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Non-ProfitOrganizations (NPOs) are increasingly being promoted as preferred providers toreplace weak government services in Low and Middle Income Countries (LMIC) butresults on ground show mixed performance. The variation in national policycontexts is one explanation for uneven NPO performance but has beenunder-explored in reproductive health literature. This paper collates gray andpublished literature providing an overview of how policy context impacts on NPOperformance in reproductive health. Socio-political context, state policies anddonor dependency indirectly influence NPO working by shaping operational space,autonomy, networking and mandate. These influences need to be recognized andmodified so as to enable NPOs to better achieve their attributedcharacteristics of client responsive and quality services aimed at marginalizedpopulations. Policy measures are needed to build better policy space and regulatoryframeworks for NPOs, state-NPO collaboration forums, and greater reliance oninternal funding.

Over the past few years, the issue of what is meant by "good
governance" has generated increasing attention and debate both at the
national and international level [Streeten (1997)]. The role of state
and how that role is to be exercised is appearing high on the agenda of
politicians, policy-makers and academicians in the developing world.
Governance has been defined by the World Bank as "the manner in which
power is exercised in the management of the country's economic and
social resources" [World Bank (1994)]. The somewhat narrow scope of this
definition has been broadened in recent years to "the sum of the many
ways individuals and institutions, public and private, manage their
common affairs" [Commission on Global Governance (995)] The Human
Development Report [UNDP (1999)] goes beyond these definitions and gives
a much more radical notion of good governance, underpinning the
importance of peoples' participation in shaping their own governance and
development. This type of governance has been labeled as "humane
governance".

Background: A number of developing countries have contracted out public health facilities to the Non-Government Organizations (NGOs) in order to improve service utilization. However, there is a paucity of in-depth qualitative information on barriers to access services as a result of contracting from service users' perspective. The objective of this study was to explore perceived barriers to utilizing Maternal and Neonatal Health (MNH) services, in health facilities contracted out by government to NGO for service provision versus in those which are managed by government (non-contracted).

Background: A number of developing countries have contracted out public health facilities to the Non-Government Organizations (NGOs) in order to improve service utilization. However, there is a paucity of in-depth qualitative information on barriers to access services as a result of contracting from service users' perspective. The objective of this study was to explore perceived barriers to utilizing Maternal and Neonatal Health (MNH) services, in health facilities contracted out by government to NGO for service provision versus in those which are managed by government (non-contracted). Methods: A community-based qualitative exploratory study was conducted between April to September 2012 at two contracted-out and four matched non-contracted primary healthcare facilities in Thatta and Chitral, rural districts of Pakistan. Using semi-structured guide, the data were collected through thirty-six Focus Group Discussions (FGDs) conducted with mothers and their spouses in the catchment areas of selected facilities. Thematic analysis was performed using NVivo version 10.0 in which themes and sub-themes emerged. Results: Key barriers reported in contracted sites included physical distance, user charges and familial influences. Whereas, poor functionality of health centres was the main barrier for non-contracted sites with other issues being comparatively less salient. Decision-making patterns for participants of both catchments were largely similar. Spouses and mother-in-laws particularly influenced the decision to utilize health facilities. Conclusion: Contracting out of health facility reduces supply side barriers to MNH services for the community served but distance, user charges and low awareness remain significant barriers. Contracting needs to be accompanied by measures for transportation in remote settings, oversight on user fee charges by contractor, and strong community-based behavior change strategies.

AbstractContracting out of health services increasingly involves a new role for governments as purchasers of services. To date, emphasis has been on contractual outcomes and the contracting process, which may benefit from improvements in developing countries, has been understudied. This article uses evidence from wide scale NGO contracting in Pakistan and examines the performance of government purchasers in managing the contracting process; draws comparisons with NGO managed contracting; and identifies purchaser skills needed for contracting NGOs. We found that the contracting process is complex and government purchasers struggled to manage the contracting process despite the provision of well‐designed contracts and guidelines. Weaknesses were seen in three areas: (i) poor capacity for managing tendering; (ii) weak public sector governance resulting in slow processes, low interest and rent seeking pressures; and (iii) mistrust between government and the NGO sector. In comparison parallel contracting ventures managed by large NGOs generally resulted in faster implementation, closer contractual relationships, drew wider participation of NGOs and often provided technical support. Our findings do not dilute the importance of government in contracting but front the case for an independent purchasing agency, for example an experienced NGO, to manage public sector contracts for community based services with the government role instead being one of larger oversight. Copyright © 2011 John Wiley & Sons, Ltd.

