ABSTRACT
BACKGROUND: Harnessing of private sector resources could play an important role in efforts to promote universal access to safe obstetric care including caesarean delivery in low- and middle-income countries especially in rural contexts but any such attempt would need to ensure that the care provided is appropriate and patterns of inappropriate care, such as high caesarean delivery rates, are not reproduced for the entire population. OBJECTIVE: To examine the contracting arrangements for using private general practitioners to provide caesarean delivery services in rural district hospitals in South Africa. METHOD: We utilised a mixed-method study design to examine the contracting models adopted by five rural district hospitals in the Western Cape, South Africa. Between April 2021 and March 2022, we collected routine data from delivery and theatre registers to capture the profile of deliveries and utilisation of contracted private GPs. We also conducted 23 semi-structured qualitative interviews with key stakeholders to explore perceptions of the contracting arrangements. RESULTS: All five hospitals varied in the level of use of private general practitioners and the contracting models (three private in-sourcing models - via locum agencies, sessional contracts, and tender contracts) used to engage them. Qualitative interviews revealed insights related to the need for flexibility in the use of contractual models to meet local contextual needs, cost implications and administrative burden. CONCLUSION: Structured appropriately, private public partnerships can fill important gaps in human resources in rural district hospitals. Policy makers should look to developing a 'contracting framework' which requires compliance with a set of underlying principles but allows for flexibility in developing context specific contracting arrangements. These underlying principles should include a 'risk' based delivery model, adherence to public sector- evidence-based protocols, time-based rather than per delivery/type of delivery remuneration models, group liability arrangements, and processes to monitor outcomes.
Subject(s)
General Practitioners , Pregnancy , Female , Humans , South Africa , Hospitals, Public , Public Sector , Cesarean SectionABSTRACT
Governments in sub-Saharan Africa are exploring public-private-engagements for the delivery of health services. While there is existing empirical literature on public-private-engagements in high-income countries, we know much less about their operation in low and middle-income countries. Obstetric services are a priority area where the private sector can make an important contribution in terms of skilled providers. The objective of this study was to describe the experiences of managers and generalist medical officers, of private general practitioner (GP) contracting for caesarean deliveries in five rural district hospitals in the Western Cape, South Africa. A regional hospital was also included to explore perceptions of public-private contracting needs amongst obstetric specialists. Between April 2021 and March 2022, we conducted 26 semi-structured interviews with district managers (n = 4), public sector medical officers (n = 8), an obstetrician in a regional hospital (1), a regional hospital manager (1) and private GPs (n = 12) with public service contracts. Thematic content analysis using an inductive, iterative approach was applied. Interviews with medical officers and managers revealed justifications for entering into these partnerships, including retention of medical practitioners with anaesthetic and surgical skills and economic considerations in staffing small rural hospitals. The arrangements held benefits for the public sector in terms of bringing in required skills and having after hours cover; and for the contracted private GPs who could supplement their income, maintain their surgical and anaesthetic skills and keep up to date with clinical protocols from visiting specialists. The arrangements held benefits for both the public sector and the contracted private GPs and were deemed to be an example of how national health insurance could be operationalised for rural contexts. Perspectives of a specialist and manager from a regional hospital provided insight into the need for different public-private solutions for this level of care in which contracting out of elective obstetric services should be considered. The sustainability of any GP contracting arrangement, such as described in this paper, will require ensuring that medical education programmes include basic surgical and anaesthetic skills training so that GPs opening practice in rural areas have the required skills to provide these services for district hospitals where needed.
ABSTRACT
OBJECTIVE: Researching how public-private engagements may promote universal access to safe obstetric care including caesarean delivery is essential. The aim of this research was to document the utilisation of private general practitioners (GPs) contracted to provide caesarean delivery services in five rural district hospitals in the Western Cape, the profile and outcomes of caesarean deliveries. We also describe stakeholder experiences of these arrangements in order to inform potential models of public-private contracting for obstetric services. DESIGN: We used a mixed-methods study design to describe rural district hospitals' utilisation of private GP contracting for caesarean deliveries. Between April 2021 and March 2022, we collated routine data from delivery and theatre registers to capture the profile of deliveries and maternal outcomes. We conducted 23 semistructured qualitative interviews with district managers, hospital-employed doctors and private GPs to explore their experiences of the contracting arrangements. SETTING: The study was conducted in five rural district hospitals in the Western Cape province, South Africa. RESULTS: The use of private GPs as surgeon or anaesthetist for caesarean deliveries differed widely across the hospitals. Overall, the utilisation of private GPs for anaesthetics was similar (29% of all caesarean deliveries) to the utilisation of private GPs as surgeons (33% of all caesarean deliveries). The proportion of caesarean deliveries undertaken by private GPs as the primary surgeon was inversely related to size of hospital and mean monthly deliveries. Adverse outcomes following a caesarean delivery were rare. Qualitative data provided insights into contributions made by private GPs and the contracting models, which did not incentivise overservicing. CONCLUSION: The findings of this study suggest that private GPs can play an important role in filling gaps and expanding quality care in rural public facilities that have insufficient obstetric skills and expertise. Different approaches to enable access to safe caesarean delivery are needed for different contexts, and contracting with experienced private GP's is one resource for rural district hospitals to consider.
