Perceived quality of primary healthcare post-National Health Insurance pilot implementation

Background: Contracting private medical practitioners for the National Health Insurance pilot project in 2012 by the National Department of Health in South Africa was envisaged to reduce workload at referral district hospitals by reducing self-referral by clients as the perceived quality of care at the primary healthcare level improves. Aim: To describe the effect of contracting private medical practitioners at primary healthcare facilities on the self-referral rate of clients at district hospitals as a proxy for perceived quality of care in a National Health Insurance pilot district. Setting: The study was set in Tshwane National Health Insurance pilot district compared to Ekurhuleni district. Methods: We compared findings before and after implementing the National Health Insurance private medical practitioners contracting between a pilot and a non-pilot district. A quasi-experimental ecological study design was used to compare district hospital outpatient department indicators of clients follow-up, self-referral, self-referral rate and referred in the two districts from June 2012 to May 2014 using single and controlled interrupted time-series analyses. Results: Controlled interrupted time series analysis found decreases in self-referral rate (-1.8 [-2.2, -1.1] [p < 0.0001]) and the initial trend of headcounts of self-referral (-516 [-969, -66] [p = 0.0260]), but an increase in headcounts of referred clients (1293 [77, 2508] [p = 0.0376]) in the pilot compared with the non-pilot district. Conclusion: We concluded that the implementation of contracting private medical practitioners in primary healthcare facilities might have resulted in an improved perceived quality of care at primary health care facilities. However, the higher number of outpatient department headcounts for follow-up and the increase in referred cases in the pilot district would need to be investigated.