Contracting of private medical practitioners in a National Health Insurance pilot district: What has been the effect on primary healthcare utilisation indicators?

  • African Journal of Primary Health Care and Family Medicine, Volume 12, No. 1, Year 2020

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Study Justification:
The study aimed to investigate the effect of contracting private medical practitioners (MPs) on the utilization of primary healthcare (PHC) services in a National Health Insurance (NHI) pilot district in South Africa. This study is important because it evaluates the impact of a key component of the NHI program and provides insights into the effectiveness of contracting private MPs in improving access to healthcare.
Highlights:
– The study used a quasi-experimental ecological study design to compare PHC utilization indicators in the NHI pilot district with a non-pilot district.
– Single interrupted time series analysis showed an increase in adults remaining on anti-retroviral therapy, clients seen by a nurse practitioner, and clients aged 5 years and older in both districts.
– Controlled interrupted time series analysis found no difference in all parameters before and after the intervention.
– The increase in PHC utilization in the pilot district may not be solely attributable to the implementation of contracting private MPs, but likely the result of other healthcare reforms and transitions taking place in both districts around the same time.
Recommendations:
Based on the findings of the study, the following recommendations can be made:
1. Further research should be conducted to evaluate the specific impact of contracting private MPs on PHC utilization indicators, taking into account other healthcare reforms and transitions.
2. The NHI program should continue to monitor and evaluate the effectiveness of contracting private MPs in improving access to healthcare and consider adjustments to the implementation strategy if necessary.
3. Policy makers should consider implementing complementary interventions alongside contracting private MPs to ensure comprehensive and effective healthcare delivery.
Key Role Players:
1. National Department of Health: Responsible for overseeing the implementation of the NHI program and contracting private MPs.
2. District Health Management Information System officers: Collect and collate data on PHC utilization indicators.
3. Healthcare providers: Private medical practitioners contracted under the NHI program.
4. Provincial government: Provides support and resources for the implementation of the NHI program.
Cost Items:
1. Contracting private medical practitioners: Budget allocation for the payment of contracted private MPs.
2. Data collection and analysis: Funding for the collection and analysis of PHC utilization data.
3. Monitoring and evaluation: Resources for monitoring and evaluating the effectiveness of contracting private MPs.
4. Implementation of complementary interventions: Budget allocation for the implementation of additional interventions to support the NHI program.
Please note that the cost items mentioned are for planning purposes and do not represent actual costs. The actual budget allocation would depend on various factors and would need to be determined by the relevant authorities.

The strength of evidence for this abstract is 5 out of 10.
The evidence in the abstract is not very strong. While the study design is described as quasi-experimental, the findings suggest that the increase in primary healthcare utilization in the pilot district may not be attributable to the contracting of private medical practitioners. The study relies on secondary data collected from the District Health Management Information System, which may have limitations. To improve the strength of the evidence, the study could consider using a randomized controlled trial design, collecting primary data, and including a larger sample size. Additionally, the study could explore other potential factors that may have influenced the increase in healthcare utilization in the pilot district.

Background: In 2012, the National Department of Health in South Africa started contracting of private medical practitioners (MPs) as part of the first phase of National Health Insurance (NHI) in 11 pilot districts to improve access to healthcare. Aim: The aim of this study was to describe the effect of contracting private MPs on the utilisation of primary healthcare (PHC) services in public healthcare facilities. Setting: A National Health Insurance pilot district compared to a non-pilot district. Methods: A quasi-experimental ecological study design was used to compare selected PHC utilisation indicators in the District Health Management Information System from June 2010 to May 2014 between a pilot and a non-pilot district. Both single and controlled interrupted time series analyses were used for comparing before and after implementation of the intervention. Findings: Single interrupted time series analysis showed an increase in adults remaining on anti-retroviral therapy, clients seen by a nurse practitioner and clients 5 years of age and older in both districts. However, controlled interrupted time series analysis found no difference in all parametres. Despite a decrease in total headcounts in both districts using single interrupted time series analysis, controlled interrupted time series analysis found no differences in all parameters before and after the intervention. Conclusions: The increase in utilisation of PHC services in the pilot district may not be attributable to the implementation of contracting private MPs, but likely the result of other healthcare reforms and transitions taking place in both districts around the same time.

