Improvement in Access and Equity for Maternal and Neonatal Health Services

Comparative Advantages of Contracted Out vs. Non-Contracted Out Facilities


  • 8.2% births take place in public sector facilities.
  • Innovative ways for health delivery and financing are required to improve access to maternal and neonatal care.
  • Basic Health Units have shown promise in improving health services at primary care levels.
  • Contracting-out of Rural Health Centers (RHCs) for maternal and neonatal care is being evaluated for the first time in Pakistan.


  • To study the comparative effectiveness (if any) of contracted out vs. non-contracted out RHCs on the improvement in:
    • Quality of care for maternal and neonatal health
    • Improvement in health service utilization
    • ​Equity
  • To quantify estimates of the cost of providing contracted out services

Project Team:​​​

The project team comprises of Drs Shehla Zaidi, Fauziah Rabbani, Shiraz Shaikh, Peter Hatcher, Nousheen Pardhan, Mr Gul Nawaz Khan, Mr Hassan Fazli and Mr Atif Ali


  • A cross-sectional survey was carried out for a comparison of intervention (NGO-managed RHCs) and control (government-managed RHCs) in Thatta and Chitral.
  • Health facility Assessment Surveys assessed quality of care parameters at contracted and non-contracted RHCs.
  • Household surveys assessed service utilization, patient expenditure, health seeking behavior, household knowledge and practices, and delivery outcomes.
  • Focus Group discussions assessed in-depth exploration of financial barriers, including reasons for non-usage.
  • Provider cost analysis was used for standardized international checklists for unit cost calculation of facility-based services.

Outcomes Measured:

  • Maternal care utilization
  • Newborn care utilization
  • Emergency care maternal and newborn care utilization
  • Quality of care index of health facilities
  • Patient satisfaction
  • Median out of pocket expenditure for range of Maternal and Neonatal Health (MNH) services
  • Community perception on barriers to utilization
  • Unit cost of provider

Policy and Practice Implication:

  • Provide evidence for decisions on up-scaling of contracting out of RHCs for MNH services.
  • Monitor reduction in client expenditure as a result of contracting.
  • Assess whether benefits of contracting out filter down to the poorest and if additional safety nets are required for the poor to accompany contracting.
  • Provide unit costs for implementing a contracted out Basic Emergency Obstetric and Neonatal Care, and Comprehensive Emergency Obstetric and Neonatal Care model.
  • Identify successful design related features of current contracting initiative that can be replicated for other contracting initiatives.