Quality of Tuberculosis Care Provided in Different Models of Public-Private Partnership in South Africa
Aims The study evaluates quality of care for the treatment of tuberculosis (TB) provided in different public-private partnerships (PPP) and compares their performance with that of public sector providers. Methods Quality of care analysis comparing three different models of directly observed treatment (DOT) provision: purely public, public-private workplace partnership (PWP), and public non-governmental organisation (NGO) partnership (PNP). For each type of provision model, two sites were identified using key informant interviews with provincial TB programme officials, and then selected by non-randomised, purposive sampling according to their availability, urban-rural locations, different reimbursement mechanisms, and willingness to participate in the study. Three dimensions of quality of TB care - structure, process and outcome - were assessed. Criteria or specific attributes of the TB service were identified for evaluation, drawing on the National TB Programme guidelines. Key results The PWP sites had the highest score in all three aspects of quality of care. The PNP sites scored higher than the purely public model in 2/5 categories of the structural quality of care assessment. Accessibility was better because of the availability of TB treatment after hours. In terms of process quality, the sites achieved similar scores, reflecting a very good knowledge of the treatment guidelines for both private and public providers. On average, the PWP sites achieved the highest score, followed by purely public sites and PNP sites. Patients supervised in the public clinics generally had lower treatment completion rates than those supervised in the occupational health clinics in the workplace and in the community. Overall, the cure rate was between 58% (a purely public site) and 83% (a PWP site). None of the study sites achieved the national target cure care of 85%. Conclusion The study suggests that the quality of care is superior in both PPP models compared to the purely public sector model of delivery. Partnerships with community-based NGOs and employer-based medical services should be established where they provide improved quality of care in TB treatment or when the government does not have the capacity to provide services. It is important, however, that the government maintains quality control. The capacity of the public sector to monitor the quality of care provided in the partnerships is therefore crucial