The impact of contracting-out on health system performance: a conceptual framework

Despite the increased popularity of contracting-out of health services in developing countries, its effectiveness on overall health system performance is not yet conclusive. Except for substantial evidence of contracting-out's positive effect on access to health services and some evidence on improved equity in access, there is little evidence of contracting-out's impact on quality and efficiency. Most studies on the subject evaluate specific contracting-out projects against narrowly specified project objectives, not against more broadly defined health system goals. For this reason, conclusions of positive effects pertaining to project level may not hold at system level. This paper presents a conceptual framework that is expected to facilitate comprehensive, rigorous, and standardized evaluation of contracting-out at health system level. Specifically, this framework supports: full and standardized description of contracting-out interventions, study of the determinants of effectiveness, examination of provider and purchaser responses, assessment of the impact of contracting-out on all dimensions of health system performance, and cross-project analyses.