54334 Performance-Based Contracting for Health Services in Developing Countries: A Toolkit BY BENJAMIN LOEVINSOHN Published in 2008 by the World Bank. Summary for web of Section 3, pp. 19­66: "How to Contract: What Works and What Doesn't"* This book was written to help bridge the yawning gap between many developing countries and the Development Goals for health. Right now, that gap looks daunting. But we can narrow the gap significantly by contracting, especially using non-state providers. The status quo, in which millions are denied basic health services, is not acceptable. Contracting is an effective way to improve the daily lives of the most vulnerable. Contracting is the means by which a funder buys specific services from those non-state providers. This practical "how to" guide is aimed at staff of government agencies, insurance companies, social insurance funds, nongovernmental organiza- tions, faith-based organizations, private health care providers, and international development partners. * This summary was written by Michael H.C. McDowell, an international public health communications consultant. www.rbfhealth.org OCTOBER 2009 How to Contract: What Works and What Doesn't SUMMARY BY MICHAEL H. C. MCDOWELL Contracting works best with a systematic approach, and with that in mind, we have devised a checklist, headlined below, and spelled out through specific "tasks". Don't feel overwhelmed by the detail, just aim for steady progress, not perfection, and focus on a few key issues: · Definethecontract'sobjectives;pickindicatorsof notrepeatingoldones.Importantly,becreativeandadapt success;whatresultsdoyouwanttoachieve? towhatworkslocally.A"contractingcycle"involvesspeak- · Makesurethatbothcontractorsandpurchasers ingtostakeholders;definingtheservices;designingthe focusontheobjectivesandtangibleresults monitoringandevaluation;decidinghowtoselectthe · Definethesize,andlocationofeachcontract"lot," contractorsandsettingthepriceofthecontract;arranging whowillbetargeted,andwhere forcontractmanagement;draftingthecontractandbid · Definethescopeofservicestobedelivered;whatser- documents;organizingthebiddingprocessandmanaging vicesdocontractorsneedtoprovidetopatientsand thecontract. communities? · Maximizethemanagerialautonomyofthecontrac- tors;holdthemaccountablebutdon'tmicromanage Speaking To Stakeholders them · Developaplanwhichaddresseshowthecontracts TASK 1 · How To Consult With Them: aimtobalance willbemanaged,andhowmonitoringandevaluation theinterestsofoftencompetingandvariedstakeholders; willbedone getthisrightatthebeginning,andyoupreventproblems later,e.g.,meetwitheachgrouptomakethemcomfort- Contractingismoreartthanscience,butapproaching ablewithcontracting.Thengetbacktothemwithdraft thingssystematicallycanavoidsimplemistakes;ideally, proposalsandactualcontracts. youshouldonlybemakingnewandinterestingmistakes, 1. Dialogue with Stakeholders 7. Carry Out Bidding 2.Define the Process and Manage Services the Contracts The Seven Steps of Contracting 6. Draft Contract and 3. Design the Monitoring Bidding Documents and Evaluation 5. Arrange for 4. Decide How to Contract Management Select Contractors 1 www.rbfhealth.org TASK 2 · Identify"Champions,"i.e.,peoplewhoreally taski.e.makeitcleartheyarenotbeingsetupforfailure "get"thevalueofcontractingoratleastarepositivelyopen butarereal"partners"inapublic-privateendeavor. totryingit.These"champions"maybebusinesspeople, communityleaders,politicians,ortheiradvisors. Define the Services TASK 3 · DirectlyAddresstheLegitimateConcernsof Stakeholders:e.g.,governmenthealthofficialsareoften TASK 4 · Defining the Objectives of the Contract: deeplysuspiciousofcontractingandcanbe"blockers". thisisabsolutelyfundamentaltosuccess.Fromthevery Givethemevidenceofcontractingsuccessesandsuggest outset,makeobjectivesexplicitandmeasurable,focused thatbetterhealthserviceswillshowtheminagoodlight, onresults.Limitindicatorstonomorethan10;emphasize andfreethemtoconcentrateonthe"bigpicture,"includ- independentlymeasurableindicators--stressoutputsand ingsettinglong-termstrategy. outcomes,ratherthaninputsorprocesses.Forexample, focusonimmunizationcoverage,notonhowmanysyring- Reassureofficialsthatthepublicsectorwillhavethe