Intended for healthcare professionals

Analysis And Comment Health policy

Contracting out health services in fragile states

BMJ 2006; 332 doi: (Published 23 March 2006) Cite this as: BMJ 2006;332:718
  1. Natasha Palmer, lecturer in health economics and policy (,
  2. Lesley Strong, research fellow1,
  3. Abdul Wali, research associate1,
  4. Egbert Sondorp, senior lecturer in public health and humanitarian aid1
  1. 1 Health Policy Unit, London School of Hygiene and Tropical Medicine, London WC1E 7HT
  1. Correspondence to: N Palmer
  • Accepted 23 January 2006

Non-governmental organisations are contracted to provide most of Afghanistan's health services. What can we learn from their approach and is it sustainable in the longer term?

Many Western health systems contract out healthcare services, including the NHS. Contracts are less common in low income countries, but contracts with non-governmental organisations (NGOs) to deliver health services are increasingly being promoted in so called fragile states—countries affected by conflict, emerging from conflict, or otherwise lacking the will or capacity to implement pro-poor policies.1 Contracts with NGOs are seen as an effective way to expand services quickly. This is important to reach many of the poorest people living in these countries and thus to make progress towards the millennium development goals for health, but many questions about contracting remain unanswered.

Embedded Image

The challenge of outsourcing

Use of contracts

In a pilot project in Cambodia, NGOs were contracted to provide district health services on behalf of the government. An extensive evaluation showed that districts with health services that were contracted out to NGOs delivered care more efficiently and equitably than those that remained under government control.2 These findings have encouraged promotion of the contracting out approach in weaker health systems.3

Many low income countries that are implementing or discussing contracting of health care belong to the group of around 40 countries currently referred to as fragile states—for example, Cambodia, Afghanistan, Pakistan, Southern Sudan, and Democratic Republic of Congo.1 The contracts are usually funded by a donor in response to the need to expand services rapidly and the lack of functioning government infrastructure and workforce to deliver these services. As a result, perhaps paradoxically, the weaker the country's government capacity, the more likely it is that contracting is adopted. A notable example of this phenomenon is Afghanistan.

The Afghan case

After over 20 years of conflict, Afghanistan's health …

View Full Text

Log in

Log in through your institution


* For online subscription