Perceived quality of primary healthcare post-National Health Insurance pilot implementation

Hillary Mukudu,Adam Fusheini,Caiphus Moloto,Jude Igumbor,Kennedy Otwombe

doi:10.4102/hsag.v26i0.1580

Abstract

BackgroundContracting private medical practitioners for the National Health Insurance pilot project in 2012 by the National Department of Health in South Africa was envisaged to reduce workload at referral district hospitals by reducing self-referral by clients as the perceived quality of care at the primary healthcare level improves.AimTo describe the effect of contracting private medical practitioners at primary healthcare facilities on the self-referral rate of clients at district hospitals as a proxy for perceived quality of care in a National Health Insurance pilot district.SettingThe study was set in Tshwane National Health Insurance pilot district compared to Ekurhuleni district.MethodsWe compared findings before and after implementing the National Health Insurance private medical practitioners contracting between a pilot and a non-pilot district. A quasi-experimental ecological study design was used to compare district hospital outpatient department indicators of clients follow-up, self-referral, self-referral rate and referred in the two districts from June 2012 to May 2014 using single and controlled interrupted time-series analyses.ResultsControlled interrupted time series analysis found decreases in self-referral rate (−1.8 [−2.2, −1.1] [p < 0.0001]) and the initial trend of headcounts of self-referral (−516 [−969, −66] [p = 0.0260]), but an increase in headcounts of referred clients (1293 [77, 2508] [p = 0.0376]) in the pilot compared with the non-pilot district.ConclusionWe concluded that the implementation of contracting private medical practitioners in primary healthcare facilities might have resulted in an improved perceived quality of care at primary health care facilities. However, the higher number of outpatient department headcounts for follow-up and the increase in referred cases in the pilot district would need to be investigated.

Highlights

Understanding the effects of the perceived quality of primary healthcare (PHC) is critical to the attainment of universal health coverage (UHC) globally (World Health Organization 2019)
A pre- to post-National Health Insurance (NHI) comparison of all measured outpatient departments (OPD) indicators (Table 3) showed increases that were more pronounced in Ekurhuleni district than in Tshwane district, except for the OPD headcounts not referred, which was reduced
These controlled interrupted time series analysis (CITSA) findings of a reduction in self-referral and self-referral rate could be explained by the implementation of medical practitioners (MPs) contracting in the pilot district and are in line with findings in countries that have implemented some form of UHC with strong PHC, such as the United Kingdom, and contrast to those without, such as the United States of America (Forrest 2003:692–695)

Summary

Introduction

Understanding the effects of the perceived quality of primary healthcare (PHC) is critical to the attainment of universal health coverage (UHC) globally (World Health Organization 2019). In South Africa, structural challenges with the public PHC system have contributed to a perception of poor quality of services, which include a shortage of staff, poor staff attitudes, long waiting times, low standards of cleanliness, drug stock-outs, poor infection control and inadequate security for both staff and clients and the nonavailability of integrated patient-level health information system for data collection and reporting (National Department of Health, South Africa [NDoH] 2015) All this is happening at the time when the country is experiencing a convergence of epidemiological challenges as a result of human immunodeficiency virus or acquired immunodeficiency syndrome (HIV or AIDS) and antiretroviral treatment, non-communicable diseases (NCDs) such as hypertension, diabetes mellitus, asthma, cancers, cardiac diseases, mental health problems and other lifestylerelated diseases and complex social and behavioural changes and injuries (NDoH South Africa 2015).

Objectives

Methods

Results

Discussion

Conclusion