Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine ß The Author 2014; all rights reserved. Advance Access publication 25 June 2014
Health Policy and Planning 2015;30:759–767 doi:10.1093/heapol/czu053
The drive for universal healthcare in South Africa: views from private general practitioners Rebecca Surender,1* Robert Van Niekerk,2 Bridget Hannah,3 Lucie Allan4 and Maylene Shung-King5 1 Department of Social Policy and Intervention, University of Oxford, Oxford OX1 2ER, UK, 2Institute for Social and Economic Research, Grahamstown, Eastern Cape, 6139, 3Institute of Social and Economic Research, 4Department of Pharmacy, Rhodes University and 5 University of Cape Town, Private Bag, Rondebosch 770, South Africa
Accepted
13 May 2014 To address problems of inadequate public health services, escalating private healthcare costs and widening health inequalities, the South Africa (SA) Government has launched a bold new proposal to introduce a universal, comprehensive and integrated system for all SAs; National Health Insurance. Though attention has been devoted to the economics of universal coverage less attention has been paid to other potential challenges, in particular the important role played by the clinicians tasked with implementing the reforms. However, historical and comparative analysis reveals that whenever health systems undergo radical reform, the medical profession is instrumental in determining its nature and outcomes. Moreover, early indications suggest many SA private general practitioners (GPs) are opposed to the measures—and it is not yet known whether they will comply with the proposals. This study therefore analyses the dynamics and potential success of the reforms by directly examining the perceptions of the SA medical profession, in particular private-sector GPs. It draws on a conceptual framework which argues that understanding human motivation and behaviour is essential for the successful design of social policy. Seventy-six interviews were conducted with clinicians in the Eastern Cape Province in 2012. The findings suggest that the SA government will face significant challenges in garnering the support of private GPs. Concerns revolved around remuneration, state control, increased workload, clinical autonomy and diminished quality of care and working conditions. Although there were as yet few signs of mobilization or agency by private clinicians in the policy process, the findings suggests that it will be important for the government to directly address their concerns in order to ensure a stable transition and successful implementation of the reforms.
Keywords
Medical profession, South Africa, universal healthcare reform
KEY MESSAGES
Examines doctors’ attitudes towards universal healthcare (UHC) in South Africa (SA) in the context of imminent White Paper release.
Analyses the role of key actors and implementers in the health policy process and the factors that influence successful implementation of UHC in developing country context.
Findings suggest large sections of private doctors will not support the proposals that may undermine reform efforts.
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*Corresponding author. Department of Social Policy and Intervention, University of Oxford, Barnett House, 32 Wellington Square, Oxford OX1 2ER, UK. E-mail: [email protected]
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Introduction
Background and proposed reforms Few in SA (especially the medical profession) doubt that current health arrangements are in need of reform. The health system confronts a significant ‘quadruple burden of disease’ (Coovadia et al. 2009) and on key morbidity and mortality indicators its performance is poor for a middle-income economy. Moreover, the current healthcare system remains highly inequitable. Though at 8.5% of Gross Domestic Product (GDP), SA exceeds the WHO (2011) recommendation that countries devote at least 5% of GDP to health, the expenditure is unevenly distributed among its population of 50 million. Although only 16% of the population belong to private insurance (medical) schemes they consume more than 50% of total healthcare funds; the remaining 84% relying on an underfunded public sector. Approximately (Rand) R11 150 per capita is presently spent on private patients compared with R2 776 spent on public patients. The distribution of human resources is also dominated by private practitioners, with 59% of doctors, 93% of dentists and 89% of pharmacists in private practice (McIntyre 2010; Ruiters and Van Niekerk 2012). Although in theory, public-sector primary-care services are free and charges in public hospitals are means tested, many barriers to access exist including availability of and distance to facilities and cost of transport. Moreover, differences in the quality of service provision in each sector regarding medicines, equipment, waiting times and infection control are conspicuous (Bateman 2012; Mkokeli 2012; Kahn 2013b). The private sector however also faces a crisis of affordability and sustainability. Though patients enrolled in medical-aid schemes are subsidized by both employers and the state (tax exemptions to medical-aid schemes currently constitute R10 billion per year) private healthcare costs have increased by 120% over the past 10 years and there is a growing mismatch between services and costs. The remaining 95 medicalaid-schemes have experienced spiralling contributions; increased from 7% of average wages in 1980 to 14% by 2008, with increasing substantial out of pocket co-payments. Consequently, SA has the highest share of healthcare expenditure funded from voluntary health insurance in the world (McIntyre 2012; Doherty and McIntyre 2013). It is these combined problems of inadequate public health services, escalating costs of private care and excessive health inequalities that the recent proposals attempt to address. A central plank of the reform is ‘primary healthcare re-engineering’, which seeks to balance the existing emphasis on hospital-centred curative care by focusing on prevention and health promotion at the community level. Although GPs will form part of the first line of service in districts, it is important to note they will be just one component of a wider Primary Health Care (PHC) platform which will include a range of frontline health providers in District Clinical Specialist Teams,
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Despite concerted attempts in South Africa (SA) since 1994 to improve the health status of historically disadvantaged populations, the healthcare system continues to be fragmented and unequal, with the majority of the population relying on a public sector which has significantly less resources than its private equivalent. In order to address these inequalities, the SA government has launched the most radical and ambitious reform strategy to date—the introduction of a National Health Insurance (NHI) (RSA and DoH 2011, ‘Green Paper’). Notwithstanding the term ‘insurance’ the reforms aim to achieve a universal tax funded system: comprehensive, integrated and available to all South Africans. The proposal seeks to make healthcare a social right rather than a market product and is in keeping with the current international drive for universal healthcare in developing countries (WHO 2005; UN 2012). Regardless of the government’s determination to enact the proposals, it is yet unknown whether they will be implemented as envisaged or whether clinicians will comply with them. Although much attention has been devoted to the proposal’s infrastructure requirements and fiscal affordability, relatively little attention has been paid to the important role played by key stakeholders tasked with implementing the reforms. However, policy analysis underscores the need to understand actors’ beliefs, motivations and behaviour when analysing the likely robustness and outcomes of policies (Lipsky 1980; Walt and Gilson 1994; Le Grand 2003). In particular, historical and comparative analysis shows that whenever health systems undergo radical reform, the role of the medical profession is without exception crucial in determining its eventual success and character. The inception of the UK National Health Service (NHS) in 1948 and US Medicaid in 1968 demonstrates the power of the medical profession in extracting concessions from the State at times of major system change (Klein 2001; Rodwin 2011). Recent battles between the profession and governments across Africa, Asia and Latin America about values, means and interests (Chatterjee 2006; Carasso et al. 2012; World Bank 2013), have resulted in negotiated settlements in which the eventual arrangements reflect not the original preferences of policymakers, but the political bargains and compromises they were able to achieve (Reich 1995; Paim et al. 2011; Lagomarsino et al. 2012). Evidence from other developing country attempts to introduce universal healthcare demonstrates that despite radical reform efforts, many systems stubbornly remain two-tier without a motivated medical workforce (Watts 2000; Homedes and Ugalde 2005; World Bank 2013). Assumptions concerning human motivation and behaviour are thus central to the successful design of health policy. This study analyses the dynamics and feasibility of the NHI reforms by examining the views of doctors, chiefly privatesector general practitioners (GPs), on them. The study focuses on private GPs because the reorganization prioritizes primary healthcare and proposes (at least initially) to draw upon human resources in the private sector to help serve the needs of the wider population. Private GPs are thus strategically and organizationally significant for the success of the reforms. Furthermore, recent surveys and media reports indicate that the sector is opposed to the proposals (Wild 2012; Kahn 2013;
Loggerenberg 2013). This article assesses GPs expectations of, and their likely response to, the proposals. It seeks to contribute to a better understanding of the substantive issues facing SA healthcare as well as the challenges encountered in translating health policy intentions into successful outcomes in low- and middle-income countries generally.
