Contracting and performance incentives

Contractual arrangements in health systems

Improving the performance of health systems is an essential objective for any person or institution working in the health sector. Health-system reforms, whether in the developed or the developing countries, have generally entailed institutional reshufflings which have led to multiplication, diversification and occasionally specialization of the actors involved in health, whether in the public, private or voluntary sectors.

The isolation that often characterized traditional health actors has become impossible to sustain. In addition, as new independent or autonomous actors come on stage, it becomes impossible to rely on hierarchical authority. This compels health actors to reconsider their relations. The relationships they develop may be based on consultation; however, there are limits to this moral commitment. It is increasingly common for such relations to be based on contractual arrangements, which formalize agreements between actors, who accept mutually-binding commitments.

The purpose of this site is to enable actors in the field to make effective use of contractual arrangements. This site endeavours to do so by:

- improving knowledge not only of the potential of contracting, but also of its limits and the prerequisites for effective use of it.

- making it possible to share experience from different situations and countries;

- disseminating tools to improve the skills of actors in the field.

However, the multiplication of specific contractual arrangements may have harmful consequences. For example, the juxtaposition of uncoordinated ad hoc contractual arrangements may result in disparities and inequities that are hard to justify. The surge in the number of such contractual arrangements may also make it impossible for the public authorities to regulate and supervise the dynamic, as a result of which they may drift off course in various ways with harmful consequences for the population. This makes it important for ad hoc contractual arrangements to be a part of the health system and to be integrated within a global political strategy. In order clearly to link each contractual arrangement with national health policy, it is important to lay down contractual policies. The different contractual arrangements agreed between actors are the practical expression of a collective and concerted strategy (which may itself be more or less formal (for example a framework agreement or aims-based contract)). It is the responsibility of the State, or more precisely of the Ministry of Health, to develop, implement and evaluate this contractual policy. However, it is impossible for it to perform its stewardship function without the participation of all the actors responsible for its implementation through specific contractual arrangements. Thus firmly encompassed by a contractual policy, the contractual approach represents a strategic means of improving health system performance. What is at stake is not merely a relationship between contracting parties; it is the search for and development of genuine and lasting partnerships.

This site has been developed simultaneously in English and in French. For each of the main domains that appear on the left of the screen, an introduction is offered in English and in French. However, the specific documents and information that make up the contents of these domains are not always available in both languages. It will be up to Internet users to decide whether they are able to make use of the information in the language in which it is available.

We encourage you regularly to consult this site, which will be updated as often as possible. You will find on it new information and new documents. However, the site will offer the broadest and fullest information possible only if you make an active contribution to it. On many points, you are invited to provide us with information: we intend to make the best possible use of it and to help to disseminate information that is not always readily accessible.