Resumen
This paper contributes to the debate about the understanding of contextual factors in contracting out public services in developing countries. It argues that contractual rela-tionships that the Ministry of Health enters with faith-based health service providers in Malawi are not effective due to poor design, implementation and management ar-rangements. As a result the contracts have become more mechanisms for quantitative increase and access to services rather than tools for ensuring quality and accountability in service delivery. Although the arrangement contributes to the increased access to health services, it is not cost-effective and the quality of services in church health facili-ties remains low, because the process is filled with management and governance chal-lenges. Meanwhile, the Ministry of Health is often accused of delaying payments to the church health service providers thereby sustaining the efficiency and accountability malaise.