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Association (SAMA) and local Independent Practitioners’ Association (IPA)]. Interviews examined respondents’ understanding and knowledge of the proposals, the anticipated impact on them personally (volume and nature of work, clinical autonomy, remuneration) and the wider health system (equity, quality, efficiency), and the response of the profession to the proposals. Interviewees were identified via publically available databases of GPs in the EC and Independent general practitioner (IGP) lists and some ‘snowballing’. Interview guides were developed and administered by the study researchers. Interviews ranged between 30 and 90 min, were taped and transcribed and transcripts coded and analysed using the software package NVivo 10. The process conformed to standard rules for qualitative analysis (Auerbach and Silverstein 2003; Grbich 2007). A thematic approach to analysis was adopted with major themes ranked according to frequency and intensity of responses. To ensure confidentiality, individual responses are anonymized and identified only by organizational type. For convenience private GP practices have been grouped according to size: solo/small private practice (S/SPP) 1–3 partners, medium private practice (MPP) 4–6 partners and large private practice (LPP) 7þ partners.
Methods
Results
A case study (Yin 1984; Stark and Torrance 2005) of the Eastern Cape (EC) Province was undertaken in 2012 after the release of the Green Paper. Given that a key objective of NHI is to improve the health outcomes of the most disadvantaged, EC was chosen as one of the most impoverished and socioeconomically unequal Provinces in the country; with a poverty rate of 71%, poor population health outcomes and the lowest public-sector health spending. The Province incorporates the previous Transkei and Ciskei Bantustans which endured extremely weak administration during the apartheid era. Four of the province’s nine districts were selected for fieldwork: Cacadu, Nelson Mandela Metropolis, Amathole and Oliver Reginald (OR) Tambo, which is also one of the 11 national pilot sites. Criteria for site selection included demographic factors, rural/urban composition and location, and number and mix of clinicians and facilities including hospitals. As with most qualitative studies, the sampling criteria were purposive rather than random with no attempt to achieve a statistically representative sample. However, efforts were made to achieve a balanced mix of respondents in terms of race, gender, varied practice types, geographical location and socioeconomic status of the populations served, in order to give voice to as wide a range of experiences and views as possible (see Figure 1 for descriptors). Seventy-six interviews were conducted. Because the focus of the study was to explore primarily the views of private-sector GPs, they formed the majority of interviewees (N ¼ 54/71%), though several were currently working (in sessions) or had previously worked for the public sector and therefore were familiar with both sectors. Interviews were also held with other key stakeholders for contextual purposes and to triangulate findings: 8 hospital doctors, 10 public-sector GPs and 6 representatives of professional associations [SA Medical
In general, most respondents had a fairly accurate understanding of the objectives and mechanisms of the proposals, largely via medical associations, discussions with colleagues and the media. Overall, few interviewees disagreed with the need to improve the current system and as might be expected, all clinicians held the view that in principle healthcare should be available to the whole population. However, many argued that existing arrangements already constituted a ‘universal’ system because theoretically public healthcare was available to all citizens and means testing ensured that those lacking financial means were not refused treatment. These respondents argued that more efficient management of existing resources rather than additional resources or radical reform was needed. Relatively few supported the idea of a UK-style single-payer system—with most private-sector GPs ideologically opposed to such a ‘nationalized’ system.
Scepticism about feasibility of NHI Generally, the majority of respondents were very critical towards the NHI proposals. Views ranged from scepticism about the feasibility of the initiative to outright hostility. A main argument against NHI viability was that it was fiscally unaffordable: It looks like just a pie in the sky, I mean how are you going to finance this thing? . . . We’ve got about 5 million people who are paying tax. They are going to subsidise the other 45 million? That’s just not practical. (MPP) . . . first world medicine costs a pretty penny. That’s the problem . . . but where is the money going to come from? Who is going to pay for it? . . . it’s going to be totally unaffordable. (LPP)
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municipal ward-based home and community services and school based services. According to the Green Paper, the NHI will be funded through general tax sources, new dedicated taxes and the removal of tax subsidies for private insurance. These reforms are quite different to past incremental reorganizations and will have far-reaching implications for the private health sector. Key features involve the creation of an NHI Fund to collect, pool and distribute funds, a purchaser–provider split and delegated service delivery management to District Health Authorities. The gate-keeping role of primary-care clinicians and the referral system will be strengthened and there will be greater managerial autonomy for hospitals. Private health insurance will be allowed to continue but is envisaged to eventually play only a complementary role after tax subsidies for premiums are removed. Details about the role of private providers are still unfolding though current staff shortages and capacity means that private GPs will be included in the reformed system with government acknowledging that private doctors (initially at least) are an essential factor in implementing a successful NHI. There is a cautious timetable for the rollout of the new system, to be implemented over 15 years, with 11 pilot sites currently in place (Minister of Health 2012)
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Lack of human resource and institutional capacity were also felt to undermine the feasibility of the proposals. Respondents across all sectors argued that the system could not be easily expanded due to insufficient clinicians and allied staff, infrastructure and, especially, administrative and management capacity: Do we have enough personnel . . . skilled people? Do we have a radiologist in Bizana? Do we have lab technicians there? . . . There are facilities there, but [no] personnel. (Public-Sector GP)
Impact of NHI on remuneration Despite initial scepticism, when asked to consider the potential impact of NHI on them individually and the wider system, private GPs voiced several concerns. Chief among these was the impact on remuneration. The universal assumption was that the state would not be able to pay practitioners at current private-sector rates and so doctors would suffer reduced income. The language of commerce and business was pervasive and indicative of the strong market ethos of the private sector:
I don’t think there is the management capacity to micro manage all these facilities, all these processes . . . to make sure that all the procurement processes and things are done properly—they haven’t got the capacity. (IPA Rep)
We are not making huge profits. We really aren’t. We’re just getting through . . . removing one sale from this practice or to work at a cheaper remuneration would make the practice nonviable . . . it’s a private company, if the company goes bankrupt, what happens? The guys will leave. Certainly a large number of the doctors will leave the country. (MPP)
Even among the minority of clinicians who in principle supported the proposals, there were major reservations. Many argued that changing the finance would do little to address fundamental system weaknesses such as low numbers and quality of staff in rural areas:
[NHI] can’t make me work harder than what I’m working now, for less money. Let’s face it, it’s a business, I’m running a private practice, I’ve got fourteen families dependent on me and my partners. (MPP)
The rural areas are highly understaffed and you will never get regular doctors working there . . . to go to a village and send your children to a bush school . . . where there is no proper shopping centre . . . no employment for spouses . . . they [government] live in a dream world. No qualified doctors will go there . . . except for idealists and missionaries. (Hospital Specialist)
The notion that doctors were rational actors who would seek to maximize their economic well-being was prominent. Although all stated that they wanted to provide patients with good care, several indicated that they were ‘not charity workers’. There was extensive discussion that the likely tariffs and prices would not reflect ‘true’ costs and would not compensate fully for medical training, overheads, transport and insurance:
The common opinion among private-sector respondents was therefore that the implementation of the NHI proposals was politically driven, non-viable and unlikely to materialize. A typical view was that ‘it won’t happen in my lifetime’.
