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.

Towards developing new private sector obstetric care and contracting models in South Africa: Insights from public hospitals using private general practitioners to provide caesarean deliveries

“…The methods and findings of the research that informed this practice article are described in detail elsewhere, [13][14][15] and we summarise here only the key findings and insights from the research and the thought process in using those insights for proposing an alternative model of private obstetric care.…”

“…The implications of scaling up these models within district hospitals is explored in our previously published articles. [13][14][15] The research examined contracting models adopted by rural district hospitals to contract private GPs for caesarean deliveries. In order to be able to use the insights from this research, which was conducted in a specific rural setting, to inform the development of an alternative private obstetric care model for SA as proposed in this article (and to inform the development of alternative models more broadly in other settings), we identified the key underlying features that we believe were critical to the delivery of appropriate care at the five hospitals.…”

“…[12] We carried out research to examine the care and contracting models used by five rural district hospitals in the Western Cape Province to contract private general practitioners (GPs) to provide caesarean delivery services. [13][14][15] Drawing on insights from the research, this article outlines a potential alternative model for private sector obstetric care with the aim of stimulating discussion by all relevant stakeholders on the development of new obstetric models in SA.…”