The difficult relationship between faith-based care organisations and the public sector in sub-Saharan Africa. The case of contracting experiences in Cameroon, Tanzania, Chad and Uganda’

By Delphine Boulenger and Bart Criel

Series in Health Service Organisation and Policy, n°29,  ITG PRess 2012,  Study on behalf of Medicus Mundi

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Mission hospitals or faith-based organisations in Cameroon, Tanzania and Chad are commissioned by the authorities to directly deliver medical care, or to manage health care delivery in a district. In turn they receive money or human resources. In Uganda the situation is sligthly different, denominational hospitals work partly under contract for organisations (“primary recipients”) that themselves receive money from the American aid program PEPFAR.

While the authorities use the contracts to offer better care to their population, the churches strive for official recognition and support. It is not self-evident that these contracts work. Do they? And why (not)? This study highlights tensions between parties, even though officials tend to minimise these. The agreements are often vague or incomplete – or they have never been put to paper. Often they do not fit into the more general policies. There is a large dichotomy in understanding between the central level and the local health authorities, due to an incomplete decentralisation process, making the policies very fragmented. The contracts have made hardly a difference to the shortage of money, people and means. And often the government has not kept its promises, contract or not. Only when the means have been made available, as in the case of PEPFAR funded projects do contracts come up to expectations.

PEPFAR-contracts have the tendency to bypass the national structures; they are appreciated by the people in the field, because they are dependable and have clear mechanisms of follow-up and evaluation.

If churches and civil authorities want to cooperate in health care, they better revise their historical agreements and understandings, and go for contracts with clear follow-up and evaluation procedures. Though the most important thing is to adapt the contracts to the local realities.

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