My concern is that as a private practitioner I have overheads and expenses and I don’t want to subsidize the state . . . many of us are highly qualified . . . they can’t just get us on the cheap. (LPP)
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Figure 1 Description of study respondents
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Don’t expect me to leave my practice and go into a rural area because then . . . I’m travelling at my expense, my maintenance of the vehicles. (S/SPP) Our insurance costs are already sky high . . . and with more feet through the door the mistakes are only going to get more . . . is government going to underwrite us . . . pick up the tab when the malpractice suits roll in . . . (MPP)
. . . they’ll have to pay me for my experience . . . the time I’ve trained and spent already . . . and my feeling is they must do it according to your qualifications. It’s not x doctors, x amount of money, no! (LPP) Doctors appeared to have quite a sophisticated understanding of the different (at times, perverse) incentives flowing from different potential finance systems. Many predicted that whatever the eventual payment mechanisms it would be possible to ‘game the system’ through adverse selection or diluted care. At the end of the day the bottom line is going to be the money . . . if the NHI wants to not pay you per patient [but] pay you for amount of hours that you work . . . I can say oh well I’ll see a patient an hour, as slow as I possibly can work and take my time and it doesn’t matter. (MPP) Is it a flat rate? Whether you are coming in with a broken leg, or coming in to have a Caesarean section, or coming in with the flu? If it is a flat rate, why should we take the expensive cases? (S/SPP) Finally, several private-sector GPs aired concerns that the reforms would create new winners and losers. Existing tensions between providers in the current entrepreneurial system would intensify and become potentially distorting. Some worried that ‘weaker’ practices would become bolstered by government contracts and be made more viable despite poor quality services. Most were concerned that pressure to accept NHI patients would dramatically change their ability to provide the current quality of care to private patients—who would migrate to rival private providers. There was a sense that there would be heightened competition and a culture of ‘everyone looking over their shoulder’: Some will contract . . . some will be reluctant to contract . . . and some will cream it . . . Your elite practices in affluent areas will actually benefit from only private patients . . . I will lose patients . . . I will lose patients to somebody who says ok, I will set up an elite
practice . . . though it’s going to be smaller because of the tax. (MPP) Private patients feel they are paying you . . . therefore they want your services now . . . they don’t want to wait . . . so if you now are doing NHI clinics, you are going to alienate your private patients . . . if they are now going to sit in a waiting room that is overcrowded and they are going to be seen only for 5 minutes . . . they are not coming back to me, I’ll lose my existing patients . . . they will go and see someone else. (LPP)
Impact of NHI on workload, professional life and clinical autonomy Doctors expressed concerns about how the new system would impact their working conditions and clinical autonomy and anticipated a dramatic rise in workload due to the increased population access. Many anticipated that if they were to receive a lower tariff per patient and had to trade ‘quantity for price’, this would lead to ‘factory line medicine’. They predicted that increased pressures on providers and rationed care for patients were inevitable. There were repeated references to the current public system’s ‘conveyer belt medicine’, sub-optimal consultation times for patients and overwork for providers. . . . you need to examine the patient and to do it properly . . . it takes about 15 minutes . . . that’s 4 patients an hour . . . some practices see 120 a day! ok, that depends on them . . . but their patients aren’t getting satisfactory care . . . never physically examined in meetings with a doctor! That’s not healthcare. (LPP) I’d like guarantees that we won’t be overworked . . . a set amount of patients a day, with limitations on after-hours work . . . At the moment [we] are three doctors and we do every third weekend and every third night but you get to sleep and you get to survive, whereas . . . for the government you wouldn’t sleep in a whole night. (S/SPP) Anxiety about the physical working environment, inferior medical equipment and infrastructure that was likely to exist in public clinics also featured extensively: What kind of facilities are we going to work in? . . . not even a chair to sit down in or proper telephones or water, never mind X-ray and diagnostic equipment . . . it will be going back into the dark ages. (MPP) For most respondents autonomy was paramount and synonymous with private medicine and private practitioners deeply valued the fact they could determine their own ‘tradeoffs’, work balances and method of practice: The thing I like about private practice is that I can control the number of people I see in a day, which is about 30. And the whole environment is quite controlled . . . it suits me and my time and my stress levels - the way I work now, where I can control it. (LPP)
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Many took the view that it was nonsensical for one flat price regardless of the quality of the service. Because doctors varied in terms of their education, training, expertise and facilities, the idea that there should be flat rate pay scales flew in the face of market principles and competition. Many argued that the skill and reputation of a doctor should determine the price they charged and the custom they attracted, not a bureaucratic mechanism:
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At the moment . . . the [Provincial] guys in charge can’t even make state hospitals work—they just don’t have the expertise, you know they don’t have the knowledge. I don’t know if it’s the will lacking or whatever it is but they just can’t do the job. (SAMA Rep) It’s a joke to think they have the ability to manage something as big as NHI . . . if it’s not corruption, it’s mismanagement and incompetence . . . they can’t even manage the pay roll for the public doctors they have now. (Public-Sector GP) Despite strong concerns from the majority of private practitioners, it is important to highlight that opinions were not unanimous. Because not all practitioners faced the same sets of conditions, unsurprisingly, experiences and opinions varied. Most public-sector GPs in hospital settings largely welcomed the reforms, anticipating that increasing capacity in the private sector would lessen their workload. Additionally, some private practitioners, particularly smaller practices in less affluent areas also welcomed the potential increased work prospects and better security of remuneration that the new arrangements afforded: As a small independent practitioner I’d like to be honest with you: if it means more money in my pocket at the end of the day I don’t have a problem with it – I’ll go with it. If at the end of the month it means more money in my pocket I think it’s OK. (S/SPP) I think it’s gonna depend on the doctor. I mean, some of them will embrace it . . . We’re not a high turnover practice . . . we have a relationship with our patients . . . [We’re] not just a sausage factory. Whereas some practices are geared to that, they have a fast throughput . . . one could question the quality of medicine that they practice. (MPP)
Ability of private practitioners to influence the policy process Given the strong negative reactions of private practitioners towards the NHI proposals, interviews explored the extent to which they were preparing to defend their interests. It was striking that on the whole there was little evidence
of organized opposition from the profession or willingness to try to influence the policy process. Some predicted that doctors would vote with their feet and take early retirement or emigrate. However, more common was a feeling of resignation with little motivation to challenge the reforms. Relatively few interviewees had been active in attending meetings or voicing concerns via their professional associations or directly via the media. Despite general discontent that they had not been sufficiently included in the consultation process and resentment about reforms being ‘forced down throats’ and government ‘riding roughshod’ over them, doctors appeared pessimistic about their ability to change or influence things: At the end of the day the doctors are not in the driving seat—government will do what it wants to do . . . we don’t have any power . . . (Hospital Specialist) We are not the ones who will call the shots. We have been abused by all sides—government on one side and the medical-aids and hospitals on the other . . . no one is entering the profession any more. (MPP) Explanations for this ‘passivity’ ranged (as in other countries) from simple lack of time to the individualistic culture of general practice. However, several respondents were cynical about the motives of the government and for these clinicians, the perceived anti private-sector sentiments of the Ministry of Health generated mistrust and hostility and contributed to their unwillingness to engage with the policy process: Motsoaledi [Health Minister] has already said the privatesector is a monster . . . so we are sitting with a major problem; we already dislike each other ok, so how are you going to appease us, because we know what their intention and their agenda is. They want to basically take the privatesector and wring its neck, to see if they can force us all to work for the state sector. (LPP) Another considerable factor undermining an organized response from the medical profession was the fractured nature of the profession itself, apparent in the manner in which clinicians spoke and identified themselves. Fragmentation appeared along geographical and organizational lines; regional, rural, urban, private, public, tertiary and primary divides. Another factor adding to the complexity of relationships was the continuation of racial divisions and in particular that doctors in private practice interacted very strongly along racial divides. It was striking how racially divided the larger practices in this study were, and that the majority of small/solo practices comprised mostly Black and Indian doctors. The legacy of racial and structural rifts meant clinicians faced fundamentally different pressures and had very different demands: SAMA can’t represent doctors’ views as a whole, because . . . they all have different needs. Private-sector doctors feel very differently about this than those of us working in rural health . . . if my priority is access to healthcare, that’s a very different issue than if you’ve
