Embedding quality at the core of universal health coverage in South Africa South Africa's White Paper on National Health Insurance 1 represents the government's statement of intent on achieving universal health coverage (UHC)ie, to provide all people with access to a common set of comprehensive health services of sufficient quality, while also ensuring that the use of these services does not expose the user to financial hardship. The White Paper recognises that the health and development of South Africans is largely dependent on the social determinants of health, and that the best way to obtain improved health outcomes is through a multisectoral, multistakeholder primary health-care (PHC) approach that puts the individual at the centre of health and development programmes. The White Paper recognises that service coverage and affordability are crucially important, but not sufficient, to ensure achievement of UHC. As such, a strong emphasis is placed on improving the quality of care at the entry point into the health care system (ie, the PHC system). In South Africa, although PHC facilities are the communities' first point of contact with the health system, inadequate service provision, overburdened clinics with long queues, and poor quality of services has resulted in many people bypassing PHC facilities and going straight to hospital outpatient departments where services are perceived to be better. The National Department of Health thus started preparation for UHC through National Health Insurance by improving the quality of PHC services. The Department's rationale was that improved PHC services would increase communities' confidence in these services, and decrease the occurrence of PHC services being bypassed. The Ideal Clinic Realisation and Maintenance (ICRM) programme was designed in response to the deficiencies in the quality of PHC services, and to lay a strong foundation for the implementation of National Health Insurance. An ideal clinic is defined as a clinic with good infrastructure (ie, physical condition and spaces, essential equipment, and information and communication tools), adequate staff numbers, adequate medicines and supplies, good administrative processes, and adequate bulk supplies; such a clinic uses applicable clinical policies, protocols, and guidelines,

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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.