Improvement in Access and Equity for Maternal and Neonatal Health Services

Comparative Advantages of Contracted out versus Non-Contracted our Facilities


  • 8.2% of births taking 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 the health services at primary care level
  • Evaluation of Contracting-out of Rural Health Centers for maternal and neonatal care is being conducted for the first time in Pakistan.


  • To study the comparative effectiveness, if any, of contracted out RHCs versus non contracted out RHCs in:
    • Improvement in quality of care of maternal and neonatal health
    • Improvement in Health service utilization
    • Improvement in equity
  • To quantify the estimates of the cost of providing contracted out services

Project Team: 

Dr Shehla Zaidi, Dr Fauziah Rabbani, Dr Shiraz Shaikh, Dr Peter Hatcher, Gul Nawaz Khan, Dr Nousheen Pardhan, Hassan Fazli, Atif Ali


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

Outcome Measured:

  • Maternal care utilization
  • Newborn care utilization
  • emergency care maternal and newborn care utilization
  • Quality of care index of health facilities
  • Patient satisfaction
  • Median OOP expenditure for range of MNH services
  • Community perception on barriers to utilization
  • Unit cost of provider

Policy and Practice Implication:

  • Evidence for decisions on up-scaling of Contracting Out of Rural Health Centers for MNH services.
  • Monitor reduction in client expenditure as a result of contracting.
  • Assess whether benefits of Contracting Out filter down to the poorest or additional safety nets for the poor are required to accompany contracting.
  • Provide unit costs for implementing a contracted out BemONC and CemONC model.
  • Identify successful design related features of current contracting initiative that can be replicated for other contracting initiatives.