eswerebought.Settargetsbroadly,e.g.,ifimmunization samelevelofresourcesandstandardsasnon-state stoodat50percentandthetargetis80percent,thena providers(NSPs).Introducethemto"champions"of 78percentscoreshouldbepraised.Don'tletperfection contractingfromothercountrieswhoillustratethe"win- betheenemyofthegood. win"sideofcontracting,e.g.,theoftentime-consuming andexasperatinghiringandmanagingofpersonnelcan TASK 5 · Include Objectives Related to Equity and bepassedontocontractors.Buildin"ownership"among Quality: beexplicit,e.g.,onequity,emphasizeuseof localpoliticiansandgovernmentofficials,havingthem servicesbythepoorest,thegeographicallyunderserved, notonlysignorwitnesscontractsbutreviewquarterly orthosewidelydispersed. performancereports. TASK 6 · Consider Pay for Performance (P4P):use Ontheotherhand,letcontractorsseethattheselection bonuseslinkedtoaccomplishmentsorthenumberofser- processisopenandtransparent,thatpaymentswillbe vicesprovidedbutmakesurethereisindependentverifica- madepromptly,andthatresourceswillbeadequatetothe tionsothatincreasingquantitydoesnotdamagequality. Paying for Performance in Haiti InordertoimprovetheperformanceofNGOsdeliveringprimaryhealthcareinHaiti,USAIDthroughManagementSciencesfor Health(MSH)startedtopaythemabonusbasedontheirperformanceonkeyindicatorssuchasimmunizationcoverage,skilled birthattendance,andprenatalcare.Theseindicatorsweremeasuredusingthehealthmanagementinformationsystembutwere independentlyverifiedthroughadataaudit.AsthepercentageofNGOsbeingpaidonperformancebasis(i.e.,offeredperfor- mancebonusesiftheyachievedspecifiedresults)increased,thecoverageoftheseservicesalsoincreased. Performance of NGOs in Haiti as Use of Bonuses Increases Indicator DHS 2000 2002 2003 2004 2005 % of children fully vaccinated 34 65 91 92 100 % of women receiving at least 3 prenatal visits 29 50 41 48 60 % of deliveries assisted by skilled attendant 58 64 57 63 77 % of NGOs paid on performance basis 35 37 44 93 Source: Based on R. Eichler et al., 2006. 2 www.rbfhealth.org TASK 7 · Ensure that Purchasers and Contractors Design the Monitoring and Evaluation Focus on Objectives: torepeat,readthecontractcare- fully;neglectthisanditcanleadtomistakeslater.Make TASK 10 · Decide How Data Will Be Collected: for surecontractorsknowtheywillbeheldtoaccountfor eachindicator,itshouldbeclearhowdatawillbecollected non-performance;havepurchasers,contractors,andfield (seeTable1).Italsomakessensetodescribeeachdata monitorsregularlyreviewkeyindicators. collectionmethod,e.g.,routinelycollecteddatafromthe healthmanagementinformationsystem(HMIS);house- TASK 8 · DefinetheSizeandLocationofEachContract holdsurveys;healthfacilityassessments;andsupervisory "Lot":a"lot"or"package"beingthesizeandlocation checklists.(seeTable2) ofanindividualcontract,whichisusuallydefinedbythe purchaser. TASK 11 · Collect Baseline Data:thiscanbetricky becausecollectingthisinformationusuallyhastobedone Beclearaboutwhereyouwishcontractorstoworkand atthesametimeasservicesarebeingdesignedand whothetargetpopulationsare. servicedeliveryisstarting.Key,attheverybeginning,is pickingtheorganizationwhichwillcollectthedata. Chooseafewlargelots,ratherthanmanysmallones;this willcreatefoureconomiesofscale:i)financingeconomies TASK 12 · Set a Clear Schedule for Data Collection: ofscale,duetofixedcosts;ii)easiercontractmanage- householdsurveysshouldbeonceortwiceayear;health ment;iii)moreefficientmonitoringandevaluation;iv) facilityassessmentsdoneannually;supervisorychecklists economiesofscaleincapacitybuilding.Largelots,with usedeverytwomonths;andHMISdatareviewedatleast theirbiggerbudgets,encouragemoreorganizationsto quarterly. bid;furthermore,itiseasiertobuildcapacitywithlarger lots,e.g.,teaching70NGOshowtoworkwithfemalesex TASK 13 · Look for Comparison/Control Groups: workersismuchharderthanbuildingthecapacityofjust7 "benchmark,"i.e.,compareperformanceofcontractorsto NGOs.Butit'sabalance:ingeneral,experiencesuggests eachotherandotherhealthserviceproviders,especially itmakessensetohavebetween7and20lots. usingcontrolled"beforeandafter"comparisonstoshow "lessonslearned." TASK 9 · Define the Scope of Services--Focus on "what" not "how": avoidtellingcontractors"how"they TASK 14 · Assign Responsibility for Collection, shoulddeliverservices.Whatmattersismeetingthegoals, Analysis, and Dissemination of Data:makeMonitor- nottheprocesse.g.prioritizingimmunizationcoverage ingandEvaluation(M&E)someone'sfulltimejob,possibly iscommonsense,butspecifyingthatcontractorsmust usingathird-partyfirm. achievethisbygoinghouse-to-houseorstandingonstreet corners,isunnecessary. Table 1: Partial List of Indicators Means of Approximate Indicator Baseline value data collection target % of all women pregnant during the last year 1) HMIS 53% 75% receiving at least one antenatal care visit from a 2) Household survey (HHS) (HHS) skilled health care provider Score out of 100 on an index of quality of 1) Health facility survey (HFS) 16 65 care as judged by third party, which includes 2) Supervisory checklist (HFS) the adequacy of waste management, drug availability, provider knowledge, patient- provider interaction, etc. 3 www.rbfhealth.org Table 2: Means of Data Collection Schedule and Responsibility for Means of data arrangements Schedule for follow- Counterfactual or data collection and Budget requirement collection for baseline on data collection comparison group analysis datacollection Household survey Third party with July 200_, Firm will Every two years after US$250,000 per Some non-contracted assistance from MOH be recruited by March, the baseline round of survey X 3 = areas (5 districts) will primary health care 200_ US$750,000 also be surveyed department Health Facility Third party with July 200_, Firm will Every year Total = US$400,000 Health facilities Assessment assistance from MOH be recruited by March, nation-wide will be contract management 200_ included in sample. unit. Sample size will allow comparison of contracted and in non contracted facilities TASK 15 · Budget Sufficient Funds for Monitoring TASK 19 · Maximize Interest of Possible Contrac- and Evaluation: areasonableexpectationis4­7percent tors: drumupinterestbyconsultingbroadlywithpotential ofthetotalvalueofthecontracts. contractors,advertisingwidely,holdinginformationor "pre-bidconferences",keepRequestforProposal(RFP) documentssimple,ensuretheselectionprocessistrans- Decide How to Select Contractors and parentandunderstandable,allowsmallerNGOstoform consortia,andavoidbidorperformancebonds. Establish the Price TASK 16 · Use a Competitive Selection Process: TASK 20 · Select a Contractor:ideallythrough throughopencompetition,clearlyshowingthereisa"level competition,atleastpartlybasedonprice;second-best, playingfield,"emphasizingthereareno"favorites"inthe establishafixedbudgetbeforethecompetition;and, biddingprocess,no"fix,"andinvitingthebestandthe least-preferred,throughnegotiation(sincenegotiationsare brightesttobid,thusreducingthechancesforcorruption oftenconductedbehindcloseddoors,transparencycan whichplaguessomanyno-bidcontracts. becompromised). TASK 17 · Develop Clear Selection Criteria before the beginning of the selection process: pitchthe Arrange for Contract Management and criteriarealistically,nottoohighortoolow.Makesureor- Develop a Contracting Plan ganizationshavetheexperience,skills-sets,minimumsize, andtrackrecord;insistonthreeyearsofauditedaccounts, TASK 21 · Define Responsibility and Clarify the proofofreasonableturnoveroffunds;andgoodstanding Contract Management Structure:managingcontracts inthecountryinvolved. requiresaclearlydefined,reasonablysizedteamwith explicitresponsibilitiesandauthority.Thereareprosand TASK 18 · Establish a Transparent and Indepen- constodifferentmodelse.g.ministriesofhealth(MOH) dent Evaluation Process:setupanindependent,com- havelimitedexperienceorknowledgeofmanagingcon- petentevaluationcommitteewhosemembersindividually tractsbuttheyhavetechnicalknowledgeofthesector rateproposals,e.g.,toensuretransparency,it'susefulto andcanfeelrealownership.Thelocalgovernmentlevel includestafffromdevelopmentpartnersandfrominterna- isobviouslysmallerandwhileitmaybeinefficienttobuild tionalagenciessuchasUNICEFandWHO(excludingthe capacity,localofficialscanoftenbettermonitorcontrac- WorldBank)andtheNGOcommunity. torperformance. 