BACKGROUND: Workforce motivation and retention is important for the functionality and quality of service delivery in health systems of developing countries. Despite huge primary healthcare (PHC) infrastructure, Pakistan's health indicators are not impressive; mainly because of under-utilization of facilities and low patient satisfaction. One of the major underlying issues is staff absenteeism. The study aimed to identify factors affecting retention and motivation of doctors working in PHC facilities of Pakistan. METHODS: An exploratory study was conducted in a rural district in Khyber Puktunkhwa (KP) province, in Pakistan. A conceptual framework was developed comprising of three organizational, individual, and external environmental factors. Qualitative research methods comprising of semi-structured interviews with doctors working in basic health units (BHUs) and in-depth interviews with district and provincial government health managers were used. Document review of postings, rules of business and policy actions was also conducted. Triangulation of findings was carried out to arrive at the final synthesis. RESULTS: Inadequate remuneration, unreasonable facilities at residence, poor work environment, political interference, inadequate supplies and medical facilities contributed to lack of motivation among both male and female doctors. The physicians accepted government jobs in BHUs with a belief that these jobs were more secure, with convenient working hours. Male physicians seemed to be more motivated because they faced less challenges than their female counterparts in BHUs especially during relocations. Overall, the organizational factors emerged as the most significant whereby human resource policy, career growth structure, performance appraisal and monetary benefits played an important role. Gender and marital status of female doctors was regarded as most important individual factor affecting retention and motivation of female doctors in BHUs. CONCLUSION: Inadequate remuneration, unreasonable facilities at residence, poor work environment, political interference, inadequate supplies, and medical facilities contributed to lack of motivation in physicians in our study. Our study advocates that by addressing the retention and motivation challenges, service delivery can be made more responsive to the patients and communities in Pakistan and other similar settings.

Background There is dearth of evidence on provider cost of contracted out services particularly for Maternal and Newborn Health (MNH). The evidence base is weak for policy makers to estimate resources required for scaling up contracting. This paper ascertains provider unit costs and expenditure distribution at contracted out government primary health centers to inform the development of optimal resource envelopes for contracting out MNH services. Methods This is a case study of provider costs of MNH services at two government Rural Health Centers (RHCs) contracted out to a non-governmental organization in Pakistan. It reports on four selected Basic Emergency Obstetrical and Newborn Care (BEmONC) services provided in one RHC and six Comprehensive Emergency Obstetrical and Newborn Care (CEmONC) services in the other. Data were collected using staff interviews and record review to compile resource inputs and service volumes, and analyzed using the CORE Plus tool. Unit costs are based on actual costs of MNH services and are calculated for actual volumes in 2011 and for volumes projected to meet need with optimal resource inputs. Results The unit costs per service for actual 2011 volumes at the BEmONC RHC were antenatal care (ANC) visit USD$ 18.78, normal delivery US$ 84.61, newborn care US$ 16.86 and a postnatal care (PNC) visit US$ 13.86; and at the CEmONC RHC were ANC visit US$ 45.50, Normal Delivery US$ 148.43, assisted delivery US$ 167.43, C-section US$ 183.34, Newborn Care US$ 41.07, and PNC visit US$ 27.34. The unit costs for the projected volumes needed were lower due to optimal utilization of resources. The percentage distribution of expenditures at both RHCs was largest for salaries of technical staff, followed by salaries of administrative staff, and then operating costs, medicines, medical and diagnostic supplies. Conclusions The unit costs of MNH services at the two contracted out government rural facilities remain higher than is optimal, primarily due to underutilization. Provider cost analysis using standard treatment guideline (STG) based service costing frameworks should be applied across a number of health facilities to calculate the cost of services and guide development of evidence based resource envelopes and performance based contracting.

