Why GPs don't contract for NHI in the Eastern Cape

As part of the strategy to introduce national health insurance (NHI) in South Africa, the National Department of Health embarked on a process of re-engineering primary health care. Achieving this goal requires the participation of the public and private sector providers. Charles Hongoro reports on a study to find out why there is such a low uptake of national contracts by general practitioners (GPs) to provide these services. Here are the findings.

The National Department of Health (NDOH) formulated a contract for general practitioners (GPs) that would allow them to work in public primary health care clinics, with the quality of their clinical work being assured by the district clinical specialist team.

The contract fee is based on an hourly rate, regardless of years of experience. In addition to the national contract, a service level agreement (SLA) was designed that specifically sets out the services to be offered by the GP in a particular district and the special conditions regarding the implementation of the agreement.

The GP contracts were officially announced as part of ministerial consultations on NHI in 2013, and the contract forms were uploaded on the government website, with disappointing results. At the time of the study, none of the GPs interviewed in the district had signed up to the national NHI GP contract.

This study sought to characterise existing GPs, and establish the nature of the obstacles to contracting with the state.

Profiling the GPs
Data was collected through profiling 42 GP practices and administering structured questionnaires. Most GPs, 57% (n=24) were located in Mthatha (urban area) and the rest were distributed across the rural sub-districts of OR Tambo district.

Of the 42 GPs interviewed, most (91%) were African, and the mean age was 43.3 years (Table 1).

All the GPs had basic medical training; a few had specialised training (n=3), and 50% (n=19) had additional professional education. Most of the GPs (56%) had graduated from the local university (Walter Sisulu) and the rest (36.6%) from the universities of Pretoria (2.4%), Cape Town (4.9%), KwaZulu-Natal (9.8%) and the Medical University of South Africa (19.5%). The mean practice registration period for the GPs was 12.7 years (1 – 37 years).

The majority of the practices were registered (90.5%) and most of the GPs practised solo (87.8%), with the remainder being salaried or locum doctors. The reported mean number of patients seen by GPs per day was 31, ranging widely from 10 to 100 patients per day.

For adults without medical aid cover (uninsured), the mean cash fee was R311, ranging from R130 to R400. The common cash fee, however, was R300. These covered consultations plus additional services such as diagnostics and medicines. For uninsured children, the common cash fee was R250.

The majority of GPs had a dispensing licence for medicines (85.7%), and existing licences were renewable, with only 14 (33%) GPs indicating that their licences were continuous (i.e. with no expiry date).

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Availability of human resources
All practices had at least a receptionist, with the majority having one or two support staff (78.6%). Overall, all GP practices were equipped with and/or had access to basic and functional equipment required to provide general practitioner services which included the following index equipment: otoscope, ophthalmoscope, electrocardiography, ultra-sound scan, spirometer and audiometer. In addition to these index pieces of equipment, most facilities met the basic infrastructure requirements to be registered as practice settings in South Africa.

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Reasons for not signing up NHI GP contract
•    “Did not attend the roadshows organised in the district and therefore the details of the contract were not explained”
•    “The contract was not offered to the GPs”
•    “The engagement style at the meetings was more dictatorial and one’s inputs were not taken into consideration”
•    “The contract terms were not properly explained”
•    “Nothing actually took off which led to my being discouraged from participating”
•    “Information given on NHI contract was not clear”
•    “I never had clarity on certain issues; not satisfied with terms and conditions of contract”
•    “Remuneration not adequate”

Low uptake of government general practice contract
At the time of the study, none of the GPs interviewed in the district had signed up to the national GP contract. A myriad of reasons for the slow uptake were provided, but the key reason for the slow uptake was that the contract was never thoroughly explained to them and attempts to do so were more information sessions, with very little interaction between the public officials and the potential private contractor GPs.

Most GPs were uncertain about the conditions of the contract, while a few respondents indicated that the contract remuneration was indeed very low. A notable number of the GPs indicated that they were not offered the contract, which corroborates the aforementioned finding of lack of information about the proposed contract.

Despite the fact that most doctors did not sign the new contract, the majority acknowledged having other state contracts (70.7%): with the district (51.6%), regional hospital (11.9%), central hospital (16.1%) or a combination of these (9.6%). Only two GPs acknowledged having service contracts with a community health centre in the district.