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There were frequent protests that clinical autonomy was already being eroded by the existing system of managed care being ‘forced’ on doctors by medical schemes. Complaints about prescribed drug lists, patient protocols, guidelines and pre-authorization before admitting or referring were widespread. Nevertheless, the assumption was that coming under ‘state control’ would only exacerbate these trends. In this context, the issue that elicited the strongest negative reaction was the suggestion that doctors would come under provincial government control. There was universal condemnation of current public-sector governance and complete lack of confidence in government’s ability to manage or regulate. The idea of losing autonomy to the state elicited a more emotive reaction from clinicians across all sectors than a potential cut in pay:
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got a thriving private practice in the centre of town. (SAMA Rep) . . . doctors have very different perspectives, different priorities and speak different languages . . . So it’s a complex relationship . . . At the moment the medical fraternity in SA doesn’t have a feeling as a whole community . . . there’s no such thing as a uniform medical community . . . It’s very splintered. (IPA Rep)
Discussion
(some financial, others to do with enhanced continuing professional development) will also be instituted. The government has also focused on strengthening public-sector administrative and managerial capacity to ensure the system is ‘fit for purpose’ and a National Academy for Leadership and Management in Healthcare is in the process of being established under the auspices of the National Department of health (DOH). Whether these plans are enough to command the trust and co-operation of private GPs, is yet to be seen, though this must remain the goal for policy makers—not least because their support and motivation is essential for the stable transition and sustained implementation of the reforms. One strategy for achieving greater buy-in from GPs will be to avoid a ‘one size fits all’ model. This study found substantial material difference between practices, the pressures they face and consequently the demands they have regarding NHI. Although some did not begrudge increased patient loads or were willing to trade autonomy for securer remuneration, other practices prized autonomy above all else. Flexibility in arrangements and models, with choice of contracts, conditions of service and career advancement pathways, will be both pragmatic and tactical. Variation in remuneration packages, with transparency in the criteria being used to determine prices will be essential. Upgrading the conditions and infrastructure in public-sector clinics and enabling those who wish to, to provide services from their own premises will also encourage more engagement. Finally, allowing larger practices (or groups of practices working in consortium) greater autonomy from close government management (as proposed for some hospitals) may also be strategic. It is interesting to observe that in terms of influencing the policy process, the SA profession appears mostly to be ‘reactive’ rather than proactive, to the extent it is mostly trying to block reform rather than initiate it. One explanation for the relatively muted response is that is it just too early in the process (especially given the scepticism about the feasibility of the initiative). Equally, the findings may signify that due to historical legacies, the exceptionally fragmented nature of the profession undermines its power as an actor in the policy arena. However, in either scenario, government would be foolish to ignore the professions’ discontent. There are certainly recent examples of the SA medical profession using its power to block reform and assert its own interests, including stalling government attempts to issue a ‘Licence or Certificate of Need’ (2004) and the recent victory for the profession in the courts in the 2001 ‘dispensing row’ (Pretorius et al. 2012). Given the necessary reliance on the private sector to contribute to healthcare services in the immediate term, policy makers will need to identify strategies to incentivise them to achieve desired outcomes. To this extent, current policy makers may do well to consider previous efforts to engage with the SA private health sector, in particular the system of ‘part-time district surgeons’ (PDS) initiated during apartheid but continued out of necessity by the 1994 democratic government. In order to address the acute shortage of public-sector primary-care services during the transition, provincial Departments of Health contracted with private GPs to work part time for the public-sector. Research on
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To the extent that the SA government intends to create an integrated and universal system of healthcare provision, it will face according to the results of this study significant challenges in garnering the support of sections of the medical profession. Although several public and some private GPs regarded a state led NHI beneficial for both patients and themselves, most private GPs were opposed to the measures which they viewed as impractical and threatening to their commercial and professional interests. Respondents feared lower remuneration but increased workload and despite public statements about strengthening primary-care and the referral system no one expected greater empowerment for primary-care providers. Other concerns revolved around clinical autonomy and the quality of services and conditions of work, though the most fervent focused on government control, with little confidence in government’s ability to implement or manage the new system. It is important to contextualize the strong response of clinicians in this study within the historic weaknesses of the Eastern Cape provincial administration (Van Niekerk 2012) and to recognize that wide institutional differences between Provinces will mean that the reforms will be implemented more successfully in some than others. Nevertheless, it seems that the dynamics identified here are not unique or fundamentally divergent from the national situation. Recent acrimonious debates between the Minister of Health and medical associations underscore that concerns about remuneration, autonomy, state capacity and lack of consultation are deeply felt (Archer 2014a,b; Malan 2014). Perhaps more direct confirmation of the study findings is the DoH’s struggle to recruit GPs to participate in the 11 pilot sites currently underway. Only 96 private-sector doctors signed contracts to work in NHI pilot clinics between March 2013 and 2014, well short of the target of 600 set for the year (Kahn 2014). Moreover, the majority of those participating were in Gauteng Province (one of the richest and best capacitated provinces) with the lowest participation rate in the EC site where this study was conducted (Cook 2013). Because this research was undertaken a number of developments have occurred which suggest that policy makers are responding to some of the concerns. Following a national consultation exercise by the Minister of Health during 2012, a new national GP contract model is being shaped which addresses some of the concerns articulated here. Although the current remuneration for doctors contracting with pilot sites has been derided as too low and rigid (a flat hourly rate of R355), the proposed national contract will permit additional allowances for clinical experience, travel and for working in rural or very deprived areas. Additional performance incentives
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Conclusion Health policy analysis shows that although in most contexts the state, market and profession exist in a delicate balance, the power of the medical profession has traditionally been a key determinant in shaping how that balance is either maintained or changed. Judging from these research results, the government has not yet been able to convince private medical doctors (in particular GPs) that the NHI scheme is viable, or indeed, desirable. Because doctors working in private practice constitute nearly 70% of the total number of GPs working in SA, they will need to be convinced of the new proposals if the NHI scheme is to be implemented effectively.
Acknowledgements The work was supported by the Sandisa Imbewu Grant from Rhodes University, SA and a John Fell Grant (Grant Number CV0035) from the University of Oxford, UK. Both funding
agreements ensured the authors’ independence in designing the study, interpreting the data and, writing and publishing the report. Conflict of interest statement. None declared.
References Archer C. 2014a. NHI: Let’s Talk about this Revolution. http://mg.co.za/ article/2014-02-06-lets-talk-about-this-revolution, accessed 7 February 2014. Archer C. 2014b. Right of Reply: Motsoaledi Makes Fools of Us. http://mg.co. za/article/2014-02-13-right-of-reply-motsoaledi-makes-fools-of-us, accessed 14 February 2014. Auerbach C, Silverstein L. 2003. Qualitative Data: An Introduction to Coding and Analysis. New York: NYU Press. Bateman C. 2012. ‘Will our public healthcare sector fail the NHI?’ SAMJ, Vol. 102. No. 11. Carasso BS, Lagarde M, Cheelo C, Chansa C, Palmer N. 2012. Health worker perspectives on user fee removal in Zambia. Human Resources for Health 10: 40. Chatterjee P. 2006. India’s doctors protest over caste quota plans. The Lancet 367: 1892. Cook R. 2013. GPs contracting with the NDoH: the practice and the promise. Presentation to the Child Health Priorities Conference, Johannesburg. Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D. 2009. The health and health system of South Africa: historical roots of current public health challenges. The Lancet 374: 817–34. Doherty J, McIntyre D. 2013. Addressing the failings of public health systems: should the private-sector be an instrument of choice?. In: Surender R, Walker R (eds) Social Policy in a Developing World. cheltenham: Elgar. Grbich C. 2007. Qualitative Data analysis: An Introduction. London: Sage. Homedes N, Ugalde A. 2005. Human resources: the Cinderella of health sector reform in Latin America. Human Resources for Health 3: 1. Kahn T. 2013a. ‘Province Health Vacancies for Doctors, Nurses, Shocking’. www.bdlive.co.za/national /health/2013/01/17, accessed 25 January 2013. Kahn T. 2013b. ‘Doubts in Soweto over NHI’. www.bdlive.co.za/national/ health/2013/03/06, accessed 18 October 2013. Kahn T. 2014. ‘Doctors-Too-Greedy-for-Nhi-Says-Motsoaledi’. http:// www.bdlive.co.za/national/health/2014/03/06/, accessed 06 March 2014. Klein R. 2001. The New Politics of the NHS. Harlow: Longman. Lagomarsino G, Garabrant A, Adyas A, Muga R, Otoo N. 2012. Moving towards universal health coverage: health insurance reforms in nine developing countries in Africa and Asia. The Lancet 380: 933–43. Le Grand J. 2003. Motivation, Agency and Public Policy: Of Knights and Knaves, Pawns and Queens. Oxford: Oxford University Press. Lipsky M. 1980. Street-Level Bureaucracy: Dilemmas of the Individual in Public Services. New York: Russel Sage Foundation. Loggerenberg D. 2013. ‘NHI: Economic Suicide for Doctors?’ News 24. http:// www.health24.com, accessed 05 July 2013. Malan M. 2014. Motsoaledi Frenzy Over NHI. http://mg.co.za/article/201402-21-00-motsoaledi-frenzy-over-nhi, accessed 21 February 2014. McIntyre D. 2010. National Health Insurance: Providing a vocabulary for public engagement. South African Health Review, Durban, Health Systems Trust. McIntyre D. 2012. The political economy of the health industry and the private health funding crisis. In: Reuters G, Van Niekerk R (eds).