Subject(s)
General Practitioners , Female , Pregnancy , Humans , South Africa , Hospitals, Public , Hospitals, District , Cesarean SectionABSTRACT
BACKGROUND: Evidence on the risk factors for COVID-19 hospitalization, mortality, hospital stay and cost of treatment in the African context is limited. This study aims to quantify the impact of known risk factors on these outcomes in a large South African private health insured population. METHODS AND FINDINGS: This is a cross sectional analytic study based on the analysis of the records of members belonging to health insurances administered by Discovery Health (PTY) Ltd. Demographic data for 188,292 members who tested COVID-19 positive over the period 1 March 2020-28 February 2021 and the hospitalization data for these members up until 30 June 2021 were extracted. Logistic regression models were used for hospitalization and death outcomes, while length of hospital stay and (log) cost per patient were modelled by negative binominal and linear regression models. We accounted for potential differences in the population served and the quality of care within different geographic health regions by including the health district as a random effect. Overall hospitalization and mortality risk was 18.8% and 3.3% respectively. Those aged 65+ years, those with 3 or more comorbidities and males had the highest hospitalization and mortality risks and the longest and costliest hospital stays. Hospitalization and mortality risks were higher in wave 2 than in wave 1. Hospital and mortality risk varied across provinces, even after controlling for important predictors. Hospitalization and mortality risks were the highest for diabetes alone or in combination with hypertension, hypercholesterolemia and ischemic heart disease. CONCLUSIONS: These findings can assist in developing better risk mitigation and management strategies. It can also allow for better resource allocation and prioritization planning as health systems struggle to meet the increased care demands resulting from the pandemic while having to deal with these in an ever-more resource constrained environment.
Subject(s)
COVID-19 , COVID-19/epidemiology , COVID-19/therapy , Cross-Sectional Studies , Health Expenditures , Hospital Mortality , Hospitalization , Humans , Male , South Africa/epidemiologyABSTRACT
The COVID-19 pandemic is likely to widen the health care demand-supply gap, especially in low- and middle-income countries (LMICs). The virus has had the greatest impact on older persons in terms of morbidity and mortality, and is occurring at a time of rapid population ageing, which is happening three times faster in LMICs than in high-income countries. Addressing the demand-supply gap in a post-COVID-19 era, in which resources are further constrained, will require a major 'reset' of the health system. In this article, we argue that the impact of ageing populations needs to be factored into the post-COVID-19 policy and planning reset including explicit, transparent prioritisation processes.
Subject(s)
COVID-19 , Developing Countries , Aged , Aged, 80 and over , Aging , Humans , Pandemics , Policy , SARS-CoV-2ABSTRACT
BACKGROUND: Monitoring Caesarean Section (CS) rates is essential to ensure optimal use of the procedure. Information on CS rates in the South African private sector is limited and information from this study will assist in planning for the proposed NHI in South Africa. OBJECTIVES: The objectives of this paper are to assess mode of delivery patterns and to determine CS rates amongst South African private health insurance scheme members; and to assess the extent to which CS rates are influenced by age and health status of the mother. METHODS: The 2015 claims for members of 10 health insurance schemes were analysed to assess delivery type patterns. Mode of delivery patterns were assessed by 6 delivery types: emergency, elective and "other" for caesarean deliveries; and non-assisted, assisted and "other" for vaginal deliveries; as well as by age and health condition of the mother. RESULTS: Of a total of 6,542 births analysed, 4,815 were CS giving a CS rate of 73·6% (95% CI 72·5%;74·7%). Emergency CS were the most common mode of delivery (39·7%), followed by elective CS (39·5%). CS rates increased with increasing maternal age and were higher for women with a medical condition. CONCLUSIONS: CS rates for the South African private sector are considerably higher than the safe rates recommended by the WHO. The high CS rates is a cause for concern for the health system under the proposed NHI. To support initiatives encouraging evidence based practice, further research is required to understand the drivers for the high CS rates.
