The market for primary health care in South Africa represents a growing opportunity for private providers targeting lower income employed workers, who often prefer not to use the public sector. A new model of service provision is emerging in the form of private companies providing fixed price primary care services in urban areas. Whilst the range of services delivered was quite limited compared to the public sector, apparently effective delivery, clearly better patient experiences, and a similar cost to the public sector, all suggest that the public sector can learn about some aspects of service delivery from these companies.

Researchers from the London School of Hygiene and Tropical Medicine and the Centre for Health Policy, University of Witwatersrand, used a case-study approach to evaluate the performance of the main primary care provider models in South Africa.  The private clinic company chosen as an example was selected because it was the largest, longest established and most geographically dispersed of the clinic chains in existence at the time of the study. 

Organisation of the clinic chain was structured and hierarchical.  At all clinics, a computerised system was used as an aid to diagnosis and to access recommended treatment protocols.  The system also recorded all drugs dispensed and checked them against the treatment protocols it had recommended.  Head office was thus able to review and audit clinical practice and to track costs on a daily basis. Clinical staff were working in a very structured environment relative to their colleagues in other forms of private practice.  Clinic managers were supervised by area managers based at the company’s head office, to which clinical and financial data were transmitted daily.

Experience of using the private facilities was positive. Users were happy with the clinics’ service provision, and cited feelings of being treated promptly and with respect. Cost per patient visit at the private chain clinics was within the range of public service providers and considerably lower than in private general practice. Furthermore:

• Standards in the clinics were excellent in terms of cleanliness, space and availability of drugs and equipment.  Waiting times were usually 10 to 40 minutes, far shorter than the 50 minutes to 3 hours recorded in public sector facilities.
• The technical quality of curative care in the private clinics was high.

However, continuity of chronic care provided by the clinics was poor, most likely because of the charges.  Some services including immunisations and treatment of TB were not available, and patients were referred on to the public sector or general practice for such treatments.  It appeared that patients used the clinics selectively, mainly for curative care, using the public sector for chronic conditions and out-of-hours emergencies. Such ‘dual’ use of public and private sectors by patients is unlikely to be efficient or to provide the best quality of care, raising issues of the desirability of limited-scope private providers for reaching broader public health goals of equity and efficiency.

Contracting could be used to draw these clinics into public sector service delivery.  However, their current geographic focus on peri-urban areas, where the public sector is already well established, reduces the potential for this. Nevertheless, important lessons for health sector policy-makers from these new models should not be overlooked:

• The private clinics managed to achieve high user ratings while tightly controlling staff time and drug resources, suggesting that other aspects of perceived quality, such as short waiting times and staff attitudes, are important to users.
• The public sector can learn much about delivering acceptable primary care services at low cost from this private sector model. It shows that care can be made more acceptable to users without increasing resource use.

Source(s):
‘A new face for private providers in developing countries: what implications for public health?’, Bulletin of the World Health Organisation 81(4): 292-297, by N. Palmer et al., 2003 Full document.

Funded by: UK Department for International Development

id21 Research Highlight: 20 May 2004

Further Information:
Natasha Palmer
Health Economics and Financing Programme
Department of Public Health and Policy
London School of Hygiene and Tropical Medicine
London WC1E 7HT
UK 

Contact the contributor: Natasha.palmer@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

University of the Witwatersrand, South Africa

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