We adopted a quasi-experimental ecological study to investigate the causal effect of private MPs contracting on utilisation of PHC services of the NHI pilot programme in a pilot NHI district by comparing utilisation of PHC services with a non-NHI pilot district. The study was conducted in one of the NHI pilot districts of South Africa, which has a population of 2 921 488 people, receiving PHC services from 68 facilities (PHC facility ratio of 1:36 980). The estimated medical scheme coverage in the district at the time of the study was 33.2%, and the Department of Health (DoH) expenditure on PHC was 56.7%.21 It is also the most diverse district in terms of socio-economic status of the population. The findings were compared with those in a non-NHI district with a population of 3 178 470 people accessing 90 PHC facilities (PHC facility ratio of 1:42 421). The estimated medical scheme coverage was 25.5% and DoH expenditure on PHC services was 83.1%.21 Selection of comparison district was not only based on proximity of the two districts but also on similarities in demographic profiles, being under the same provincial government and uniformity in the implementation of health programmes. The districts also have a similar burden of disease profile as measured by death by broad cause, namely, injuries, non-communicable diseases, HIV, TB and communicable diseases.22 We studied the population of children above 5 years old and adults utilising public PHC facilities in an NHI pilot and a non-NHI district from June 2010 to May 2014. However, PHC clients utilising services less likely to be affected by the presence of MPs at the community clinics (nurse-driven services), such as maternal, child health and reproductive services, were excluded from the study.23 In this study, we used routinely collected secondary data. District Health Management Information System monthly reports from June 2010 to May 2014 for the two districts were collated. Each PHC facility in the district collected data and sent them to a DHMIS officer, who created electronic formats (in Microsoft Excel). Data in DHMIS were deemed complete for the selected variables as the values for the elements were reported monthly for the period of the study. We used PHC headcounts because PHC is the focus of the implementation of the first phase of the NHI pilot programme. The complete list of variables, definitions, use, impact model and mechanism of the impact model is shown in Table 1. Definitions and impact model of primary healthcare data elements and indicators in District Health Management Information System. PHC, primary healthcare; ART, anti-retroviral therapy; MP, medical practitioner. The use of a comparison district was done to control for time varying confounders. Interrupted time series analysis (ITSA) compared selected PHC data elements across time within the single population of an NHI pilot district accounting for underlying trends in the outcomes, which avoids between-group differences such as selection bias of unmeasured confounders. However, this did not exclude confounders, which do not form part of the underlying trend, such as interventions or events occurring around the time of the NHI pilot project. To limit these threats, we selected a control district of a non-NHI pilot district to control for other examples of time varying co-interventions implemented in both districts that could affect the outcomes. The selection of variables and time points was based on requirements of analysis using both single and controlled ITSA.24 We measured and compared selected monthly PHC headcounts in the two districts, which met the criteria of ability to change relatively quickly after the implementation of MPs contracting or after a clearly defined lag.24,25 The unit measure for selected data points was months as per DHMIS reporting. A total of 48 time periods, with 24 before (June 2010 to May 2012) and 24 after (June 2012 to May 2014) implementation of contracting MPs, were selected. The minimum required for ITSA is 10 before and 10 after implementation of a programme to have at least 80% power. The selection can detect a change level of at least 5 standard deviations of the pre-data if the autocorrelation is > 0.4.26

N/A

Based on the provided description, it appears that the study focused on the effect of contracting private medical practitioners (MPs) on the utilization of primary healthcare (PHC) services in a National Health Insurance (NHI) pilot district. The study used a quasi-experimental ecological study design and compared selected PHC utilization indicators between the pilot district and a non-pilot district. The study analyzed data from June 2010 to May 2014 and used interrupted time series analysis to assess the impact of contracting private MPs on PHC utilization.

The findings of the study showed an increase in adults remaining on anti-retroviral therapy, clients seen by a nurse practitioner, and clients 5 years of age and older in both the pilot and non-pilot districts. However, the controlled interrupted time series analysis found no difference in all parameters before and after the intervention. Therefore, the increase in PHC utilization in the pilot district may not be solely attributable to the implementation of contracting private MPs, but could be influenced by other healthcare reforms and transitions taking place in both districts around the same time.

It is important to note that the study excluded PHC clients utilizing services less likely to be affected by the presence of MPs, such as maternal, child health, and reproductive services. The study used routinely collected secondary data from the District Health Management Information System (DHMIS) and compared selected PHC headcounts in the two districts.