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the PDS system undertaken at the time revealed the same sets of conflicts and tensions between government and private GPs as in the present situation. Particularly salient for NHI are findings from case studies which show that the most successful PDS schemes were those that used a more ‘relational’ rather than formal contractual approach (PRICON Study 2000). That is, ‘influencing providers via an emphasis on co-operation, mutual shared interest and their role as independent professionals’ rather than a contractual sanctions based approach’ were most effective (Palmer and Mills 2003). An explicit acknowledgement of ‘mutual dependence’ between government and clinician together with activities which built greater communication and trust between parties were the key. Similarly, in the long term, the challenge for the current government will be to achieve a shift in ethos and norms if NHI is to succeed. Encouraging providers to explore shared notions of professional standards and social responsibility instead of the entrenched and deep-rooted market culture which presently encourages self-interested and profit maximizing behaviour will be essential for a new NHI system with patient centred values. Key to all of this will be the need to counteract historical mistrust and acrimony by bringing the profession into the process more and facilitating more consultation, transparency and information flows. Finally, it is important to recognize that despite their significance both numerically and strategically, GPs are but one strand of the medical workforce and GP contracting just one element of the policy change—which focuses on primary healthcare re-engineering more broadly. This includes the deployment of integrated clinical specialists at district level including obstetricians, gynaecologists, midwives, paediatricians, paediatric nurses, anaesthetists, as well as family physicians and primary healthcare nurses. School based PHC services will in most instances be lead by professional nurses. It is therefore essential that further research is undertaken concerning the perceptions and interests of these other groups of medical personnel—arguably the majority of implementers—to ensure that policy design is informed by the experiences of all ‘front line’ implementers and that practical solutions are found to challenges.
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Universal Healthcare in Southern Africa. Scottsville: University of KwaZulu Natal Press.
Ruiters G, Van Niekerk R. 2012. Universal Healthcare in Southern Africa. Scottsville: University of Kwa-Zulu Natal Press.
Minister of Health. 2012. ‘National Health Insurance: Presentation on NHI Pilot Districts Selection’. www.doh.gov.za/docs/presentations/ 2012/nhipilot.pdf.
Stark S, Torrance H. 2005. ‘Case study’. In: Somekh B, Lewin C (eds). Research Methods in the Social Sciences. London: Sage Publications, pp. 33–40.
Mkokeli S. 2012. ‘ANC Plan to Grab Control of Top State Hospitals’. bdlive.co.za/national/health/2012/12/28, accessed 25 January 2013. Paim J, Travassos C, Almeida C, Bahia L, Macinko J. 2011. The Brazilian health system: history, advances, and challenges. The Lancet 377: 1778–97. Palmer N, Mills A. 2003. Classical versus relational approaches to understanding controls on a contract with independent GPs in South Africa. Health Economics 12: 1005–20.
PRICON Study. 2000. ‘New Purchaser/Provider Relationships in Primary Health Care: The Desirability of Contracts Between Health Providers and Private Providers. Cape Town: Centre for Health Policy, Univ. of Witwatersrand and Health Economics Unit. Reich MR. 1995. The politics of health sector reform in developing countries: three cases of pharmaceutical policy. Health Policy 32: 47–77. Rodwin. 2011. Conflicts of Interests and the Future of Medicine. Oxford: OUPM. Republic of South Africa (RSA), Department of Health (DoH). 2011. National Health Insurance: Healthcare for all South Africans (Green Paper), www.doh.gov.za, accessed 13 March 2013.
Van Niekerk R. 2012. Revisiting History: the Creation of Provinces and the Politics of Social Policy in a Democratic South Africa. Social Policy and Administration, Vol. 46. No. 6. Walt G, Gilson L. 1994. ‘Reforming the health sector in developing countries: the central role of policy analysis’. Health Policy and Planning 9: 353–70. Watts J. 2000. Strikes continue in South Korea as doctors fight drug reform. The Lancet 356: 1583. Wild S. 2012. www.bdlive.co.za/articles/2012/07/06/doctors-will-get-nhipay. World Bank. 2013. The Impact of Universal Coverage Schemes in the Developing World: A Review of the Existing Evidence (UNICO Studies Series 25). Washington DC: The World Bank. World Health Organization (WHO). 2005. ‘Sustainable Health Financing, Universal Coverage and Social Health Insurance’. World Health Assembly Resolution 58.33. Geneva. World Health Organization (WHO). 2011. National Health Account Database. http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS. Yin RK. 1984. Case Study Research: Design and Methods. Beverley Hills: Sage Publications.
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Pretorius JC, South MS, Care NR. 2012. BHF ‘upset but undeterred by Appeal Court ruling’. South African Medical Journal 102: 819–20.
United Nations (UN). 2012. The Future We Want. http://un.org/doc/ N1243688.pdf.
Health Policy and Planning 2015;30:759–767 doi:10.1093/heapol/czu053
The drive for universal healthcare in South Africa: views from private general practitioners Rebecca Surender,1* Robert Van Niekerk,2 Bridget Hannah,3 Lucie Allan4 and Maylene Shung-King5 1 Department of Social Policy and Intervention, University of Oxford, Oxford OX1 2ER, UK, 2Institute for Social and Economic Research, Grahamstown, Eastern Cape, 6139, 3Institute of Social and Economic Research, 4Department of Pharmacy, Rhodes University and 5 University of Cape Town, Private Bag, Rondebosch 770, South Africa
Accepted
13 May 2014 To address problems of inadequate public health services, escalating private healthcare costs and widening health inequalities, the South Africa (SA) Government has launched a bold new proposal to introduce a universal, comprehensive and integrated system for all SAs; National Health Insurance. Though attention has been devoted to the economics of universal coverage less attention has been paid to other potential challenges, in particular the important role played by the clinicians tasked with implementing the reforms. However, historical and comparative analysis reveals that whenever health systems undergo radical reform, the medical profession is instrumental in determining its nature and outcomes. Moreover, early indications suggest many SA private general practitioners (GPs) are opposed to the measures—and it is not yet known whether they will comply with the proposals. This study therefore analyses the dynamics and potential success of the reforms by directly examining the perceptions of the SA medical profession, in particular private-sector GPs. It draws on a conceptual framework which argues that understanding human motivation and behaviour is essential for the successful design of social policy. Seventy-six interviews were conducted with clinicians in the Eastern Cape Province in 2012. The findings suggest that the SA government will face significant challenges in garnering the support of private GPs. Concerns revolved around remuneration, state control, increased workload, clinical autonomy and diminished quality of care and working conditions. Although there were as yet few signs of mobilization or agency by private clinicians in the policy process, the findings suggests that it will be important for the government to directly address their concerns in order to ensure a stable transition and successful implementation of the reforms.
Keywords
Medical profession, South Africa, universal healthcare reform
KEY MESSAGES
Examines doctors’ attitudes towards universal healthcare (UHC) in South Africa (SA) in the context of imminent White Paper release.
Analyses the role of key actors and implementers in the health policy process and the factors that influence successful implementation of UHC in developing country context.
Findings suggest large sections of private doctors will not support the proposals that may undermine reform efforts.
