Voir page 296 le resume en francais. En la pagina 296 figura un resumen en espanol.
The use of private health care providers in low- and middle-income countries (LMICs) is widespread and its implications are the subject of continuing debate (1-6). One view is that private providers are likely to be more efficient than the public sector and hence that government should contract out services to the private sector. An alternative view is that private providers are often not superior in quality or efficiency to the public sector, and that contracts are not straightforward to design and implement. Finally, there is increasing recognition that neither public nor private providers have uniform characteristics, and that this distinction might overlook more important issues, such as the extent to which a provider uses public funds efficiently and serves the goals of public health (3).
The present paper contributes to this debate by describing a new model of private primary care provision emerging in South Africa, in which private companies provide standardized primary care services at a relatively low cost. Drawing on data from several case studies carried out across a range of South African primary care facilities, the paper compares aspects of service delivery by one such company with the most likely alternatives for patients on a low income: a private general practitioner or a public sector clinic. The final part of the paper discusses the opportunities and threats presented by this new model and its potential as a partner for the public sector in health service delivery.
Public sector primary care is free in South Africa, yet around 30% of people without medical insurance still choose to pay out of their own pocket to attend facilities in the private sector. Even in the lowest income quintile this proportion is estimated to be 20% (7). The market for private patients is lucrative and most general practitioners are in private practice (8). The high use of the private sector is partly due to the inaccessibility of public services, but in urban areas it might be because of perceptions of greater privacy (9, 10), speed of service (10), and quality of diagnosis, prescribing and counselling (11-14). Such perceptions aside, other evidence suggests that general practitioners often deliver care of questionable technical quality, especially with respect to the quality of diagnosis and use of appropriate drugs, indicating that there is scope for improvement of the services on offer (15, 16). The profits to be made from out-of-pocket payment for primary care services are encouraging the formation of private companies aiming to compete with general practices by running clinics with higher standards of patient care at a lower charge. Patients attending these clinics pay a flat fee per visit (which includes drugs, laboratory tests, and X-rays) or are covered by low-cost medical insurance schemes. Currently, there are more than 100 such private, branded, primary care clinics in South Africa owned by a handful of companies (exact numbers fluctuate in a highly competitive market), and some companies have already opened clinics in the main cities of neighbouring countries. Larger companies are achieving widespread coverage and brand recognition. Some company managers have also expressed an interest in contracting with the government to deliver services on their behalf, but as yet they have had no clear response from the South African Department of Health.
The private clinic company used as an example in this paper was evaluated as part of a larger study examining the potential of a range of private providers to deliver services on behalf of the South African government. It was selected because it was the largest, most geographically dispersed, and long-established of the clinic chains active in the market at the time of the research. The company ran clinics in urban areas throughout South Africa, which were usually located close to centres of employment such as factory complexes. …