Delivery of Community Health Services: Assessing the Purchasing and Provision of Basic Health Services in Honduras

In recent years, Central American countries have been implementing strategies to expand basic health services to remote and poor rural areas. In most cases, health extension services have been carried out by contracting with nongovernmental organizations (NGOs) and other nonpublic entities to manage or deliver health services. However, contracting with non-state providers has not been easily accepted in these countries as it is often seen as arising out of an ideological desire to "privatize" publicly financed health services or ultimately to limit or end government involvement in health care. This is what is happening in Honduras, where the Ministry of Health is promoting the extension of services with a community based approach within a decentralization strategy framework. The new health services extension models in Honduras rely on organizational and management arrangements that differ from the traditional Ministry of Health (MOH) health facility model. In particular, the facilities are managed by their communities under different legal and institutional arrangements, depending upon their organizational structures. Their staff are not civil servants, and, as a result, their management has considerably more flexibility in hiring and firing workers. In addition, they have multiple sources of financing. Patients contribute to the financing of these arrangements either with co-payments or pre-payments according to level of income (the sliding scale is determined by the community). The purpose of this study is to identify and compare the costs, efficiency, quality and coverage, as well as the institutional arrangements and organizational structure of the alternative models with one another, and with the traditional services delivery approach of the MOH to determine the feasibility of scaling-up these innovative models of extension of health services. To this purpose, we conducted a health facility survey to collect information on (i) Perceived quality, (ii) Technical quality, (iii) Accessibility (with regards to providers), (iv) Accessibility to communities, and (v) Price/out of pocket payments from users. In addition, the cost of providing key elements of the service package is estimated, including: (i) coverage for vaccination, well-baby care, prenatal care and curative consultations for acute respiratory infection and diarrheic disease, (ii) use of iron supplementation among pregnant women, (iii) knowledge and use of oral re-hydration among women, and (iv) use of vaccination cards for infants. Information on outputs produced have been collected based on these components, as well as their inputs over the last 3 months at each of the facilities. The cost of providing selected components of the basic package of health services in each type of facility was calculated. Results from our analysis show that even though the overall cost of service delivery in the new community models is higher, access to basic health services and quality of care, both technical and perceived, are generally better than in the traditional public health care facilities. Findings also indicate that the new models are more cost efficient than the traditional MOH health care centers suggesting the feasibility of either scaling up these new models and/or alternatively reforming certain aspects of the traditional health care facilities.