

We will encourage our member organisations to implement the lessons learnt. As operational actors very much in touch with the field, these organisations are likely to play a significant support role, in particular with the faith-based bodies and facilities involved in the contracting process.

We will also disseminate these lessons to international organizations (such as the WHO) able to convey the message to the Ministries of Health in the field. Finally, the donors’ attention should also be drawn to the problems identified in the study. Our launch event in Geneva, in May 2009, is a first step in that direction. 

The survival of the faith-based health sector depends in part on the professionalization of its management: only then will it be able to face and respond to the changes taking place in the health sector. The complex developments of the African health policies and the need of facilities, already short of resources, to make themselves credible in the eyes of ever more demanding partners, require more elaborate technical skills. Far from being incompatible with an idealistic health mission, this professionalization is an obligatory requirement. In the end this professionalization will take place through the complete delegation by the Church of its management responsibilities and by leaving the definition of the sector strategy to qualified and competent technical managers.

We also will have to pay attention to new developments in the field of contracting. The increasing influence of performance contracts (of which the PEPFAR contracts are only one but maybe a rather extreme example) seems an irreversible trend, which will in the short term become much more widespread. It is therefore important to be aware of the lessons which may be drawn from the positive effects of these arrangements, without blindly ignoring their potentially negative aspects. In any case, a status quo,  only taking into account the traditional contracting experiences, would be even more dangerous as their analysis shows that there are many shortcomings in their functioning: guiding the field actors efficiently implies being fully in touch with the reality of the current developments.

So let us look back – and then go ahead.

Guus Eskens, President
Medicus Mundi International Network
The Hague/Basel/Geneva, May 2009