In this month's Bulletin

Contracting and health

David Evans introduces this Bulletin theme issue on the subject of contracting and health services with an editorial. Evans proposes that contracting takes numerous forms and cannot be limited to the purchase of services. In another editorial, Christopher C Potter & Jennifer Harries argue that policy-making should not be driven by ideological concerns but informed by practical realities. The authors are commenting on a paper by Sameen Siddiqi et al. showing that when it comes to implementation one limiting factor can be the local reality. Siddiqi et al. discuss the pros and cons of contracting out health services based on the experience of some countries in WHO's Eastern Mediterranean Region.

Interview and news (pp. 844-851)

In this month's interview, David Evans, Director of WHO's Department of Health Systems Financing, argues that if poorly implemented, contracting may harm health systems performance, but if managed well, the benefits can be immense. Theresa Braine reports from Mexico on a host of new innovative schemes, including microcredits, to cushion the poor against the financial risks of getting sick. Paul Garwood reports from Afghanistan and Pakistan on how programmes to encourage women to become health workers are vital to improving health. Carolyne Nakazibwe reports on a Ugandan district that has dramatically reduced the number of womens' deaths due to pregnancy and childbirth.

Community health insurance in Burkina Faso (pp. 852-858)

Community health insurance is a promising health financing option in sub-Saharan Africa, but field experience and observational studies have identified low enrolment rates as a key obstacle to effective expansion. In their study, Manuela De Allegri et al. found out that a number of factors, including ethnicity, education and distance from health facilities, affect whether families enrol in such schemes. They call for action to offset potential barriers to enrolment on individual, household and community levels.

Public-private partnerships for hospitals (pp. 890-896)

Some countries where hospitals are mostly publicly owned have been exploring innovative ways of involving the private sector. These public-private partnerships have attracted considerable international interest. But does this model work? Martin McKee et al. review experiences from countries including Australia, Spain and the United Kingdom. They conclude that, although evidence is limited, four issues have emerged: cost, quality, flexibility, and complexity.

Private providers and TB control (pp. 876-883)

Over the past decade, there has been a rapid increase in the number of initiatives involving private "for-profit" health-care providers in national tuberculosis (TB) control efforts. Knut Lönnroth et al. reviewed 15 such initiatives with respect to contractual arrangements, quality of care and success achieved in tuberculosis TB control. The authors conclude that although private "for-profit" providers can be effective, more analysis is needed of attempts to scale up TB control.

Regulating contracting practices (pp. 897-902)

In recent years, health systems have increasingly made use of contracting practices. Despite promising results, there have also been failures and occasionally harsh criticism of such practices. Abatcha Kadaï et al. discuss the benefits of setting ground rules and regulating contracting practices, as well as the tools that are available to help do this. Three of the authors write from first-hand experience in preparing and implementing national policies on contracting in Chad, Madagascar and Senegal.

Performance-based financing in Rwanda (pp. 884-889)

Concern that traditional centrally planned financing mechanisms in low-income countries have disappointing results has prompted a new approach: performance-based financing. Robert Soeters et al. discuss how this is being tested in a growing number of countries whereby fund holder organizations purchase health services from health providers. The authors report encouraging results from Rwanda as they present the changes that successful performance-based financing can achieve for the district health system.

Public health classic: the social contract (pp. 916-918)

Guy Carrin assesses the relevance of Jean-Jacques Rousseau's work, The Social Contract or Principles of Political Right, published in 1762, in today's context of contracting in the health sector. Carrin argues that The Social Contract does not provide practical advice on specific contracts, but that its principles help in understanding the need for cooperation in the health sector. He gives the example of a country with an uncontrolled development of nongovernmental organizations (NGO) offering health services. Carrin argues that an official social contract would allocate a proper role in the health sector to NGOs.

Contracting: not an end in itself (pp. 910-913)

In this Round Table base paper, Jean Perrot states that contracting is often seen as a form of privatization and a means for the private sector to expand its presence within the health sector in a covert way. He argues that contracting calls for an honest state. If the state is beset by corruption, Perrot writes, contracting will provide a means of rewarding private interests and will not necessarily be in the public's interest. The first discussant, Jacky Mathonnat, agrees that contracting services to private providers may increase the volume and share of health services provided by the private sector. The key is to evaluate whether contracting can help a country to achieve its public health goals. The final discussant, Viroj Tangcharoensathien, argues that contracting cannot strengthen health systems in countries where governments have limited capacity to provide health-care services.