5. Abramson W.B. (2001), ‘Monitoring and Evaluation of Contracts for Health Service Delivery in Costa Rica’, Health Policy and Planning, 16(4): 404-411.

This study about contracting of primary health services, the contractor’s budget is 95 % financed by the government. Additional income is generated through user fees for non-contract services including dental prosthesis and upper GI endoscope. Up scaling feasibility the prevailing sentiment of many medical professionals in Costa Rica, as elsewhere is traditional and not geared to the new approach.  The contract contains a fully developed list of indicators for gauging contractor performance. It stipulates that overall results from a 6-month evaluation inferior to 90% of the agreement would have a direct and proportional impact of up to 2.5 % on the budget available for the following 6 months. Thus, the following semester’s budget would be reduced automatically. Under the Costa Rican health sector reforms, contracts were formalized as a strategy to improve quality of care, increase coverage and reduce costs. The five specific objectives are to satisfy the health needs of the population to improve access to health care for the target population to gain knowledge of user options on health care services and establish strategies to improve user satisfaction, to optimize the effective and efficient use of health service delivery resources, to work for the benefit for the individual. The contract includes an evaluation protocol that defines who will evaluate the contract, the frequency of evaluations, data sources for the evaluation and how the results will be used. Evaluation of the contract performance is to be made every 6 months. The contract also reserves the right of the government to conduct periodic audits of the contractor use of equipment, infrastructure and materials including medical supplies and medicines. The contract stipulates the lack of compliance with the agreed upon level of materials and equipment could be the cause of termination of the contract. A cost analysis comparing the contracted out clinic with four others operated by the government but are otherwise equivalent indicates that the public-private partnership offers some advantages. The average cost per consultation at the cooperative clinic in the first 5 months of operation was 44.54 per cent lower and this cost advantage increased over time. The average cost of a consultation at the cooperative clinic was US $ 11.25 while that at the four comparison clinics was US $ 16.20. (AJPH)