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Improving the quality of primary health care: public and private provision
Anne Mills, Natasha Palmer, Lucy Gilson, Di McIntyre, Helen Schneider, Edina Sinanovic and Haroon Wadee
2005-01-14

The quality of primary health care (PHC) delivered to people in developing countries is often poor and coverage is not yet universal. This is despite a focus on the public delivery of comprehensive PHC over the past 20 years. People frequently consult private providers including qualified medical professionals and unqualified health practitioners. A better use of private care providers, therefore, might be a potential solution, including contracting them to provide services on behalf of the public sector.

Research from the London School of Hygiene and Tropical Medicine, the University of Witwatersrand and the University of Cape Town examines the performance of various models of PHC provision in South Africa. It attempts to determine the strengths and weaknesses of private and public provision of primary care and the potential for increased arrangements between the public and private sectors. It assesses whether private providers give good quality service at a cost that is comparable to that of the public sector. The different models considered were individual General Practitioner (GP) contracts commercial companies running PHC clinics on contracts physicians in independent or group practices commercial companies running clinic chains and the public integrated model of clinics.

Performance was measured by looking at the cost and quality of providers in terms of their infrastructure, treatment given and acceptability to patients. While it emerged that there were clear distinctions between the different models, it was found that performance was strongly influenced by the context of each type of service provision and thus simply comparing public with private providers was not helpful. Moreover, the performance of private providers may well alter, if the introduction of a contract changes the context of the service provision.

One of the elements that varied among the different models was cost structure and this clearly had clear consequences for the quality and acceptability of care provided. Contracted GPs committed most expenditure to their own salaries and to drugs, while relatively low expenditure on premises resulted in a lack of equipment, and a cramped and poorly maintained environment. In contrast the private clinic chain model, generally enjoyed facilities of high structural quality.

The main findings of the report were the following:

• Care delivered by two of the private provider models contracted GPs and the clinic chain was comparable to public sector care in terms of cost per patient.
• There were no private care provider models that consistently showed a better overall technical quality of care than public clinics. Care by GPs lacked standardisation and the clinic chain failed to deliver standardised chronic care.
• Users perceived the quality of service of private providers except for contracted GPs to be far superior to that of others.
• The performance of both models involving contracts was badly affected by weak contract design and implementation.
• It is important to recognize that there is great variety among the private providers with whom the public care sector might contract, and differences in their operational methods and structures. There are implications for contract design:The method of payment should not create negative incentives for care providers, such as a very high patient turnover as seen in the case of contracted GPs.
• User power needs to be encouraged if possible such as providing them with a voice, for example, in community management of clinics, or the ability to exit care provision, for instance by providing them with vouchers to pay for care.
• Since it is difficult to monitor performance even where the service is provided under contract, primary care providers who are to be contracted should be selected carefully. The clinic chain had an advantage in that it had good internal monitoring and evaluation mechanisms, however the influence of its for-profit motivations would need to be countered by good contract management.

This research highlights the importance of understanding how provider performance is affected by the differences in context and structure. As private and public providers both exhibit good and bad practice and the use of resources, the merits of contracting out care to private service providers should be decided on the basis of each individual case.

(Source: id21 Research Highlight: November, 25, 2004)

Further information contact:
Anne Mills, Health Economics and Financing Programme, London School of Hygiene and Tropical Medicine (LSHTM) Email: Anne.Mills@lshtm.ac.uk

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