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*Corresponding author. Department of Social Policy and Intervention, University of Oxford, Barnett House, 32 Wellington Square, Oxford OX1 2ER, UK. E-mail: [email protected]
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Introduction
Background and proposed reforms Few in SA (especially the medical profession) doubt that current health arrangements are in need of reform. The health system confronts a significant ‘quadruple burden of disease’ (Coovadia et al. 2009) and on key morbidity and mortality indicators its performance is poor for a middle-income economy. Moreover, the current healthcare system remains highly inequitable. Though at 8.5% of Gross Domestic Product (GDP), SA exceeds the WHO (2011) recommendation that countries devote at least 5% of GDP to health, the expenditure is unevenly distributed among its population of 50 million. Although only 16% of the population belong to private insurance (medical) schemes they consume more than 50% of total healthcare funds; the remaining 84% relying on an underfunded public sector. Approximately (Rand) R11 150 per capita is presently spent on private patients compared with R2 776 spent on public patients. The distribution of human resources is also dominated by private practitioners, with 59% of doctors, 93% of dentists and 89% of pharmacists in private practice (McIntyre 2010; Ruiters and Van Niekerk 2012). Although in theory, public-sector primary-care services are free and charges in public hospitals are means tested, many barriers to access exist including availability of and distance to facilities and cost of transport. Moreover, differences in the quality of service provision in each sector regarding medicines, equipment, waiting times and infection control are conspicuous (Bateman 2012; Mkokeli 2012; Kahn 2013b). The private sector however also faces a crisis of affordability and sustainability. Though patients enrolled in medical-aid schemes are subsidized by both employers and the state (tax exemptions to medical-aid schemes currently constitute R10 billion per year) private healthcare costs have increased by 120% over the past 10 years and there is a growing mismatch between services and costs. The remaining 95 medicalaid-schemes have experienced spiralling contributions; increased from 7% of average wages in 1980 to 14% by 2008, with increasing substantial out of pocket co-payments. Consequently, SA has the highest share of healthcare expenditure funded from voluntary health insurance in the world (McIntyre 2012; Doherty and McIntyre 2013). It is these combined problems of inadequate public health services, escalating costs of private care and excessive health inequalities that the recent proposals attempt to address. A central plank of the reform is ‘primary healthcare re-engineering’, which seeks to balance the existing emphasis on hospital-centred curative care by focusing on prevention and health promotion at the community level. Although GPs will form part of the first line of service in districts, it is important to note they will be just one component of a wider Primary Health Care (PHC) platform which will include a range of frontline health providers in District Clinical Specialist Teams,
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Despite concerted attempts in South Africa (SA) since 1994 to improve the health status of historically disadvantaged populations, the healthcare system continues to be fragmented and unequal, with the majority of the population relying on a public sector which has significantly less resources than its private equivalent. In order to address these inequalities, the SA government has launched the most radical and ambitious reform strategy to date—the introduction of a National Health Insurance (NHI) (RSA and DoH 2011, ‘Green Paper’). Notwithstanding the term ‘insurance’ the reforms aim to achieve a universal tax funded system: comprehensive, integrated and available to all South Africans. The proposal seeks to make healthcare a social right rather than a market product and is in keeping with the current international drive for universal healthcare in developing countries (WHO 2005; UN 2012). Regardless of the government’s determination to enact the proposals, it is yet unknown whether they will be implemented as envisaged or whether clinicians will comply with them. Although much attention has been devoted to the proposal’s infrastructure requirements and fiscal affordability, relatively little attention has been paid to the important role played by key stakeholders tasked with implementing the reforms. However, policy analysis underscores the need to understand actors’ beliefs, motivations and behaviour when analysing the likely robustness and outcomes of policies (Lipsky 1980; Walt and Gilson 1994; Le Grand 2003). In particular, historical and comparative analysis shows that whenever health systems undergo radical reform, the role of the medical profession is without exception crucial in determining its eventual success and character. The inception of the UK National Health Service (NHS) in 1948 and US Medicaid in 1968 demonstrates the power of the medical profession in extracting concessions from the State at times of major system change (Klein 2001; Rodwin 2011). Recent battles between the profession and governments across Africa, Asia and Latin America about values, means and interests (Chatterjee 2006; Carasso et al. 2012; World Bank 2013), have resulted in negotiated settlements in which the eventual arrangements reflect not the original preferences of policymakers, but the political bargains and compromises they were able to achieve (Reich 1995; Paim et al. 2011; Lagomarsino et al. 2012). Evidence from other developing country attempts to introduce universal healthcare demonstrates that despite radical reform efforts, many systems stubbornly remain two-tier without a motivated medical workforce (Watts 2000; Homedes and Ugalde 2005; World Bank 2013). Assumptions concerning human motivation and behaviour are thus central to the successful design of health policy. This study analyses the dynamics and feasibility of the NHI reforms by examining the views of doctors, chiefly privatesector general practitioners (GPs), on them. The study focuses on private GPs because the reorganization prioritizes primary healthcare and proposes (at least initially) to draw upon human resources in the private sector to help serve the needs of the wider population. Private GPs are thus strategically and organizationally significant for the success of the reforms. Furthermore, recent surveys and media reports indicate that the sector is opposed to the proposals (Wild 2012; Kahn 2013;
Loggerenberg 2013). This article assesses GPs expectations of, and their likely response to, the proposals. It seeks to contribute to a better understanding of the substantive issues facing SA healthcare as well as the challenges encountered in translating health policy intentions into successful outcomes in low- and middle-income countries generally.
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Association (SAMA) and local Independent Practitioners’ Association (IPA)]. Interviews examined respondents’ understanding and knowledge of the proposals, the anticipated impact on them personally (volume and nature of work, clinical autonomy, remuneration) and the wider health system (equity, quality, efficiency), and the response of the profession to the proposals. Interviewees were identified via publically available databases of GPs in the EC and Independent general practitioner (IGP) lists and some ‘snowballing’. Interview guides were developed and administered by the study researchers. Interviews ranged between 30 and 90 min, were taped and transcribed and transcripts coded and analysed using the software package NVivo 10. The process conformed to standard rules for qualitative analysis (Auerbach and Silverstein 2003; Grbich 2007). A thematic approach to analysis was adopted with major themes ranked according to frequency and intensity of responses. To ensure confidentiality, individual responses are anonymized and identified only by organizational type. For convenience private GP practices have been grouped according to size: solo/small private practice (S/SPP) 1–3 partners, medium private practice (MPP) 4–6 partners and large private practice (LPP) 7þ partners.
Methods
Results
A case study (Yin 1984; Stark and Torrance 2005) of the Eastern Cape (EC) Province was undertaken in 2012 after the release of the Green Paper. Given that a key objective of NHI is to improve the health outcomes of the most disadvantaged, EC was chosen as one of the most impoverished and socioeconomically unequal Provinces in the country; with a poverty rate of 71%, poor population health outcomes and the lowest public-sector health spending. The Province incorporates the previous Transkei and Ciskei Bantustans which endured extremely weak administration during the apartheid era. Four of the province’s nine districts were selected for fieldwork: Cacadu, Nelson Mandela Metropolis, Amathole and Oliver Reginald (OR) Tambo, which is also one of the 11 national pilot sites. Criteria for site selection included demographic factors, rural/urban composition and location, and number and mix of clinicians and facilities including hospitals. As with most qualitative studies, the sampling criteria were purposive rather than random with no attempt to achieve a statistically representative sample. However, efforts were made to achieve a balanced mix of respondents in terms of race, gender, varied practice types, geographical location and socioeconomic status of the populations served, in order to give voice to as wide a range of experiences and views as possible (see Figure 1 for descriptors). Seventy-six interviews were conducted. Because the focus of the study was to explore primarily the views of private-sector GPs, they formed the majority of interviewees (N ¼ 54/71%), though several were currently working (in sessions) or had previously worked for the public sector and therefore were familiar with both sectors. Interviews were also held with other key stakeholders for contextual purposes and to triangulate findings: 8 hospital doctors, 10 public-sector GPs and 6 representatives of professional associations [SA Medical
In general, most respondents had a fairly accurate understanding of the objectives and mechanisms of the proposals, largely via medical associations, discussions with colleagues and the media. Overall, few interviewees disagreed with the need to improve the current system and as might be expected, all clinicians held the view that in principle healthcare should be available to the whole population. However, many argued that existing arrangements already constituted a ‘universal’ system because theoretically public healthcare was available to all citizens and means testing ensured that those lacking financial means were not refused treatment. These respondents argued that more efficient management of existing resources rather than additional resources or radical reform was needed. Relatively few supported the idea of a UK-style single-payer system—with most private-sector GPs ideologically opposed to such a ‘nationalized’ system.
