Experiences of public-private contracting for caesarean delivery in rural district public hospitals: A qualitative interview study.

Governments in sub-Saharan Africa are exploring public-private-engagements for the delivery of health services. While there is existing empirical literature on public-private-engagements in high-income countries, we know much less about their operation in low and middle-income countries. Obstetric services are a priority area where the private sector can make an important contribution in terms of skilled providers. The objective of this study was to describe the experiences of managers and generalist medical officers, of private general practitioner (GP) contracting for caesarean deliveries in five rural district hospitals in the Western Cape, South Africa. A regional hospital was also included to explore perceptions of public-private contracting needs amongst obstetric specialists. Between April 2021 and March 2022, we conducted 26 semi-structured interviews with district managers (n = 4), public sector medical officers (n = 8), an obstetrician in a regional hospital (1), a regional hospital manager (1) and private GPs (n = 12) with public service contracts. Thematic content analysis using an inductive, iterative approach was applied. Interviews with medical officers and managers revealed justifications for entering into these partnerships, including retention of medical practitioners with anaesthetic and surgical skills and economic considerations in staffing small rural hospitals. The arrangements held benefits for the public sector in terms of bringing in required skills and having after hours cover; and for the contracted private GPs who could supplement their income, maintain their surgical and anaesthetic skills and keep up to date with clinical protocols from visiting specialists. The arrangements held benefits for both the public sector and the contracted private GPs and were deemed to be an example of how national health insurance could be operationalised for rural contexts. Perspectives of a specialist and manager from a regional hospital provided insight into the need for different public-private solutions for this level of care in which contracting out of elective obstetric services should be considered. The sustainability of any GP contracting arrangement, such as described in this paper, will require ensuring that medical education programmes include basic surgical and anaesthetic skills training so that GPs opening practice in rural areas have the required skills to provide these services for district hospitals where needed.