Subject(s)
Cesarean Section , Delivery, Obstetric/methods , Adolescent , Adult , Cesarean Section/economics , Cesarean Section/statistics & numerical data , Cross-Sectional Studies , Delivery, Obstetric/economics , Delivery, Obstetric/statistics & numerical data , Fees and Charges , Female , Health Status , Humans , Infant, Newborn , Insurance, Health , Maternal Age , Maternal Health , Middle Aged , Pregnancy , Private Sector , South Africa , Young AdultABSTRACT
With more South Africans living past the age of 60, the country faces a growing chronic disease burden. Further research and action are needed for the health system to address the budgetary and social strains of this phenomenon effectively.
ABSTRACT
BACKGROUND: Influenza vaccination is regarded as the most effective form of prevention and is particularly recommended for individuals at increased risk of developing severe influenza. Data on uptake (coverage) and costs in South Africa are limited. METHODS: This study examined influenza vaccination uptake amongst South African private health insurance scheme members. All claims received for services rendered in 2015 were collated at an individual level and the claims related to the provision of influenza vaccines were analysed. RESULTS: Of the almost 520 000 members, overall 5.0% (95% CI 4.9%; 5.1%) received the influenza vaccine in 2015. Priority risk groups such as pregnant women, older adults and those with a medical condition were significantly more likely to be vaccinated, as were members belonging to insurance schemes that offered a specific influenza vaccine benefit. The average cost of providing the vaccination was R350. CONCLUSIONS: Influenza vaccination coverage was low in this privately insured population. There were more members vaccinated in the priority risk groups. There is an urgent need to implement strategies to increase this coverage in privately insured South Africans.
ABSTRACT
AIM: In the present study, we assessed the patterns and types of antibiotics prescribed following tooth extractions, and the alignment of these practices with the evidence available. METHODS: The study used health insurance claim data from South African dental practitioners for 2013, analyzing the antibiotic prescribing patterns around tooth extractions, separately for four event types: exposed (simple) tooth extractions in: (a) healthy patients and (b) patients with chronic conditions; and impacted tooth extractions in (c) healthy patients and (d) patients with a chronic condition. RESULTS: More than 50 000 extraction events were analyzed. The findings show no consistency in prescribing patterns. The same percentage (10%) of the healthy and the chronically ill patients undergoing an exposed (simple) tooth extraction were prescribed antibiotics, while approximately 50% of both healthy and chronically ill patient groups undergoing an impacted tooth extraction received a prescription. Almost 81% of prescriptions were for narrow spectrum antibiotics, with few differences across the four event types. CONCLUSIONS: The antibiotic prescription patterns of dental practitioners reported in the present study do not appear to follow a coherent set of guidelines or meaningful indications for antibiotic use. The study highlights the need for explicit and more prudent guidelines for the use of antibiotics following tooth extractions, to reduce the risk of antibiotic resistance.
Subject(s)
Anti-Bacterial Agents/therapeutic use , Drug Prescriptions/statistics & numerical data , Postoperative Care , Practice Patterns, Dentists' , Tooth Extraction , Adult , Aged , Female , Humans , Male , Middle Aged , South AfricaABSTRACT
OBJECTIVE: The first democratic government elected in South Africa in 1994 inherited huge inequalities in health status and health provision across all sections of the population. This study set out to assess, 4 years later, the influence of race and socioeconomic status (SES) on perceived quality of care from health care providers. DESIGN: A 1998 countrywide survey of 3820 households assessed many aspects of health care delivery, including levels of satisfaction with health care providers among different segments of South African society. RESULTS: Fifty-one percent (n = 1953) of the respondents had attended a primary care facility in the year preceding the interview and were retained in the analysis. Both race and SES were significant predictors of levels of satisfaction with the services of the health care provider, after adjusting for gender, age, and type of facility visited. White and high SES respondents were about 1.5 times more likely to report excellent service compared with Black and low SES respondents, respectively. CONCLUSION: In South Africa, race and SES are not synonymous and can no longer be considered reliable proxy indicators of one another. Each has distinct and significant but different degrees of association with client satisfaction. Any assessment of equity-driven health policy in South Africa should consider the impacts of both race and SES on client satisfaction as one of the indicators of success.