Scepticism about feasibility of NHI Generally, the majority of respondents were very critical towards the NHI proposals. Views ranged from scepticism about the feasibility of the initiative to outright hostility. A main argument against NHI viability was that it was fiscally unaffordable: It looks like just a pie in the sky, I mean how are you going to finance this thing? . . . We’ve got about 5 million people who are paying tax. They are going to subsidise the other 45 million? That’s just not practical. (MPP) . . . first world medicine costs a pretty penny. That’s the problem . . . but where is the money going to come from? Who is going to pay for it? . . . it’s going to be totally unaffordable. (LPP)
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municipal ward-based home and community services and school based services. According to the Green Paper, the NHI will be funded through general tax sources, new dedicated taxes and the removal of tax subsidies for private insurance. These reforms are quite different to past incremental reorganizations and will have far-reaching implications for the private health sector. Key features involve the creation of an NHI Fund to collect, pool and distribute funds, a purchaser–provider split and delegated service delivery management to District Health Authorities. The gate-keeping role of primary-care clinicians and the referral system will be strengthened and there will be greater managerial autonomy for hospitals. Private health insurance will be allowed to continue but is envisaged to eventually play only a complementary role after tax subsidies for premiums are removed. Details about the role of private providers are still unfolding though current staff shortages and capacity means that private GPs will be included in the reformed system with government acknowledging that private doctors (initially at least) are an essential factor in implementing a successful NHI. There is a cautious timetable for the rollout of the new system, to be implemented over 15 years, with 11 pilot sites currently in place (Minister of Health 2012)
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Lack of human resource and institutional capacity were also felt to undermine the feasibility of the proposals. Respondents across all sectors argued that the system could not be easily expanded due to insufficient clinicians and allied staff, infrastructure and, especially, administrative and management capacity: Do we have enough personnel . . . skilled people? Do we have a radiologist in Bizana? Do we have lab technicians there? . . . There are facilities there, but [no] personnel. (Public-Sector GP)
Impact of NHI on remuneration Despite initial scepticism, when asked to consider the potential impact of NHI on them individually and the wider system, private GPs voiced several concerns. Chief among these was the impact on remuneration. The universal assumption was that the state would not be able to pay practitioners at current private-sector rates and so doctors would suffer reduced income. The language of commerce and business was pervasive and indicative of the strong market ethos of the private sector:
I don’t think there is the management capacity to micro manage all these facilities, all these processes . . . to make sure that all the procurement processes and things are done properly—they haven’t got the capacity. (IPA Rep)
We are not making huge profits. We really aren’t. We’re just getting through . . . removing one sale from this practice or to work at a cheaper remuneration would make the practice nonviable . . . it’s a private company, if the company goes bankrupt, what happens? The guys will leave. Certainly a large number of the doctors will leave the country. (MPP)
Even among the minority of clinicians who in principle supported the proposals, there were major reservations. Many argued that changing the finance would do little to address fundamental system weaknesses such as low numbers and quality of staff in rural areas:
[NHI] can’t make me work harder than what I’m working now, for less money. Let’s face it, it’s a business, I’m running a private practice, I’ve got fourteen families dependent on me and my partners. (MPP)
The rural areas are highly understaffed and you will never get regular doctors working there . . . to go to a village and send your children to a bush school . . . where there is no proper shopping centre . . . no employment for spouses . . . they [government] live in a dream world. No qualified doctors will go there . . . except for idealists and missionaries. (Hospital Specialist)
The notion that doctors were rational actors who would seek to maximize their economic well-being was prominent. Although all stated that they wanted to provide patients with good care, several indicated that they were ‘not charity workers’. There was extensive discussion that the likely tariffs and prices would not reflect ‘true’ costs and would not compensate fully for medical training, overheads, transport and insurance:
The common opinion among private-sector respondents was therefore that the implementation of the NHI proposals was politically driven, non-viable and unlikely to materialize. A typical view was that ‘it won’t happen in my lifetime’.
My concern is that as a private practitioner I have overheads and expenses and I don’t want to subsidize the state . . . many of us are highly qualified . . . they can’t just get us on the cheap. (LPP)
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Figure 1 Description of study respondents
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Don’t expect me to leave my practice and go into a rural area because then . . . I’m travelling at my expense, my maintenance of the vehicles. (S/SPP) Our insurance costs are already sky high . . . and with more feet through the door the mistakes are only going to get more . . . is government going to underwrite us . . . pick up the tab when the malpractice suits roll in . . . (MPP)
. . . they’ll have to pay me for my experience . . . the time I’ve trained and spent already . . . and my feeling is they must do it according to your qualifications. It’s not x doctors, x amount of money, no! (LPP) Doctors appeared to have quite a sophisticated understanding of the different (at times, perverse) incentives flowing from different potential finance systems. Many predicted that whatever the eventual payment mechanisms it would be possible to ‘game the system’ through adverse selection or diluted care. At the end of the day the bottom line is going to be the money . . . if the NHI wants to not pay you per patient [but] pay you for amount of hours that you work . . . I can say oh well I’ll see a patient an hour, as slow as I possibly can work and take my time and it doesn’t matter. (MPP) Is it a flat rate? Whether you are coming in with a broken leg, or coming in to have a Caesarean section, or coming in with the flu? If it is a flat rate, why should we take the expensive cases? (S/SPP) Finally, several private-sector GPs aired concerns that the reforms would create new winners and losers. Existing tensions between providers in the current entrepreneurial system would intensify and become potentially distorting. Some worried that ‘weaker’ practices would become bolstered by government contracts and be made more viable despite poor quality services. Most were concerned that pressure to accept NHI patients would dramatically change their ability to provide the current quality of care to private patients—who would migrate to rival private providers. There was a sense that there would be heightened competition and a culture of ‘everyone looking over their shoulder’: Some will contract . . . some will be reluctant to contract . . . and some will cream it . . . Your elite practices in affluent areas will actually benefit from only private patients . . . I will lose patients . . . I will lose patients to somebody who says ok, I will set up an elite
practice . . . though it’s going to be smaller because of the tax. (MPP) Private patients feel they are paying you . . . therefore they want your services now . . . they don’t want to wait . . . so if you now are doing NHI clinics, you are going to alienate your private patients . . . if they are now going to sit in a waiting room that is overcrowded and they are going to be seen only for 5 minutes . . . they are not coming back to me, I’ll lose my existing patients . . . they will go and see someone else. (LPP)
Impact of NHI on workload, professional life and clinical autonomy Doctors expressed concerns about how the new system would impact their working conditions and clinical autonomy and anticipated a dramatic rise in workload due to the increased population access. Many anticipated that if they were to receive a lower tariff per patient and had to trade ‘quantity for price’, this would lead to ‘factory line medicine’. They predicted that increased pressures on providers and rationed care for patients were inevitable. There were repeated references to the current public system’s ‘conveyer belt medicine’, sub-optimal consultation times for patients and overwork for providers. . . . you need to examine the patient and to do it properly . . . it takes about 15 minutes . . . that’s 4 patients an hour . . . some practices see 120 a day! ok, that depends on them . . . but their patients aren’t getting satisfactory care . . . never physically examined in meetings with a doctor! That’s not healthcare. (LPP) I’d like guarantees that we won’t be overworked . . . a set amount of patients a day, with limitations on after-hours work . . . At the moment [we] are three doctors and we do every third weekend and every third night but you get to sleep and you get to survive, whereas . . . for the government you wouldn’t sleep in a whole night. (S/SPP) Anxiety about the physical working environment, inferior medical equipment and infrastructure that was likely to exist in public clinics also featured extensively: What kind of facilities are we going to work in? . . . not even a chair to sit down in or proper telephones or water, never mind X-ray and diagnostic equipment . . . it will be going back into the dark ages. (MPP) For most respondents autonomy was paramount and synonymous with private medicine and private practitioners deeply valued the fact they could determine their own ‘tradeoffs’, work balances and method of practice: The thing I like about private practice is that I can control the number of people I see in a day, which is about 30. And the whole environment is quite controlled . . . it suits me and my time and my stress levels - the way I work now, where I can control it. (LPP)
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Many took the view that it was nonsensical for one flat price regardless of the quality of the service. Because doctors varied in terms of their education, training, expertise and facilities, the idea that there should be flat rate pay scales flew in the face of market principles and competition. Many argued that the skill and reputation of a doctor should determine the price they charged and the custom they attracted, not a bureaucratic mechanism:
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At the moment . . . the [Provincial] guys in charge can’t even make state hospitals work—they just don’t have the expertise, you know they don’t have the knowledge. I don’t know if it’s the will lacking or whatever it is but they just can’t do the job. (SAMA Rep) It’s a joke to think they have the ability to manage something as big as NHI . . . if it’s not corruption, it’s mismanagement and incompetence . . . they can’t even manage the pay roll for the public doctors they have now. (Public-Sector GP) Despite strong concerns from the majority of private practitioners, it is important to highlight that opinions were not unanimous. Because not all practitioners faced the same sets of conditions, unsurprisingly, experiences and opinions varied. Most public-sector GPs in hospital settings largely welcomed the reforms, anticipating that increasing capacity in the private sector would lessen their workload. Additionally, some private practitioners, particularly smaller practices in less affluent areas also welcomed the potential increased work prospects and better security of remuneration that the new arrangements afforded: As a small independent practitioner I’d like to be honest with you: if it means more money in my pocket at the end of the day I don’t have a problem with it – I’ll go with it. If at the end of the month it means more money in my pocket I think it’s OK. (S/SPP) I think it’s gonna depend on the doctor. I mean, some of them will embrace it . . . We’re not a high turnover practice . . . we have a relationship with our patients . . . [We’re] not just a sausage factory. Whereas some practices are geared to that, they have a fast throughput . . . one could question the quality of medicine that they practice. (MPP)
