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

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卫生服务，特别是初级卫生保健，甚至对贫困患者也是如此。但私营部门在扩大中低收入国家全民健康覆盖（UHC）方面的作用仍存在争议。支持者认为，私营部门可以增加患者的选择和获得初级保健的机会，而且竞争会激励私营提供者更积极响应，提供比公共提供者更优质的护理。然而，有证据表明，这些优势可能不会成为现实。支持私营部门作用的论点依赖于私营提供者竞争病人的假设。然而，影响市场表现的因素很多，而且卫生市场往往缺乏竞争。有效的竞争还要求患者对价格或质量的变化做出反应。尽管这些动态在确定私营初级保健提供对中低收入国家卫生系统的影响方面至关重要，但它们在文献中很少受到关注。了解私营部门提供的服务的作用和影响在南非尤为重要，因为实现全民健康覆盖的政策建议促进私营提供者签订合同，以扩大无保险患者获得高质量初级保健的机会。人们对私人初级保健提供者目前的表现和初级保健市场的运作感到担忧，但几乎没有经验证据可以为当前的辩论提供信息。扩大私营部门作为实现全民健康覆盖努力的一部分的作用，需要更全面地了解潜在的风险和利益，以及市场供需双方可能作出的反应。本研究的目的是对公立和私立初级保健服务市场进行详细的实证调查。它将一方面关注提供者绩效的决定因素，另一方面关注无保险现金支付患者对私人服务的需求。这项研究将在约翰内斯堡的索韦托进行，它将包括五个部分。首先，我们将通过人口普查、对所有提供者的测绘和访谈、对市场集中度的分析以及对私人提供者用于争夺患者的策略的调查，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（SPs），我们将比较私营和公共提供者在服务可及性、护理技术质量和推荐治疗成本方面的表现。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，使用与供应商绩效和成本相关的数据，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补贴获得私人服务的反应，并探索有关质量的信息是否影响需求。这项研究将提供重要信息，说明私营初级保健市场是否有助于改善卫生系统的可及性、质量和效率。研究结果与许多试图在混合卫生保健系统中扩大全民健康覆盖的低收入国家有关。

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.