Monitoring and evaluation of contracts for health service delivery in Costa Rica.

The Costa Rican Social Security Fund (CCSS) has been purchasing primary health care services from the Costa Rican Cooperative, COOPESALUD. The CCSS has made significant progress in establishing performance indicators and conducting evaluations of progress against those indicators. After laying out a general framework for developing performance indicators, this paper analyzes the CCSS's evaluation of its 1998 contract with COOPESALUD in terms of objectives, performance indicators, evaluation results, and use of the evaluation results. The objectives of the COOPESALUD contract, as they are stated within the body of the contract, are to increase coverage, improve quality and increase efficiency. Contract performance is measured through three categories of indicators: organization, service delivery and quality. Service delivery targets are set in terms of volume of services based upon geographic population. A 'yes' or a 'no' rating to indicate whether a particular system is in place is used for scoring organization and quality targets. While the CCSS contract is one of the most advanced in the region, many aspects could be improved. By setting indicator targets based upon population estimates, it is difficult for the CCSS to accurately assess COOPESALUD's performance. Although the CCSS conducts periodic evaluations through formal mechanisms, and some data on volume of service delivery are available, the data gathered in all three categories do not provide the purchaser with information directly related to all of the contract objectives nor to contractor performance. The indicators spelled out in the contract, and the evaluation of those indicators, do not seek to measure quantifiable results or impact through numerical data. There are no process or result indicators in place. The evaluation results could therefore tend to be fairly superficial - based upon population coverage and not on effectiveness of treatment, quality of treatment or efficient resource use.

Bolivia: a mid-course assessment of the National Mother Child Health Insurance Program.

PIP: This article presents a mid-course assessment on the National Mother Child Health (MCH) Insurance Program in Bolivia. Since the initiation of the MCH insurance program in 1996, the government anticipated the reduction of maternal and child mortality through provision of essential medical care for reproductive women, newborns and children under 5 years old. The program addresses priority health needs such as birth and antenatal care, acute respiratory illness, and diarrhea. The evaluation was conducted through interviews, information reviews, and surveys among 31 hospitals, health centers, and heath posts in 12 municipalities of Bolivia. Changes in the utilization of services, financial sustainability, and institutional capacity were observed as a result of insurance reform. In conclusion, this evaluation suggests some modifications in the program, including alteration of basic payment rates of the insurance program, creation of an administrative unit to manage program operations, and examination of problem areas such as subsidized transportation, reimbursement rates, shortage of working capital, and personnel incentives.^ieng