Abstract Background There is dearth of evidence on provider cost of contracted out services particularly for Maternal and Newborn Health (MNH). The evidence base is weak for policy makers to estimate resources required for scaling up contracting. This paper ascertains provider unit costs and expenditure distribution at contracted out government primary health centers to inform the development of optimal resource envelopes for contracting out MNH services. Methods This is a case study of provider costs of MNH services at two government Rural Health Centers (RHCs) contracted out to a non-governmental organization in Pakistan. It reports on four selected Basic Emergency Obstetrical and Newborn Care (BEmONC) services provided in one RHC and six Comprehensive Emergency Obstetrical and Newborn Care (CEmONC) services in the other. Data were collected using staff interviews and record review to compile resource inputs and service volumes, and analyzed using the CORE Plus tool. Unit costs are based on actual costs of MNH services and are calculated for actual volumes in 2011 and for volumes projected to meet need with optimal resource inputs. Results The unit costs per service for actual 2011 volumes at the BEmONC RHC were antenatal care (ANC) visit USD$ 18.78, normal delivery US$ 84.61, newborn care US$ 16.86 and a postnatal care (PNC) visit US$ 13.86; and at the CEmONC RHC were ANC visit US$ 45.50, Normal Delivery US$ 148.43, assisted delivery US$ 167.43, C-section US$ 183.34, Newborn Care US$ 41.07, and PNC visit US$ 27.34. The unit costs for the projected volumes needed were lower due to optimal utilization of resources. The percentage distribution of expenditures at both RHCs was largest for salaries of technical staff, followed by salaries of administrative staff, and then operating costs, medicines, medical and diagnostic supplies. Conclusions The unit costs of MNH services at the two contracted out government rural facilities remain higher than is optimal, primarily due to underutilization. Provider cost analysis using standard treatment guideline (STG) based service costing frameworks should be applied across a number of health facilities to calculate the cost of services and guide development of evidence based resource envelopes and performance based contracting.

Contracting non-governmental organizations (NGOs) for health service provision is gaining increasing importance in low- and middle-income countries. However, the role of the wider context in influencing the effectiveness of contracting is not well studied and is of relevance given that contracting has produced mixed results so far. This paper applies a policy analysis approach to examine the influence of policy and political factors on contracting origin, design and implementation. Evidence is drawn from a country case study of Pakistan involving extensive NGO contracting for human immunodeficiency virus (HIV) prevention services supported by international donor agencies. A multilevel study was conducted using 84 in-depth interviews, 22 semi-structured interviews, document review and direct observation to examine the national policy design, provincial management of contracting and local contract implementation. There were three main findings. First, contracting origin and implementation was an inherently political process affected by the wider policy context. Although in Pakistan a combination of situational events successfully managed to introduce extensive and sophisticated contracting, it ran into difficulties during implementation due to ownership and capacity issues within government. Second, wide-scale contracting was mis-matched with the capacity of local NGOs, which resulted in sub-optimal contract implementation challenging the reliance on market simulation through contracting. Third, we found that contracting can have unintended knock-on effects on both providers and purchasers. As a result of public sector contracts, NGOs became more distanced from their grounded attributes. Effects on government purchasers were more unpredictable, with greater identification with contracting in supportive governance contexts and further distancing in unsupportive contexts. A careful approach is needed in government contracting of NGOs, taking into account acceptance of contracting NGOs, local NGO capacities and potential distancing of NGOs from their traditional attributes under contracts. Political factors and knock-on effects are likely to be heightened in the sudden and aggressive use of contracting in unprepared settings.

BACKGROUND: The exercise of power is central to understanding global health and its policy and governance processes, including how food systems operate and shape population nutrition. However, the issue of power in food systems has been little explored empirically or theoretically to date. In this article, we review previous work on understanding power in addressing malnutrition as part of food systems that could be used in taking this issue further in future food systems research. In particular, we examine why acknowledging power is vital in addressing food systems for better nutritional outcomes, approaches to assessing power in empirical research, and ways of addressing issues of power as they relate to food systems. METHODS: We undertook a narrative review and synthesis. This involved identifying relevant articles from searches of PubMed and Scopus, and examining the reference lists of included studies. We considered for inclusion literature written in English and related to countries of all income levels. Data from included articles were summarized under several themes. RESULTS: We highlight the importance of acknowledging power as a critical issue in food systems, present approaches that can be taken by food-systems researchers and practitioners in assessing power to understand the ways in which power works in food systems and wider society, and present material relating to addressing power and developing strategies to improve food systems for better nutrition, health and well-being. CONCLUSION: A range of research approaches exist that can inform examination of power in food systems, and support the development of strategies to improve food systems for better nutrition, health and well-being. However, there is considerable scope for further work in this under-researched area. We hope that this review will support the necessary research to understand further power in food systems and drive the much-needed transformative change.