Overall, the study provides insights into the impact of contracting private MPs on PHC utilization in the context of the NHI pilot program. However, further research may be needed to fully understand the specific effects on access to maternal health services and to explore additional innovations that can improve access to maternal health within the NHI framework.
AI Innovations Description
The study described in the provided text aimed to investigate the effect of contracting private medical practitioners (MPs) on the utilization of primary healthcare (PHC) services in a National Health Insurance (NHI) pilot district in South Africa. The study used a quasi-experimental ecological study design and compared selected PHC utilization indicators between the pilot district and a non-pilot district.

The findings of the study showed that there was an increase in adults remaining on anti-retroviral therapy, clients seen by a nurse practitioner, and clients 5 years of age and older in both districts. However, when controlled interrupted time series analysis was conducted, no differences were found in all parameters before and after the intervention. This suggests that the increase in utilization of PHC services in the pilot district may not be solely attributable to the implementation of contracting private MPs, but could be the result of other healthcare reforms and transitions taking place in both districts around the same time.

The study used routinely collected secondary data from the District Health Management Information System (DHMIS) for the selected variables. The comparison district was selected to control for time-varying confounders, and interrupted time series analysis was used to compare selected PHC data elements across time within the single population of the NHI pilot district.

It is important to note that this study focused on the utilization of PHC services and did not include services such as maternal, child health, and reproductive services, which are less likely to be affected by the presence of MPs at community clinics.

Overall, the study provides insights into the impact of contracting private MPs on the utilization of PHC services in the context of the NHI pilot program. However, further research is needed to fully understand the causal relationship between contracting private MPs and improving access to maternal health.
AI Innovations Methodology
The study described in the provided text used a quasi-experimental ecological study design to assess the impact of contracting private medical practitioners (MPs) on the utilization of primary healthcare (PHC) services in a National Health Insurance (NHI) pilot district compared to a non-pilot district. The methodology employed both single and controlled interrupted time series analyses to compare selected PHC utilization indicators before and after the implementation of the intervention.

Here is a brief description of the methodology used to simulate the impact of recommendations on improving access to maternal health:

1. Study Design: The study utilized a quasi-experimental ecological study design, which compares the outcomes of interest between an intervention group (NHI pilot district) and a control group (non-pilot district). This design allows for the assessment of the causal effect of contracting private MPs on the utilization of PHC services.

2. Data Collection: The study used routinely collected secondary data from the District Health Management Information System (DHMIS). Monthly reports from June 2010 to May 2014 were collected for both the NHI pilot district and the non-pilot district. The data included PHC headcounts, which were the focus of the study.

3. Selection of Variables: The study selected specific PHC utilization indicators to assess the impact of contracting private MPs. These indicators were chosen based on their ability to change relatively quickly after the implementation of the intervention or after a clearly defined lag.

4. Interrupted Time Series Analysis (ITSA): ITSA was used to analyze the selected PHC utilization indicators. This analysis compares the outcomes over time within a single population (NHI pilot district) while accounting for underlying trends in the outcomes. It helps to avoid between-group differences and selection bias of unmeasured confounders.

5. Controlled ITSA: In addition to the single ITSA, a controlled ITSA was conducted to control for other time-varying co-interventions that could affect the outcomes. A non-NHI pilot district was selected as a control district to compare the outcomes and control for confounding factors.

6. Time Periods: A total of 48 time periods were selected, with 24 before and 24 after the implementation of contracting private MPs. This allows for the detection of changes in the outcomes and ensures sufficient statistical power.

7. Statistical Analysis: The study used statistical methods to analyze the data and assess the impact of contracting private MPs on the utilization of PHC services. The findings were compared between the NHI pilot district and the non-pilot district to determine the effect of the intervention.

By employing this methodology, the study aimed to simulate the impact of contracting private MPs on improving access to maternal health and other PHC services. However, the study concluded that the increase in PHC utilization in the pilot district may not be solely attributable to the implementation of contracting private MPs but could be influenced by other healthcare reforms and transitions taking place in both districts.


Statistics:
Citations: 1
Identifiers:
DOI: 10.4102/phcfm.v12i1.2563
ISSN: 20712928
Research Areas:
Community Interventions, Disparities, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Noncommunicable Diseases, Quality of Care, Sexual and Reproductive Health, Social Determinants, Violence and Injury
Study Countries:
South Africa
Study Design:
Cross Sectional Study, Quasi Experimental Study, randomised-control-trial
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