Table 5.

Recommendations derived from study findings

Recommendations on Institutional Factors
Contract Specification	Hire a third-party to conduct evaluation of the intended outcomes
Contract Formality	• Include clear selection criteria • Establish a unit/mechanism to ensure that the criteria are enforced
Payment Mechanism	Install a unified and homogenous payment mechanism at the outset
Recommendations on Contextual Factors
Political Context	• Foster political will for initiating and enforcing contracting out – this is the single most important contextual factor • Ensure that political support and an appropriate legal framework exists • Develop mechanisms to limit inappropriate interference by local government leaders
Geographical Context	Establish a contracting out system that acknowledges, respects and addresses geographical variations and relevant adaptations
Security Context	For a country in a conflict or post-conflict situation: • Ensure that NSPs fully understand the risks of service provision in insecure areas and the difficulties likely to arise • Establish direct and clear communication with all partners and stakeholders on all sides of the conflict
Recommendations on Institutional Factors
Internal Response: Input, output and outcome management	• Explore innovative approaches to recruitment of female health workers to address access issues • Improve pharmaceutical procurement management and monitoring to avoid stock-out and low-quality medicines • Focus on making observable change in the health of communities. Enhance patient satisfaction by monitoring behavior of health workers and managers
Internal Response: Performance monitoring	• Use multiple triangulation methods to assure quality of data • Establish a single department and system responsible for all performance monitoring • Align monitoring and evaluation mechanisms among NSPs, government and donors
External Response: Provider market	• Develop and implement policies that prevent a few large organizations from monopolizing health care delivery • Encourage economies of scale by coordinating multiple contracts to any individual NSP • Identify strategies to engage the for-profit sector in the provision of health services
Overall	• Consider multiple factors when contracting out to NSPs • Recognize that a universal BPHS policy might not be appropriate across the country; province-specific criteria could strengthen implementation