Ability of private practitioners to influence the policy process Given the strong negative reactions of private practitioners towards the NHI proposals, interviews explored the extent to which they were preparing to defend their interests. It was striking that on the whole there was little evidence
of organized opposition from the profession or willingness to try to influence the policy process. Some predicted that doctors would vote with their feet and take early retirement or emigrate. However, more common was a feeling of resignation with little motivation to challenge the reforms. Relatively few interviewees had been active in attending meetings or voicing concerns via their professional associations or directly via the media. Despite general discontent that they had not been sufficiently included in the consultation process and resentment about reforms being ‘forced down throats’ and government ‘riding roughshod’ over them, doctors appeared pessimistic about their ability to change or influence things: At the end of the day the doctors are not in the driving seat—government will do what it wants to do . . . we don’t have any power . . . (Hospital Specialist) We are not the ones who will call the shots. We have been abused by all sides—government on one side and the medical-aids and hospitals on the other . . . no one is entering the profession any more. (MPP) Explanations for this ‘passivity’ ranged (as in other countries) from simple lack of time to the individualistic culture of general practice. However, several respondents were cynical about the motives of the government and for these clinicians, the perceived anti private-sector sentiments of the Ministry of Health generated mistrust and hostility and contributed to their unwillingness to engage with the policy process: Motsoaledi [Health Minister] has already said the privatesector is a monster . . . so we are sitting with a major problem; we already dislike each other ok, so how are you going to appease us, because we know what their intention and their agenda is. They want to basically take the privatesector and wring its neck, to see if they can force us all to work for the state sector. (LPP) Another considerable factor undermining an organized response from the medical profession was the fractured nature of the profession itself, apparent in the manner in which clinicians spoke and identified themselves. Fragmentation appeared along geographical and organizational lines; regional, rural, urban, private, public, tertiary and primary divides. Another factor adding to the complexity of relationships was the continuation of racial divisions and in particular that doctors in private practice interacted very strongly along racial divides. It was striking how racially divided the larger practices in this study were, and that the majority of small/solo practices comprised mostly Black and Indian doctors. The legacy of racial and structural rifts meant clinicians faced fundamentally different pressures and had very different demands: SAMA can’t represent doctors’ views as a whole, because . . . they all have different needs. Private-sector doctors feel very differently about this than those of us working in rural health . . . if my priority is access to healthcare, that’s a very different issue than if you’ve
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There were frequent protests that clinical autonomy was already being eroded by the existing system of managed care being ‘forced’ on doctors by medical schemes. Complaints about prescribed drug lists, patient protocols, guidelines and pre-authorization before admitting or referring were widespread. Nevertheless, the assumption was that coming under ‘state control’ would only exacerbate these trends. In this context, the issue that elicited the strongest negative reaction was the suggestion that doctors would come under provincial government control. There was universal condemnation of current public-sector governance and complete lack of confidence in government’s ability to manage or regulate. The idea of losing autonomy to the state elicited a more emotive reaction from clinicians across all sectors than a potential cut in pay:
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got a thriving private practice in the centre of town. (SAMA Rep) . . . doctors have very different perspectives, different priorities and speak different languages . . . So it’s a complex relationship . . . At the moment the medical fraternity in SA doesn’t have a feeling as a whole community . . . there’s no such thing as a uniform medical community . . . It’s very splintered. (IPA Rep)
Discussion
(some financial, others to do with enhanced continuing professional development) will also be instituted. The government has also focused on strengthening public-sector administrative and managerial capacity to ensure the system is ‘fit for purpose’ and a National Academy for Leadership and Management in Healthcare is in the process of being established under the auspices of the National Department of health (DOH). Whether these plans are enough to command the trust and co-operation of private GPs, is yet to be seen, though this must remain the goal for policy makers—not least because their support and motivation is essential for the stable transition and sustained implementation of the reforms. One strategy for achieving greater buy-in from GPs will be to avoid a ‘one size fits all’ model. This study found substantial material difference between practices, the pressures they face and consequently the demands they have regarding NHI. Although some did not begrudge increased patient loads or were willing to trade autonomy for securer remuneration, other practices prized autonomy above all else. Flexibility in arrangements and models, with choice of contracts, conditions of service and career advancement pathways, will be both pragmatic and tactical. Variation in remuneration packages, with transparency in the criteria being used to determine prices will be essential. Upgrading the conditions and infrastructure in public-sector clinics and enabling those who wish to, to provide services from their own premises will also encourage more engagement. Finally, allowing larger practices (or groups of practices working in consortium) greater autonomy from close government management (as proposed for some hospitals) may also be strategic. It is interesting to observe that in terms of influencing the policy process, the SA profession appears mostly to be ‘reactive’ rather than proactive, to the extent it is mostly trying to block reform rather than initiate it. One explanation for the relatively muted response is that is it just too early in the process (especially given the scepticism about the feasibility of the initiative). Equally, the findings may signify that due to historical legacies, the exceptionally fragmented nature of the profession undermines its power as an actor in the policy arena. However, in either scenario, government would be foolish to ignore the professions’ discontent. There are certainly recent examples of the SA medical profession using its power to block reform and assert its own interests, including stalling government attempts to issue a ‘Licence or Certificate of Need’ (2004) and the recent victory for the profession in the courts in the 2001 ‘dispensing row’ (Pretorius et al. 2012). Given the necessary reliance on the private sector to contribute to healthcare services in the immediate term, policy makers will need to identify strategies to incentivise them to achieve desired outcomes. To this extent, current policy makers may do well to consider previous efforts to engage with the SA private health sector, in particular the system of ‘part-time district surgeons’ (PDS) initiated during apartheid but continued out of necessity by the 1994 democratic government. In order to address the acute shortage of public-sector primary-care services during the transition, provincial Departments of Health contracted with private GPs to work part time for the public-sector. Research on
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To the extent that the SA government intends to create an integrated and universal system of healthcare provision, it will face according to the results of this study significant challenges in garnering the support of sections of the medical profession. Although several public and some private GPs regarded a state led NHI beneficial for both patients and themselves, most private GPs were opposed to the measures which they viewed as impractical and threatening to their commercial and professional interests. Respondents feared lower remuneration but increased workload and despite public statements about strengthening primary-care and the referral system no one expected greater empowerment for primary-care providers. Other concerns revolved around clinical autonomy and the quality of services and conditions of work, though the most fervent focused on government control, with little confidence in government’s ability to implement or manage the new system. It is important to contextualize the strong response of clinicians in this study within the historic weaknesses of the Eastern Cape provincial administration (Van Niekerk 2012) and to recognize that wide institutional differences between Provinces will mean that the reforms will be implemented more successfully in some than others. Nevertheless, it seems that the dynamics identified here are not unique or fundamentally divergent from the national situation. Recent acrimonious debates between the Minister of Health and medical associations underscore that concerns about remuneration, autonomy, state capacity and lack of consultation are deeply felt (Archer 2014a,b; Malan 2014). Perhaps more direct confirmation of the study findings is the DoH’s struggle to recruit GPs to participate in the 11 pilot sites currently underway. Only 96 private-sector doctors signed contracts to work in NHI pilot clinics between March 2013 and 2014, well short of the target of 600 set for the year (Kahn 2014). Moreover, the majority of those participating were in Gauteng Province (one of the richest and best capacitated provinces) with the lowest participation rate in the EC site where this study was conducted (Cook 2013). Because this research was undertaken a number of developments have occurred which suggest that policy makers are responding to some of the concerns. Following a national consultation exercise by the Minister of Health during 2012, a new national GP contract model is being shaped which addresses some of the concerns articulated here. Although the current remuneration for doctors contracting with pilot sites has been derided as too low and rigid (a flat hourly rate of R355), the proposed national contract will permit additional allowances for clinical experience, travel and for working in rural or very deprived areas. Additional performance incentives
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Conclusion Health policy analysis shows that although in most contexts the state, market and profession exist in a delicate balance, the power of the medical profession has traditionally been a key determinant in shaping how that balance is either maintained or changed. Judging from these research results, the government has not yet been able to convince private medical doctors (in particular GPs) that the NHI scheme is viable, or indeed, desirable. Because doctors working in private practice constitute nearly 70% of the total number of GPs working in SA, they will need to be convinced of the new proposals if the NHI scheme is to be implemented effectively.
Acknowledgements The work was supported by the Sandisa Imbewu Grant from Rhodes University, SA and a John Fell Grant (Grant Number CV0035) from the University of Oxford, UK. Both funding
agreements ensured the authors’ independence in designing the study, interpreting the data and, writing and publishing the report. Conflict of interest statement. None declared.
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