This post was originally posted on the Joint Learning Network
Authors: Barry Kistnasamy, Mpho Rabada; Lucelia Konwloh, Rufus Saye; Subrata Paul; Samiul Huda; Regine Alexandra Emilien, Jacob Hughes, Sara Wilhelmsen; Tushar Mokashi
A government can decide to contract health services from non-governmental providers, but turning that decision into effective services takes careful work. The policy challenge is to align what governments purchase, which providers they engage, and how they pay them with population health needs and provider performance (World Health Organization [WHO], 2019). Doing so also requires effective governance, reliable information systems, and institutional capacity (WHO, 2017).
An MSH synthesis of contracting experiences in India, Kazakhstan, Liberia, and South Africa’s Western Cape identified common practices while emphasizing that every country has its own path, there is no single right way to establish contracting (Management Sciences for Health [MSH], 2024b). The related policy primer notes that, although resources on contracting exist, practical guidance is limited on how to establish it, including how to mobilize political will and navigate legal, regulatory, and policy environments. In response, MSH developed a framework outlining actions to create an enabling environment for contracting, while recognizing that countries will need to adapt those actions to their own contexts rather than follow a universal “how-to” sequence (MSH, 2024a). These findings point to the value of learning from implementation and from what works in different country contexts.
Work on creating an enabling environment for contracting also continued through the JLN’s Collaborative on Contracting Organizations for Health-Related Services with technical facilitation from MSH. The collaborative brought together teams from 12 countries including Bangladesh, Botswana, Ethiopia, Ghana, India, Kenya, Liberia, Malaysia, Nigeria, Philippines, South Africa, and Uganda, to exchange experience and explore practical issues in establishing or strengthening government contracting for health services.
Building on this work, Bangladesh, Liberia, and South Africa joined the JLN’s implementation Learning Lab, which ran from September 2025 to October 2026. JLF funding supported the country teams to continue peer learning and advance their country action plans. This blog looks at the work they undertook, the progress made, and the lessons they identified for the wider JLN community.
Bangladesh: Building the tools for implementation
Bangladesh’s team, representing the Ministry of Health’s Health Economics Unit, Health Services Division, and Directorate General of Health Services, focused on translating consensus into practical steps toward government-led contracting.
With JLF support, the team updated its Roadmap and Country Action Plan for Contracting of Tuberculosis and Other Health Services in Bangladesh (2026–2030) and developed a revised draft of the national contracting toolkit. The draft includes proposed verification mechanisms and fixed-price framework-contracting approaches. Peer exchange with Liberia and South Africa informed this work and the team’s advocacy for strategic purchasing. The team also worked to strengthen facility managers’ capacity to procure and manage contracts for TB and other health services.
The remaining steps include finalizing the toolkit, extending capacity-building beyond the initial cohorts, and working with the Ministry of Finance to address cross-fiscal-year contracting challenges, drawing on Liberia’s framework-agreement experience. These are important building blocks for implementation. Their effects on contracting practice and service delivery will become clearer as the tools are finalized, adopted, and used.
Liberia: Bringing contracting into national policy
Liberia’s team brought together the Ministry of Health’s Policy & Planning Unit, Private Sector Engagement Unit, and National Leprosy and Tuberculosis Control Program. Their goal was to include domestic contracting of health services in the revised National Private Sector Engagement (PSE) Strategy for 2026–2031.
The team conducted a desk review and key informant interviews, then held technical working sessions to shape the draft strategy and refine its priorities. A two-day national meeting brought government programs, private facilities, and development partners together to review and validate the strategy.
The work advanced contracting through the national policy process. The team’s remaining steps include completing any required approval, disseminating the strategy, and developing an operational framework for implementation. The strategy is intended to provide a policy basis for institutionalizing domestic contracting of TB and other health services. Its effects on service access, quality, and continuity will depend on implementation and should be assessed over time.
South Africa: Advancing a legal and institutional reform
South Africa’s Department of Health, through the Medical Bureau for Occupational Diseases (MBOD) and the Compensation Commissioner for Occupational Diseases (CCOD), focused on modernizing the legal and institutional arrangements for occupational health services for current and former mineworkers. The proposed reforms aim to establish a public-sector entity to oversee the contracting of medical examination and compensation services.
The team completed a Socio-Economic Impact Assessment (SEIA) for the draft Compensation for Occupational Diseases in Controlled Mines and Controlled Works Bill. The assessment informed stakeholder consultations and subsequent revisions. The team also sought technical guidance from the International Social Security Association, International Labour Organization, and World Health Organization on governance, administration, and digital benefit systems. In June 2026, the SEIA received certification and legal sign-off, marking progress toward the Bill’s consideration through the government approval process.
