Does contracting out lead to improvement in service volumes at primary and secondary health services? Evidence from rural districts of Sindh, Pakistan

Objectives: To determine the improvement in service volumes from baseline, if any, in the contracted out primary and secondary healthcare facilities against key performance indicators, and to explore the perceptions of health managers and experience of patients in this regard. Methods: The mixed-method study was conducted at Aga Khan University, Karachi, from November 2019 to April 2020, and comprised secondary data extracted from the district health information system related to Thatta and Sujawal districts of the Sindh province of Pakistan from July 2016 to June 2019. Apart from data analysis for baseline versus end-line comparison of key performance indicators, the study also comprised of a cross-sectional survey of health facilities, patient exit interviews and in-depth interviews with healthcare managers. Results: The key performance indicators showed improved service volumes compared to the baseline. All services, including general outpatient department (33%), consultancy services (91%) and emergency services (106%) increased in volumes. Facility-based deliveries increased by 37% and antenatal care visits increased by 100% but immunisation volumes declined. Specialist workforce increased by 47%. Healthcare managers perceived delayed/partial budget release as the key determinant of staff retention, availability of drugs, equipment, supplies, water and electricity at health facilities. Lack of control over government-appointed employees coupled with political interference created workforce shortage. Patients were satisfied with service delivery, but unavailability of medicine was the main concern for 64.3%. Conclusion: Contracting out showed improvement in service volumes, but lack of autonomy over budget allocation and utilisation, staff appointment and poor coordination among the stakeholders were key barriers to successful functionality. For patients, non-availability of drugs was the major issue.