Emergence of three general practitioner contracting-in models in South Africa: a qualitative multi-case study

Abstract

BackgroundThe general practitioner contracting initiative (GPCI) is a health systems strengthening initiative piloted in the first phase of national health insurance (NHI) implementation in South Africa as it progresses towards universal health coverage (UHC). GPCI aimed to address the shortage of doctors in the public sector by contracting-in private sector general practitioners (GPs) to render services in public primary health care clinics. This paper explores the early inception and emergence of the GPCI. It describes three models of contracting-in that emerged and interrogates key factors influencing their evolution.MethodsThis qualitative multi-case study draws on three cases. Data collection comprised document review, key informant interviews and focus group discussions with national, provincial and district managers as well as GPs (n = 68). Walt and Gilson’s health policy analysis triangle and Liu’s conceptual framework on contracting-out were used to explore the policy content, process, actors and contractual arrangements involved.ResultsThree models of contracting-in emerged, based on the type of purchaser: a centralized-purchaser model, a decentralized-purchaser model and a contracted-purchaser model. These models are funded from a single central source but have varying levels of involvement of national, provincial and district managers. Funds are channelled from purchaser to provider in slightly different ways. Contract formality differed slightly by model and was found to be influenced by context and type of purchaser. Conceptualization of the GPCI was primarily a nationally-driven process in a context of high-level political will to address inequity through NHI implementation. Emergence of the models was influenced by three main factors, flexibility in the piloting process, managerial capacity and financial management capacity.ConclusionThe GPCI models were iterations of the centralized-purchaser model. Emergence of the other models was strongly influenced by purchaser capacity to manage contracts, payments and recruitment processes. Findings from the decentralized-purchaser model show importance of local context, provincial capacity and experience on influencing evolution of the models. Whilst contract characteristics need to be well defined, allowing for adaptability to the local context and capacity is critical. Purchaser capacity, existing systems and institutional knowledge and experience in contracting and financial management should be considered before adopting a decentralized implementation approach.Electronic supplementary materialThe online version of this article (10.1186/s12939-018-0830-0) contains supplementary material, which is available to authorized users.

Moving towards universal health coverage: engaging non-state providers

“…The sixth article in the collection, by Mureithi et al [ 18 ], examines policy processes underlying the evolution and emergence of three contracting models under South Africa’s General Practitioner Contracting Initiative (GPCI) pilot. This contracting-in mechanism to address public sector physician shortfalls was piloted as part of the country’s National Health Insurance program.…”

Contracting non-state providers for universal health coverage: learnings from Africa, Asia, and Eastern Europe

“…This insurance program, which is yet to be implemented, will eventually be established as a single-payer and single-purchaser model to strategically purchase health care services from a mix of private and public providers. However, findings from the South Africa study suggests that the insurance program’s potential will be constrained by the limited capacity of the public sector to deliver primary care services [ 16 ]. For example, around 82% of the population depends on public services, yet roughly half of the overall health expenditure in the country goes to the private sector [ 16 ].…”

“…However, findings from the South Africa study suggests that the insurance program’s potential will be constrained by the limited capacity of the public sector to deliver primary care services [ 16 ]. For example, around 82% of the population depends on public services, yet roughly half of the overall health expenditure in the country goes to the private sector [ 16 ]. One of the fundamental challenges is that human resources in the health sector are overwhelmingly present in the private sector.…”

How and why policy-practice gaps come about: a South African Universal Health Coverage context

“…This challenge sums it all. Progress towards UHC have been made 27 and initiatives like bringing doctors into the clinics 66 and central chronic medicine dispensing have been met with success. 37 The focus of this paper is on understanding how policy-practice gaps come about 32 , hence successful policy outcomes were not dwelt upon.…”