The Bill and proposed governance arrangements remain in development. The team is working to finalize the draft and move it through the required government processes. If approved, the legislation would provide a basis for establishing the proposed public-sector entity. The reforms’ effects on occupational health and compensation services can be assessed as the legislation and related arrangements are implemented.
The experience may also offer questions for South Africa’s broader health-system reforms, including its National Health Insurance agenda. Any application beyond occupational health would need to be explored in light of the different needs and governance arrangements in those areas.
Lessons to carry forward
The country teams’ experiences point to three lessons for the wider JLN community.
Reform requires relationships as well as technical design. South Africa’s work on occupational health legislation involves government, industry, and labor. Its experience highlights the importance of stakeholder engagement and coordination alongside legal and technical development. Financing arrangements will also need to support the proposed reforms as they move forward.
A policy framework can set the direction for implementation. Liberia’s work to include domestic contracting in its revised PSE Strategy shows how a national policy process can bring stakeholders together around shared priorities. The next step is to translate that direction into approved, funded, and operational arrangements.
Peer learning can help countries adapt ideas to their own priorities. Bangladesh drew on experiences from Liberia and South Africa to inform its toolkit revisions and strategic-purchasing advocacy. Participants compared approaches and considered how lessons might apply in their own systems. The value lies in adapting experience to country priorities rather than assuming one model will work everywhere.
Participants also raised multi-year planning, standardized agreements, concise performance measures, public-sector ownership, and community engagement as practical considerations for contracting. These should be assessed in each country’s context. South Africa’s partnership with Pharmacy Direct offers an example of centralized medicine dispensing and distribution for people with chronic diseases. Monitoring data will be needed to determine its effects on medicine availability, shortages, and efficiency.
What comes next
Building on country priorities and implementation challenges identified during the June 2026 South Africa Summit, continued Learning Lab activities are expected to focus on practical implementation needs. These include public financing, public financial management, and payment systems for contracting; service costing, output definition, and performance-based purchasing; and contract management, monitoring, verification, and digital readiness. Governance, strategic purchasing, and institutionalization will remain cross-cutting themes.
For the wider JLN community, the country experiences raise practical questions: What helps turn action plans into routine practice? Which contracting arrangements can be sustained through domestic systems? What information is needed to assess whether reforms are improving services?
The milestones achieved mark progress in policy and institutional readiness. Continued monitoring can show whether they change contracting practice or service delivery and help identify which approaches may be adapted or scaled nationally.
References
Management Sciences for Health. (2024a). Creating an enabling environment for contracting health services: A policy primer. https://health-systems-for-tuberculosis
Management Sciences for Health. (2024b). Government contracting of non-state providers for health services: A synthesis of key practices and lessons. https://HS4TB-Contracting-Paper.pdf
World Health Organization. (2017). Strategic purchasing for universal health coverage: Key policy issues and questions. https://www.who.int/publications/i/item/strategic-purchasing-for-UHC
World Health Organization. (2019). Purchasing health services for universal health coverage: How to make it more strategic? https://www.who.int/publications/i/item/WHO-UCH-HGF-PolicyBrief-19.6
About Authors
- Barry Kistnasamy: Head of Occupational Health / Compensation Commissioner, Medical Bureau for Occupational Diseases, Department of Health, South Africa
- Mpho Rabada: Clinical Coordinator, Medical Bureau for Occupational Diseases, Department of Health, South Africa
- Lucelia Konwloh: Coordinator, Private Sector Engagement, Ministry of Health, Liberia
- Rufus Saye: Program Manager, National Leprosy and Tuberculosis Control Program, Ministry of Health, Liberia
- Subrata Paul: Focal Point, Universal Health Coverage and National Health Accounts, Health Economics Unit, Health Services Division, Ministry of Health and Family Welfare, Bangladesh
- Samiul Huda: Resident (Critical Care Medicine), Department of Anesthesia, Analgesia, and Intensive Care Medicine, Faculty of Surgery, Bangladesh Medical University, Bangladesh
- Regine Alexandra Emilien: Senior Principal Technical Advisor, Management Sciences for Health
- Jacob Hughes: Independent Consultant, Management Sciences for Health
- Sara Wilhelmsen: Independent Consultant, Management Sciences for Health
- Tushar Mokashi: Technical Lead, Joint Learning Network for Universal Health Coverage, Amref Health Africa.
The authors thank Dr. Rahul Kadarpeta, Executive Director, Joint Learning Network for Universal Health Coverage, Amref Health Africa, for editorial review.
This blog is also available on the Joint Learning Network website.