4 www.rbfhealth.org Asregardsspecializedprocurementunits,theselimitthe TASK 25 · Develop a Written Contracting Plan:pay stewardshipfunctionoftheMOHandmaybelessmo- closeattentiontothisparticularTask.Thepurchasermust tivatedthanorganizationswhosemandateistoimprove developamanualofprocedureswhichaddressescontract health.Broadlyspeaking,theMOHorotherlineagencyis managementandmonitoringandevaluation.Peoplefocus probablythebestapproach,ensuringownershipandlong ondraftingcontractsandbiddocumentsandcaneasily termstewardshipofthesector. forgetaboutthesecrucialissues. TASK 22 · Ensure Proper Staffing of the Contract Draft the Contract and Bidding Management Unit: pickaseniorpersontoeffectively Documents managerelationshipsandcommunicatewithstakehold- ers;selectskilledpeople,withgoodexperienceinthe TASK 26 · Maximize Managerial Autonomy: amajor field,troubleshootandmonitorperformance;andincludea benefitofcontractingiscuttingthrough"redtape"andpoliti- competentfinancialmanager. calinterferencewhichbedevilssomanygovernmentefforts todeliverservices.Bycontracting,realisticdecisionscan TASK 23 · Allow Sufficient Budget for Contract bemadebypeopleonthegroundwhocansolveprob- Management:calculaterealisticallythecostoflocalstaff lemsquickly;inaddition,purchaserscanmoreeasilyhold orconsultants;beaccurateinpricingneededequipment, contractorsaccountableforresults,sincecontractorshave computersandsoftware;includetransportcostsand madethedecisionsthemselvesandcannotpassthebuck perdiemsforfieldvisitsandmonitoring;figureinpositive toothers;managerialindependenceallowsandindeed incentivesforcontractmanagementstaffandlinkthese encouragesinnovationswhichcanimproveperformance. toresultsachievedbycontractorsortimelypaymentof Howcanmanagerialautonomybestrengthened?:make contractors. clear,andseparate,whatthepurchaserdoes,andwhat thecontractordoes.Whenthisisnotclear,thepurchaser TASK 24 · Consider Computerization of Contract usuallytriestoassertcontrol;focuson"what"not"how"; Tracking: managingbyhandwillbedifficultifthereare andsearchforotherwaystoincreaseautonomy. morethan6or7contracts,soitiscriticaltobuycontract managementsoftware. DECENTRALIZING DRUG PROCUREMENT IN AFGHANISTAN In Afghanistan, the government signed contracts with NGOs which gave them responsibility for procurement of medicines and other supplies. At the same time, there were other contracts that stipulated that medicines would be procured centrally by an organization with long experience in drug procurement and distribution. In addition, in a few provinces drug procurement and distribution was handled by the central ministry of health. An independent assessment showed that the availability of drugs improved much more in the places where individual contractors were responsible for procurement and distribution. Effects of Decentralized Procurement in Drug Availability Index in Afghanistan (Maximum score = 100) Approach to drug procurement and Baseline Endline Change distribution Decentralized to individual NGOs 62.4 92.1 29.7 Centralized, non-state organization responsible for 70.3 93.0 12.7 procurement and distribution Centralized, public sector procurement and distribution 57.1 71.2 14.1 Source: Ministry of Public Health, Johns Hopkins University 5 www.rbfhealth.org TASK 27 · Ensure That Contractors Can Manage tion(embarrassmentseemstoworkquitewell);demand Personnel Effectively: sothattheycanhire,fire,place replacementofkeystaffifothereffortshavenotproduced people,handlepayandbenefits,settermsofemployment thedesiredresults;andlimitthecontractor'sopportunities (e.g.,performancebonuses)andestablishstaffinglevels. formorework. TASK 28 · Use Lump-Sum Contracts: i.e.where TASK 33 · Establish Dispute Resolution Mecha- contractorsarepaidanagreed-onsumonaregular nisms: keepitsimple;first,appointamediatoraccept- basiswhichisNOTreimbursementforspecificexpenses abletobothparties;ifthatfails,useanarbitrationpanelof incurred.Lumpsumsallowmanagerstoflexiblymove respectedindividuals. moneywhereitismostneeded,prevent"micromanage- ment"whichstiflescreativity,facilitateimplementation(be- TASK 34 · Define Reporting Requirements of a causepermissionisnotneededforchangesinlineitems), Contract: