title: Can contracted out health facilities improve access, equity, and quality of maternal and newborn health services? Evidence from Pakistan.
abstract: BACKGROUND
  The case of contracting out government health services to non-governmental organizations (NGOs) has been weak for maternal, newborn, and child health (MNCH) services, with documented gains being mainly in curative services. We present an in-depth assessment of the comparative advantages of contracting out on MNCH access, quality, and equity, using a case study from Pakistan.
  
  
  METHODS
  An end-line, cross-sectional assessment was conducted of government facilities contracted out to a large national NGO and government-managed centres serving as controls, in two remote rural districts of Pakistan. Contracting out was specific for augmenting MNCH services but without contractual performance incentives. A household survey, a health facility survey, and focus group discussions with client and spouses were used for assessment.
  
  
  RESULTS
  Contracted out facilities had a significantly higher utilization as compared to control facilities for antenatal care, delivery, postnatal care, emergency obstetric care, and neonatal illness. Contracted facilities had comparatively better quality of MNCH services but not in all aspects. Better household practices were also seen in the district where contracting involved administrative control over outreach programs. Contracting was also faced with certain drawbacks. Facility utilization was inequitably higher amongst more educated and affluent clients. Contracted out catchments had higher out-of-pocket expenses on MNCH services, driven by steeper transport costs and user charges for additional diagnostics. Contracting out did not influence higher MNCH service coverage rates across the catchment. Physical distances, inadequate transport, and low demand for facility-based care in non-emergency settings were key client-reported barriers.
  
  
  CONCLUSIONS
  Contracting out MNCH services at government health facilities can improve facility utilization and bring some improvement in  quality of services. However, contracting out of health facilities is insufficient to increase service access across the catchment in remote rural contexts and requires accompanying measures for demand enhancement, transportation access, and targeting of the more disadvantaged clientele.
authors.affiliation: Department of Community Health Sciences, Aga Khan University, P.O. Box 3500, Stadium road, Karachi, 74800, Pakistan. shehla.zaidi@aku.edu.|Women and Child Health Division, Aga Khan University, P.O. Box 3500, Stadium road, Karachi, 74800, Pakistan. shehla.zaidi@aku.edu.
authors.forename: Shehla
authors.initials: S
authors.lastname: Zaidi
authors.affiliation: Department of Community Health Sciences, Aga Khan University, P.O. Box 3500, Stadium road, Karachi, 74800, Pakistan. atif.riaz@aku.edu.
authors.forename: Atif
authors.initials: A
authors.lastname: Riaz
authors.affiliation: Department of Community Health Sciences, Aga Khan University, P.O. Box 3500, Stadium road, Karachi, 74800, Pakistan. fauziah.rabbani@aku.edu.
authors.forename: Fauziah
authors.initials: F
authors.lastname: Rabbani
authors.affiliation: Department of Community Health Sciences, Aga Khan University, P.O. Box 3500, Stadium road, Karachi, 74800, Pakistan. iqbal.azam@aku.edu.
authors.forename: Syed Iqbal
authors.initials: SI
authors.lastname: Azam
authors.affiliation: Department of Community Health Sciences, Aga Khan University, P.O. Box 3500, Stadium road, Karachi, 74800, Pakistan. syeda.nidanaim@gmail.com.
authors.forename: Syeda Nida
authors.initials: SN
authors.lastname: Imran
authors.affiliation: Department of Community Health Sciences, Aga Khan University, P.O. Box 3500, Stadium road, Karachi, 74800, Pakistan. nousheen.pradhan@aku.edu.
authors.forename: Nouhseen Akber
authors.initials: NA
authors.lastname: Pradhan
authors.affiliation: Department of Community Health Sciences, Aga Khan University, P.O. Box 3500, Stadium road, Karachi, 74800, Pakistan. gul.nawaz@aku.edu.
authors.forename: Gul Nawaz
authors.initials: GN
authors.lastname: Khan
mesh_terms: D000328:Adult; D003284:Contract Services; D032982:Contracts; D003430:Cross-Sectional Studies; D004522:Educational Status; D005260:Female; D000069576:Health Equity; D005102:Health Expenditures; D006268:Health Facilities / Q000592:standards* / Q000706:statistics & numerical data; D006297:Health Services Accessibility; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D000068101:Maternal-Child Health Services / Q000191:economics / Q000592:standards*; D010154:Pakistan; D011203:Poverty; D011247:Pregnancy; D011787:Quality of Health Care; D019035:Rural Health Services / Q000191:economics / Q000592:standards*; D012424:Rural Population; D012923:Social Class