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

Abstract

Background: The 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.

Methods: This 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.

Results: Three 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.

Conclusion: The 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.

Keywords: Contracting; Contracting-in; General practitioner; Health policy and systems research; Low-and-middle-income countries; Non-state provider; Primary health care; Public private sector; South Africa; Universal health care.

Fig. 1

Centralized-purchaser model.The NDOH as the purchaser directly recruits and contracts GPs. Contracts are signed by a district manager (DM) an authorized signatory at NDOH. Placement, orientation, training, supervision and monitoring of GPs are done by staff at the district health office (DHO). GPs provide PHC services to patients attending PHC clinics with day-to-day oversight from a Facility Manager (FM). GPs are paid monthly by an external payroll company on behalf of the NDOH. This is effected on submission of a completed timesheet, signed and verified by the FM, GPCI Coordinator and DM. The DM is the final signatory required to effect payment. The DHO compiles and submits monthly and quarterly reports to the NDOH, containing information on the number of GPs appointed, hours worked and the estimated number of patients seen per hour

Fig. 2

Contracted-purchaser model.The purchaser is an independent Service Provider (SP) contracted to manage implementation of the GPCI on behalf of the MOH. The SP - a large South African health not-for-profit organization with a national footprint – sub-contracts a variety of organizations which assume different roles in the contract management process. These organizations act as a Consortium, which is responsible for advertisement, recruitment, contracting, supervision, monitoring and payment. Recruited GPs are contracted directly by the SP, and their contracts are signed by the GP and an authorized signatory of the SP. Once a GP is appointed, the SP liaises with the DHO to determine a facility for placement. A district-based support partner (DSP) in each district – a sub-contracted district-based organization which is funded to support local health system strengthening – is then responsible for orientation, training, supervision, monitoring and performance management of the GPs. At a facility level, the FM is responsible for overseeing daily activities. GPs are paid monthly upon submission of a timesheet that is verified and co-signed by the FM, an authorized representative of the DSP and the SP’s project manager at the national office. The timesheets are then submitted to the SP’s finance department for verification and payment. The SP submits monthly and quarterly performance reports to the NDOH

Fig. 3

Decentralized-purchaser model.The provincial department of health (PDOH) is the purchaser. The GP enters a contract with the PDOH represented by the DHO, and the contract is signed by the GP and DM (as a representative of the PDOH). Recruitment and placement are done by the sub-district health office in conjunction with the DHO. The sub-district manager (SDM) is responsible for orientation, training, supervision and monitoring of GPs. GPs provide PHC services to patients attending PHC clinics with day-to-day oversight from a Facility Manager (FM). GPs are placed on the DHO payroll and paid at the end of the month based on the number of hours indicated in the contract. The GPs complete monthly timesheets that are in turn verified and signed by the FM, SDM, GPCI Coordinator and DM. These timesheets are not used to effect payment, but rather as an oversight mechanism to confirm the number of hours worked. The sub-district health office compiles and submits monthly and quarterly reports to the DHO and PDOH for review and submission to the NDOH