Despite the emphasis placed over the last two decades on public delivery of comprehensive and equitable primary care to developing country populations, coverage remains far from universal and quality often poor. Users often patronise private providers, ranging from informal drug sellers to trained professionals. Interest is increasing on the potential for making better use of private providers, including contractual approaches. The research aim was to examine the performance of different models of primary care provision, in order to identify their strengths and weaknesses from the perspective of a government wishing to develop an overall strategy for improving primary care provision. Models evaluated were: (a) South African general practitioners district surgeons providing services under public contracts; (b) clinics provided in Lesotho under a sub-contract between a construction company and a South African health care company; (c) GP services provided through an IPA to low income insured workers and families; (d) a private clinic chain serving low income insured and uninsured workers and their families; and (e) for comparative purposes, South African public clinics. Performance was analysed in terms of provider cost, and quality of infrastructure, treatment practices, acceptability to patients (and communities). The diversity of the arrangements made direct comparisons difficult; however, clear differences were identified between the models and conclusions drawn on their relative performance and the influences upon performance. The study findings demonstrate the strong influence of contextual features over provider performance; indicate that a crude public/private comparison is not helpful; and highlight key issues in contract design likely to influence performance. Finally, the study argues that there is a need, before contracting out service provision, to consider how the performance of private providers might change when the context within which they are working changes with the introduction of a contract.
Mills, A.; Palmer, N.; Gilson, L.; McIntyre, D.; Schneider, H.; Sinanovic, E.; Wadee, H. The performance of different models of primary care provision in Southern Africa. Social Science and Medicine (2004) 59 (5) 931-943. [DOI: 10.1016/j.socscimed.2003.12.015]