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Table 5 Recommendations derived from study findings

From: Factors influencing performance by contracted non-state providers implementing a basic package of health services in Afghanistan

Recommendations on Institutional Factors
 Contract Specification Hire a third-party to conduct evaluation of the intended outcomes
 Contract Formality • Include clear selection criteria
• Establish a unit/mechanism to ensure that the criteria are enforced
 Payment Mechanism Install a unified and homogenous payment mechanism at the outset
Recommendations on Contextual Factors
 Political Context • Foster political will for initiating and enforcing contracting out – this is the single most important contextual factor
• Ensure that political support and an appropriate legal framework exists
• Develop mechanisms to limit inappropriate interference by local government leaders
 Geographical Context Establish a contracting out system that acknowledges, respects and addresses geographical variations and relevant adaptations
 Security Context For a country in a conflict or post-conflict situation:
• Ensure that NSPs fully understand the risks of service provision in insecure areas and the difficulties likely to arise
• Establish direct and clear communication with all partners and stakeholders on all sides of the conflict
Recommendations on Institutional Factors
 Internal Response: Input, output and outcome management • Explore innovative approaches to recruitment of female health workers to address access issues
• Improve pharmaceutical procurement management and monitoring to avoid stock-out and low-quality medicines
• Focus on making observable change in the health of communities. Enhance patient satisfaction by monitoring behavior of health workers and managers
 Internal Response: Performance monitoring • Use multiple triangulation methods to assure quality of data
• Establish a single department and system responsible for all performance monitoring
• Align monitoring and evaluation mechanisms among NSPs, government and donors
 External Response: Provider market • Develop and implement policies that prevent a few large organizations from monopolizing health care delivery
• Encourage economies of scale by coordinating multiple contracts to any individual NSP
• Identify strategies to engage the for-profit sector in the provision of health services
 Overall • Consider multiple factors when contracting out to NSPs
• Recognize that a universal BPHS policy might not be appropriate across the country; province-specific criteria could strengthen implementation