Understanding the consequences for quality and efficiency of expanding services through the private sector in South Africa

了解南非私营部门扩大服务对质量和效率的影响

• 批准号: MR/T023635/1
• 负责人: Duane Blaauw
• 金额: $ 99.07万
• 依托单位: University of the Witwatersrand
• 依托单位国家: 英国
• 项目类别: Research Grant
• 财政年份: 2020
• 资助国家: 英国
• 起止时间: 2020 至 无数据
• 项目状态: 未结题
• 来源: https://gtr.ukri.org/projects?ref=MR%2FT023635%2F1
• 关键词: Understanding; consequences; quality; efficiency; expanding

The private sector provides a large proportion of health services in many low- and middle-income countries (LMICs), particularly for primary health care (PHC), even for poor patients. But the role of the private sector in expanding universal health coverage (UHC) in LMICs remains contentious. Proponents argue that the private sector could increase patient choice and PHC access, and that competition incentivises private providers to be more responsive and provide better quality care than public providers. However, evidence suggests that these advantages may not materialise. Arguments supporting the role of the private sector rely on the assumption that private providers compete for patients. Yet many factors influence market performance and health markets are often not competitive. Effective competition also requires that patients respond to changes in price or quality. Although these dynamics are critical in determining the health system impacts of private PHC provision in LMICs, they have received little attention in the literature.Understanding the role and impact of private sector provision is especially important in South Africa as policy proposals for achieving UHC promote the contracting of private providers to expand access to quality PHC for uninsured patients. There are concerns about the current performance of private PHC providers, and the functioning of the PHC market, with little empirical evidence to inform current debates. Expanding the role of the private sector as part of efforts to achieve UHC requires a more thorough understanding of the potential risks and benefits, and the likely responses of both the supply and demand sides of the market.The aim of this study is to undertake a detailed empirical investigation of the market for public and private primary care services. It will focus on the determinants of provider performance on the one hand, and demand for private services from uninsured cash-paying patients on the other. The study will be conducted in Soweto, Johannesburg, and it will include five components. Firstly, we will undertake a detailed description of the local PHC market through a census, mapping and interviews of all providers, an analysis of market concentration, and investigation of the strategies which private providers use to compete for patients. Secondly, using 'fake' standardised patients (SPs), we will compare the performance of private and public providers in terms of accessibility to services, technical quality of care and cost of treatment recommended. Thirdly, we will establish the relationship between competition and performance outcomes, testing if greater competition leads to better outcomes. Fourthly, using linked data on provider performance and cost, we will investigate if accessibility, quality and cost are important determinants of the demand for services by uninsured patients. Finally, in a small randomised pilot, we will test study how populations would react to the introduction of subsidised access to private services, and explore if information about quality influences demand.The study will provide important information on whether the private PHC market can contribute to better health system access, quality and efficiency. The results are relevant to many LMICs trying to expand UHC within mixed health care systems.

在许多低收入和中等收入国家，私营部门提供了很大比例的保健服务，特别是初级保健，甚至对贫困病人也是如此。但是，私营部门在扩大中低收入国家全民健康覆盖（UHC）方面的作用仍然存在争议。支持者认为，私营部门可以增加病人的选择和初级保健的机会，竞争激励私营提供者比公共提供者更敏感，提供更好的质量护理。然而，有证据表明，这些优势可能不会实现。支持私营部门发挥作用的论点所依据的假设是，私营提供者为病人展开竞争。然而，许多因素影响市场绩效，保健市场往往缺乏竞争力。有效的竞争还要求病人对价格或质量的变化作出反应。虽然这些动态是至关重要的，在确定卫生系统的影响，私营初级保健提供LMICs，他们很少受到关注literation.Understanding的作用和影响，私营部门的规定是特别重要的，在南非的政策建议，实现全民健康覆盖促进承包的私营供应商，以扩大获得优质初级保健为无保险的病人。人们对私营初级保健提供者目前的业绩和初级保健市场的运作感到关切，但目前的辩论缺乏经验证据。为了实现全民健康覆盖，扩大私营部门的作用，需要更深入地了解潜在的风险和利益，以及市场供需双方可能的反应。本研究的目的是对公共和私营初级保健服务市场进行详细的实证调查。一方面，它将侧重于提供者业绩的决定因素，另一方面，没有保险的现金支付病人对私人服务的需求。这项研究将在约翰内斯堡的索韦托进行，将包括五个组成部分。首先，我们将通过对所有提供者的普查、绘图和访谈，对市场集中度进行分析，并调查私营提供者为争夺病人而采用的战略，对当地初级保健市场进行详细描述。其次，使用“假”标准化患者（SP），我们将比较私人和公共提供者在服务可及性，护理技术质量和推荐治疗费用方面的表现。第三，我们将建立竞争与绩效结果之间的关系，测试更大的竞争是否会带来更好的结果。第四，使用有关提供者绩效和成本的关联数据，我们将调查无障碍、质量和成本是否是无保险患者对服务需求的重要决定因素。最后，在一个小型随机试点中，我们将测试研究人口对引入私人服务补贴的反应，并探索有关质量的信息是否会影响需求。这项研究将提供有关私人初级保健市场是否有助于改善卫生系统的准入、质量和效率的重要信息。这些结果与许多试图在混合医疗保健系统中扩大UHC的LMIC有关。