Understanding the consequences for quality and efficiency of expanding services through the private sector in South Africa
Medical Research Council
University of the Witwatersrand
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 the poor. But the role of the private sector in expanding universal health coverage (UHC) in LMICs is contentious. Supporters of private care provision argue that competition makes private providers more responsive, exert more effort, and provide better quality care. Yet the empirical evidence supporting this is mixed. There is also limited evidence that the demand for care is responsive to quality or costs, a pre-condition for a functioning competitive market. These dynamics are also likely to vary between countries. These questions are central to current policy proposals in South Africa, where the government plans to expand access to quality primary care services by contracting private providers. This study aims to address these questions and inform current policy debates by undertaking a detailed investigation of a self-contained market for PHC services among the urban poor in South Africa. The study has five components: (1) a detailed description of the structure of the market for PHC in Soweto; (2) an audit study of PHC providers in the market using standardised patients, allowing us to describe the relative performance of public and private providers in terms of access, quality and efficiency of treatment; (3) an investigation of the relationship between measures of market competition and performance; (4) a study of the determinants of patients' choices of PHC providers; and (5) a field experiment testing the impact of subsidised care and information about quality on demand. By describing the market structure, the differentiation strategies of providers, and the key determinants of the demand for healthcare, we will provide robust and innovative evidence that will lay out the grounds for designing future regulatory and contracting arrangements with the private sector.
8.1 Organisation and delivery of services / Research Grant