Those who had state contracts indicated that they were contracted for an average of 23.93 hours per week, ranging from 6 to 80 hours. The reported mean hourly contract rate was R308.64, with a minimum and maximum of R75 and R850 respectively.

Responses to a question of how satisfied they were with their existing contracts were overwhelmingly positive, which is surprising given the non-uptake of the NHI or national contract. Over 66.7% of the GPs agreed or strongly agreed that they were satisfied with their existing state contracts, with the remainder somewhat indifferent or disagreeing. Within the existing other state contracts, GPs reported consulting on average 30 patients per day, ranging from 6 to 100 patients per day.

Analysis of the findings of the study
The findings of the study were paradoxical: the national contract was not embraced, but at the same time 90% indicated interest in participating and the majority of doctors had other existing state contracts, largely as sessional doctors in hospitals. The reasons proffered for low uptake varied but ultimately centred on a general lack of understanding of the national contract and its governance arrangement, which manifested itself as mistrust and apprehension.

The study showed that there is a sufficient number of independent doctors that could be engaged to support primary care services in the district, with 88% of them already operating solo. With a reported average of 31 patients seen per day, the proposed NHI per capita primary care utilisation target of 3 to 3.5 visits per year is likely to be met through such contractual arrangements.

An advantage was that the majority of the general practitioners in the districts originally came from that district and fully understood the local socio-economic-cultural context and were therefore more likely to stay in those communities if their employment and business expectations were met through the proposed national contract.

Overall, the capacity to deliver clinical services on behalf of the state at primary care level was evidently available as most GPs had the basic supportive human resources, equipment and health information infrastructure to even support other forms of contracting, such as contracting out public patients to GP practices.

For a district with a population of 1.4 million people, the possibility of having 1 GP per 22 000 population, although normatively not ideal, is significant for a rural district.

The critical question is how these GPs would be distributed or located to ensure that they are accessible to all who need their services. Contracting provides the opportunity for the government to purchase services from GPs for specific areas where there is need.

Advantages and disadvantages of current government contract as GP

Advantages:

•    Well-equipped facilities and equipment allow for a variety of cases and procedures that cannot be done in GP practice (wide scope of practice)
•    Primary healthcare considered rewarding
•    Management of HIV/AIDS patients considered personally rewarding
•    Community work rewarding in general
•    A convenient working regime
•    Job satisfaction
•    There is better management of patients at facility
•    Can follow up own referred patients in hospital
•    Getting clinical support from colleagues and consultants

Disadvantages:
•    Inability to work in the same location as own GP practice
•    Inadequate infrastructure and equipment in some public facilities
•    Poor contract management
•    Lack of appropriate accommodation and recreational facilities
•    High workload and poor referrals
•    Shortage of staff
•    Finding a balance between private practice and public service work
Suggestions for improvement of the current GP contract
•    Improve availability of basic equipment, drugs and medical supplies (ordering and stock management)
•    Improve working conditions by employing more consultants, doctors and nurses and spread the workload
•    Improve staff time management in patient care
•    Administrative support units such as HR must improve communication with staff
•    Provide decent accommodation and recreational facilities for staff
•    Improve the referral system and decongest referral hospitals
•    Provide opportunities for staff to develop themselves e.g. through further training
•    Improve remuneration

Addressing the low uptake
Low uptake of the national GP contract was largely due to a variety of factors that can be explained by inadequate communication and consultations with the local GPs on contract details; that is, on services to be rendered, payment levels and additional compensation for related expenses such as travel, working regime, contracting-in and -out options.
Misunderstandings create mistrust and apprehension, which are fundamental antitheses of an effective GP contractual arrangement. Most GPs are interested in signing a national GP contract provided it is flexible and allows them to continue with their practice and the remuneration remains competitive.

Engagements with the GPs ought to be based on mutual respect whilst providing for wider contractual choices. The findings suggest that whilst GPs are interested in contracting with government, they had variable preference of contract design, which means that a one-size-fits-all contract is not advisable.

This article is based on Hongoro, C., Funani, I.N., Chitha, W. & Godlimpi, L. (2016) An assessment of private general practitioners contracting for public health services delivery in O.R. Tambo district, South Africa. Investment choices for South African education. 6(525):73 – 79.

Author: Professor Charles Hongoro, director, Population Health, Health Systems and Innovation programme, HSRC.