i.e.adescriptionofprogressmadeagainstthe andensureeveryonefocusesonoutcomesandoutputs, workplan;problemsencounteredandsolutionsundertak- notjustinputslikemoney. en;asummaryofhealthmanagementinformationsystem data;afinancialstatement;abankaccountstatement(and TASK 29 · Leave Procurement of Supplies, Equip- anannualexternalfinancialauditreport). ment, and Services to Contractors: decentralizing thesealmostalwaysresultsinbetterdeliveryofsupplies, TASK 35 · Have an Explicit Policy on User Charges: whenandwheretheyareneedede.g.asregardsquality userchargesorfeesforhealthservicesarecontroversial, of,say,drugs,thereislittleornodifferenceinthequalityof sobeclearwhethertheseareallowed.Ifallowed,they drugsboughtbythestateorthenonstatesector. mustnotdamagethegoalofgreaterequity,theircosts mustbereasonableandpubliclydisplayed,andexemp- TASK 30 · Ensure That Duration of the Contract tionsmustbemadeforthepoorest.Inaddition,funds Is Sufficiently Long: werecommendminimum4-5year collectedmustberetainedinthelocationwheretheyare termsbecauseittakestimeforbothpartiestounderstand collected. andbecomecomfortablewithcontractualarrangements anddevelopasolidworkingrelationship;inaddition,con- TASK 36 · Ensure That Contractors Use Indepen- tractorsneedreasonabletimetoimplementtheirplan;and dent Private Sector Auditors: somepurchasersmay finally,continuity,particularlyindealingwithlocalcommuni- wantthisattheendofayear. ties,isaclearadvantage. TASK 37 · Ensure That Contractors Build the Ca- TASK 32 · Have Clear Procedures for Making Pay- pacity of Health Workers:stipulatethespecificqualifi- ments: therearetwotypes,mobilizationpayments,and cationsofthehealthworkerstobehiredbutberealistic; regularpayments.Onmobilizationpayments,because beclearwhatobligationsthecontractorhasfortraining contractorsforhealthservicesareNGOsorCBOs,they andcapacity-buildingfortheirstaff;andaskhowcontrac- haveno"capital"andsoitisimportantforthemtobepaid torswillgainaccessfortheirstafftogovernment-runor uponsigningthecontract,usually10percentofthetotal. financedtrainingcourses. Withregularpayments,theseshouldbedonethrough quarterlyorhalf-yearlylump-sums,afterthecontractor TASK 38 · Address the Capacity Needs of Con- submitsacceptablereports. tractors: purchasersaresometimesreluctanttodothis becausetheyarguetheywouldnothirethecontractors TASK 32 · Establish a Clear Process for Termina- withoutthenecessarycapacity.Butitisinpurchasers' tion and Imposing Other Sanctions:spelloutthe bestintereststobuildcontractors'capacitye.g.when proceduresandrulesgoverningterminationofthecontract therearenewandeffectivetechniquesandapproaches butuseadisputeresolutionmechanismbeforeterminat- whichimproveresultsandprovideevengreatervaluefor ing.Ifthereispoorperformance,first,haveface-to-face money. meetingswithkeyofficials;thenwriteletterstotheproject manager,nexttheboardofdirectorsoftheorganiza- 6 www.rbfhealth.org TASK 39 · Clarify Responsibilities for Physical TASK 44 · Review Contracting Plan and Contract: Infrastructures: e.g.werecommendthatequipmentbe- thecontractmanagementunitshouldmakesurethecon- comethepropertyofthepurchaserafterthecontract,but tractorshavefulfilledtheirobligations,andM&Etasksand untilthenthecontractorshouldmaintainit.Similarly,build- thatthepurchaserissatisfied. ingmaintenance,repairandrehabilitationshouldbethe contractor'sresponsibilityforthedurationofthecontract. Carry Out the Bidding Process and Manage the Contract TASK 40 · Formulate the Bidding Documents: theRequestforProposal(RFP)isthedocumentgiven tointerestedbiddersandcontainsthefollowing:letterof invitationtobid;instructionstobidderonpreparingbids, theprocess,andcriteriaforselectionofcontractors;form ofthetechnicalproposal;formofthefinancialproposal; termsofreference;draftcontract. TASK 41 · Track the Schedule of the Bidding Pro- cess: competitivebiddingshouldbecompletedinsixor sevenmonths,sorecruitmentofcontractorsshouldbegin ASAP,evenbeforefinancingisfullysecured.Onewayof diagnosingcorruptionistocarefullytrackhowlongthe evaluationprocesstakesandhowlongittakestofinalize thecontracte.g.ifittakesmorethanthreeweeksfrom thetimeofthefinalbidevaluationtothetimethecontract isreadyforsigning,thenthisisalikelyearlywarningof