Models using private general practitioners to provide caesarean deliveries at five South African district public hospitals: insights for public-private contracting for obstetric care in rural areas

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.

KEYWORDS:

• Obstetric care
• public-private partnership
• Sub-Saharan Africa
• national health insurance
• universal health coverage

Responsible Editor

Maria Emmelin

Responsible Editor

Maria Emmelin

Acknowledgments

We thank all the health professionals who took the time to participate in our interviews and to the hospital managers for facilitating access to the obstetric registers. Institutional support to the study authors provided by the South African Medical Research Council (SAMRC), the University of Cape Town and the Clinton Health Access Initiative is acknowledged.

Author contributions

GS, TD, ED and SF conceptualised the study; TD, GS, ED and SF analysed the data; all authors contributed to the interpretation of the data, writing the paper and reviewing the content.

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics and consent

Ethics approval was granted by the South African Medical Research Council Human Research Ethics Committee (approval number EC003–2/2021) and permission was also granted by the Western Cape Provincial Department of Health and Wellness (approval number WC_202103_017) and the managers of the health facilities. No personal identifying information was captured from hospital records, only aggregated summary information.

All health professionals who were approached to participate in an interview were read an information sheet outlining the expectations in terms of length of the discussion, the voluntary nature of the participation and measures to ensure confidentiality. Health professionals who agreed to participate in an interview signed an informed consent form.

Paper context

Harnessing private sector resources could play an important role in promoting safe obstetric care in rural contexts but any such attempt would have to ensure that appropriate care is appropriate. Policymakers should develop a ‘contracting framework’ which requires compliance with underlying principles but allows for flexibility in developing context specific contracting arrangements. The principles include a ‘risk’ based delivery model, adherence to public sector protocols, time-based remuneration models, group liability arrangements, and outcome monitoring.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/16549716.2023.2241811.

Additional information

Funding

The study was funded by the Bill and Melinda Gates Foundation [Grant Agreement ID INV-023276].