Making doctors stay: Rethinking doctor retention policy in a contracted-out primary healthcare setting in urban Bangladesh

Background “Contracting Out” is a popular strategy to expand coverage and utilization of health services. Bangladesh began contracting out primary healthcare services to NGOs in urban areas through the Urban Primary Health Care Project (UPHCP) in 1998. Over the three phases of this project, retention of trained and skilled human resources, especially doctors, proved to be an intractable challenge. This paper highlights the issues influencing doctor’s retention both in managerial as well as service provision level in the contracted-out setting. Methodology In this qualitative study, 42 Key Informant Interviews were undertaken with individuals involved with UPHCP in various levels including relevant ministries, project personnel representing the City Corporations and municipalities, NGO managers and doctors. Verbatim transcripts were coded in ATLAS.ti and analyzed using the thematic analysis. Document review was done for data triangulation. Results The most cited problem was a low salary structure in contrast to public sector pay scale followed by a dearth of other financial incentives such as performance-based incentives, provident funds and gratuities. Lack of career ladder, for those in both managerial and service delivery roles, was also identified as a factor hindering staff retention. Other disincentives included inadequate opportunities for training to improve clinical skills, ineffective staffing arrangements, security issues during night shifts, abuse from community members in the context of critical patient management, and lack of job security after project completion. Conclusions An adequate, efficient and dedicated health workforce is a pre-requisite for quality service provision and patient utilization of these services. Improved career development opportunities, the provision of salaries and incentives, and a safer working environment are necessary actions to retain and motivate those serving in managerial and service delivery positions in contracting out arrangements.

Do NPM Strategies Lead to Negative Organizational Behavior? Lessons from the Differential Effects of Contracting Out on Voluntary Turnover

While public sector organizations have increasingly utilized New Public Management (NPM) strategies as a means of increasing the values of the market, a growing body of literature suggests that market-based reforms may generate indirect costs associated with negative organizational behaviors in the public sector. Focusing on probable consequences of government contracting out for the public workforce, this study examines the relationship between contracting out and voluntary turnover relying on a panel data of U.S. federal agencies from 2010 to 2017. The results present that contracting activity is associated with voluntary quits in the opposite direction depending on the level of job satisfaction. This finding disentangles the previous discussion on the relationship between NPM strategies and employee behavior.

Contracting Out National Immunization Program Does Not Improve Vaccination Rate Nor Socioeconomic Inequality: A Case Study of Seasonal Influenza Vaccination in South Korea

The objective of the present study was to investigate if the policy for contracting out the Korean influenza National Immunization Program (NIP) for individuals aged ≥ 65 years affects a reduction in vaccination inequality based on gender and socioeconomic position (SEP). In South Korea, initially only public health centers provided influenza vaccination for free; however, starting from the fall of 2015, the program was expanded to include private medical institutions. The policy was expected to improve overall vaccination rate and reduce its inequality, through improving access to vaccination. The present study analyzed how the gap in the vaccination rate changed between before and after contracting out. A multivariate logistic regression model stratified by gender and SEP of individuals aged ≥ 65 years was used. The study also analyzed changes in the unvaccinated rates between before and after contracting out based on an interrupted time series model. The gap in the unvaccinated rate based on SEP present prior to contracting out of the NIP for individuals aged ≥ 65 years did not decrease afterwards. In particular, the step changes were 0.94% (95% confidence interval [CI]: 0.00, 1.89) and 1.34% (95% CI: 1.17, 1.52) in men and women, respectively. In the pre-policy period, among women, the unvaccinated rate of the medical aid beneficiaries group was 1.22-fold higher (95% CI: 1.12, 1.32) than that of the health insurance beneficiaries, and the difference was not reduced post-policy implementation (odds ratio: 1.27, 95% CI: 1.20, 1.36). The findings of the study were that contracting out of the NIP was not effective in improving vaccination rate nor resolving vaccination inequality. Future studies should focus on identifying the mechanism of vaccination inequality and exploring measures for resolving such inequality.

Contracting out Rules for Family Income Sharing Arrangements: Providing Certainty and Protecting the Vulnerable

Despite equal division of assets at the end of a relationship, residual economic disparity often remains. This is especially common when one partner has left the workforce to care for children. Addressing such divergent economic prospects at the end of long-term relationships has been a perennial policy challenge. In 2019, the Law Commission completed its review of the Property (Relationships) Act 1976 (PRA). The Commission recommended replacing the current economic disparity compensation and maintenance regimes with an income pooling mechanism: Family Income Sharing Arrangements (FISAs). It also recommended that couples be able to contract out of FISAs. This article explores the rationale for changing the current regime and the conceptual underpinnings of the proposed FISA regime, using human capital as a framework. The article proposes a detailed policy regime for FISA contracting out. The proposed rules consider the needs of couples with children, where a partner has left the labour force, or where lived reality has not met the couple's ex ante expectations. The resulting rules meet the policy goal of allowing couples to contract out of FISAs, but only where their contract causes no hardship. Additional disclosure is also recommended for contracting out of the other provisions of the PRA, with greater deference recommended for such private arrangements as a result.

Outsourcing: Overview and Trends

Outsourcing is a valuable strategy for firms to gain more benefits from the global supply chain. Outsourcing can be defined as a business agreement in which a firm is contracting out certain existing parts of the firm to either domestic and/or international third parties. In this chapter, we give an overview to the benefits and disadvantages of outsourcing. We also discuss recent trends in outsourcing; in particular, with the benefit of technology development, robots are starting to join in outsourcing.