corruption. TASK 42 · Conduct Regular Monitoring Visits: achecklistforsitevisitsshouldcompriseanassess- mentofresultsfromtheroutinerecordingsystem,data onmedicines,equipmentandvehicles,informationon availabilityandmoraleofhealthworkers,satisfactionof keystakeholders,andassessingqualityofcareofrelated processes.Importantly,visitsareanopportunitytocement relationshipsamongallstakeholders,identifyissuesand solveproblemsearlyon. TASK 43 · Meet Frequently with Stakeholders:con- tractmanagersandcontractorsshouldmeeteveryoneto twomonths;setupamechanismforcontractorstoshare experiencesandideas,ideallywithoutthepurchaserpres- ent;andregularlyreporttomajorstakeholders­especially thepurchaserandlocalgovernments­onprogress. 7 www.rbfhealth.org Checklist for Contracting (Tasks shown in bold should receive particular attention.) Task Comments Step 1: Dialogue with Stakeholders 1. Establish a Consultative Process with Stakeholders: (i) Hold a couple of discussions with each set of stakeholders; (ii) Get back to stakeholders with draft proposals and contracts 2. Identify Champions 3. Address Legitimate Concerns of Stakeholders: (i) government health officials; (ii) politicians and local governments; (iii) existing health workers; (iv) potential contractors; (v) the community; and (vi) development partners/donors Step 2: Define the Services (Develop TORs) 4. Define the objectives of the contract: (i) limit the number of indicators; (ii) bias towards output/outcome indicators; (iii) ensure indicators are measurable; (iv) define indicators in detail; (v) set targets broadly. 5. Include Objectives Related to Equity and Quality 6. Pay for Performance­consider performance bonuses etc. 7. Ensure Everyone Focuses on Objectives 8. Define the Size and Location of Each Contract "Lot" 9. Define the Scope of Services--focus on "what" not "how" Step 3: Design the Monitoring and Evaluation 10. Decide How Data will be Collected--(i) HMIS; (ii) household surveys; (iii) health facility assessments; (iv) supervisory checklist 11. Collect Baseline Data 12. Devise a Clear Schedule for Data Collection 13. Look for Comparison/Control Groups 14. Assign Responsibility for Collection, Analysis and Dissemination of Data 15. Budget Sufficient Funds for Monitoring and Evaluation Step 4: Design How to Select Contractors and Establish Price 16. Use a Competitive Selection Process 17. Develop Clear Selection Criteria 18. Establish a Transparent and Independent Evaluation Process 19. Maximize Interest of Possible Contractors 20. Select the Method for Contractor Selection, Step 5: Arrange for Contract Management 21. Define Responsibility and Clarify the Contract Management Structure 22. Ensure Proper Staffing of the Contract Management Unit 8 www.rbfhealth.org Task Comments 23. Allow Sufficient Budget for Contract Management 24. Consider Computerization of Contract Tracking 25. Purchaser Develops a Written Contracting Plan (or contracting manual) Step 6: Draft Contract and Start Bidding Process 26. Maximize Managerial Autonomy--Clarify authority of both parties, etc. 27. Ensure Contractors Can Manage Personnel Effectively 28. Use Lump-Sum Contracts--rather than reimbursement based on line-items 29. Leave Procurement of Supplies, Equipment, and Services to Contractors 30. Ensure Duration of the Contract is Sufficiently Long 31. Have Clear Procedures for Making Payments: That covers (i) mobilization payments; and (ii) regular payments. 32. Establish a Clear Process for Termination and Imposing Other Sanctions 33. Establish Dispute Resolution Mechanisms 34. Define Reporting Requirements of the Contractor 35. Have an Explicit Policy on User Charges 36. Ensure Contractors Use Independent, Private Sector Auditors 37. Ensure Contractors Build the Capacity of Health Workers 38. Address the Capacity Needs of Contractors 39. Clarify Responsibilities for Physical Infrastructure 40. Formulate the Bidding Documents Step 7: Carry Out Bidding Process and Manage Contracts 41. Track the Schedule of the Bidding Process 42. Conduct Regular Monitoring Visits 43. Meet with Stakeholders Frequently 44. Review the Contracting Plan and the Contract 9 www.rbfhealth.org