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

Geetesh Solanki; Emmanuelle Daviaud; Sue Fawcus; Vishal Brijlal; Tanya Doherty

doi:10.1080/16549716.2023.2241811

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

Glob Health Action. 2023 Dec 31;16(1):2241811. doi: 10.1080/16549716.2023.2241811.

Authors

Geetesh Solanki^{1

2

3}, Emmanuelle Daviaud¹, Sue Fawcus⁴, Vishal Brijlal⁵, Tanya Doherty^{1

6}

Affiliations

¹ Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa.
² Honorary Research Associate: Health Economic Unit, University of Cape Town, Cape Town, South Africa.
³ NMG Consultants and Actuaries, Cape Town, South Africa.
⁴ Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa.
⁵ Clinton Health Access Initiative, Pretoria, South Africa.
⁶ Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa.

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; Sub-Saharan Africa; national health insurance; public-private partnership; universal health coverage.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Cesarean Section
Female
General Practitioners*
Hospitals, Public
Humans
Pregnancy
Public Sector
South Africa

Grants and funding

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