CHALLENGES

HIV prevalence in South Africa rose from 0.8% in 1990 to 4.3% in 1994 (Simelela & Venter, 2014) and was at 12.2% in 2012 (Shishana et al., 2012). In addition to its heavy HIV burden, South Africa is faced with a critical shortage of doctors. In 2013, South Africa had 60 doctors per 100 000 citizens, compared to a world average of 152 doctors per 100 000 (Econex, 2015). Strain on the country’s health care system is exacerbated by large disparities between the private and public sectors. Annual per capita health expenditure is approximately US$ 140 in the public sector, serving 84% of the population, and US$ 1 400 in the private sector serving only 16% of the population (Benatar, 2013; Mayosi & Benatar, 2014). The distribution of medical specialists in the private sector is 86.5 per 100 000 compared to 11.4 per 100 000 in the public sector (Stuckler, Basu & McKee, 2011; Econex, 2015).

INTERVENTION

The General Practitioner Down-Referral Model (GP Model) utilizes the additional capacity of the private sector to meet gaps in the provision of health care services for HIV patients in the public sector. It enables medically stable HIV patients to be down-referred from public sector hospitals to local private general practitioners (GPs). It has been specifically constructed to provide support for the overburdened public health care system, which was struggling to cope with the large number of HIV patients needing antiretroviral therapy in South Africa. The GP Model is a public-private partnership (PPP) between BroadReach Healthcare, the North West Province Department of Health (DOH), and KOSHMED and MAIPA (two independent private general practitioner associations in the North West Province). Donor funding was provided for 10-years to cover the consultation fees of the GPs participating in the Model. These fees were fixed at a negotiated rate, which was determined with input from all partners and structured so that it would be feasible for the North West Province DOH to absorb this cost if donor funding did not continue. Ten years into the GP Model, donor funding has indeed ended and discussions are at an advanced stage for the DOH to absorb these costs as initially planned.

Since the GP Model began in 2005, 4 158 patients have been transferred to private GPs for routine HIV care. In an external study conducted by Navario (2009) comparing the GP Model and primary health care clinic down-referral model (PHC), the following results were obtained: 1) the proportion of patients who remained in care at the down-referral site with suppressed viral loads was 83% and 55% in the GP Model and PHC cohorts respectively; 2) eighty-eight percent of GP Model patients had suppressed viral loads compared to 67% of PHC patients; and 3) retention on treatment was 94% among GP Model patients and 75% among PHC patients.

CASE INSIGHTS

The GP Model illustrates that down-referring by out-contracting selected health care services to private providers with additional, under-utilized capacity is a feasible mechanism to provide and increase access to quality services for public sector patients in resource-constrained environments. The GP Model also provides an example of how planning for sustainability can impact the future success of such models. Donor funding was provided for 10-years to cover the consultation fees of the GPs participating in the Model. These fees were fixed at a negotiated rate, which was determined with input from all partners and structured so that it would be feasible for the North West Province DOH to absorb this cost if donor funding did not continue. Ten years into the GP Model, donor funding has indeed ended and discussions are at an advanced stage for the DOH to absorb these costs as initially planned. As demonstrated by the GP Model, appropriate costing increases the likelihood that effective models can be successfully integrated into the public health system.