This study examined factors influencing private general practitioners' (GPs) decisions to accept sessional contracts working in South Africa's public primary care clinics. A discrete choice experiment was conducted with 74 GPs. Results showed low predicted uptake of proposed contracts. While payment rates were important, there was heterogeneity in GPs' motivations - some opposed public work, most valued payment, and some had pro-social preferences. The findings can inform contract design improvements to potentially increase uptake, though significant financial resources may be required. Targeting more pro-socially oriented GPs may also help uptake.

1. http://resyst.lshtm.ac.uk
@RESYSTresearch
Financial Incentives and Initiatives to
Improve the Quality of Primary Care in
South Africa
Duane Blaauw & Mylene Lagarde
University of the Witwatersrand
London School of Hygiene & Tropical Medicine
http://resyst.lshtm.ac.uk
@RESYSTresearch

2. Background
 South Africa
 Upper middle-income country
 Poor health outcomes & persistent health inequalities
 Entrenched dual health care system
Sector Source Popn Health
Expenditure
1º Care
Providers
1º Care
Doctors
Payment
Private
Private health
insurance
20% 60% GPs 70% FFS
Public Tax-funded 80% 40% Nurses 30% Salary
 Recent reforms to improve the quality of primary care
1. Specialist MCH support teams
2. CHW outreach teams
3. Improved school health services
4. GP contracting initiative

3. General Practitioner (GP) Contracting
 Contract private sector GPs to work number of hours
each month in public sector clinics
 Sessional payments
 Maximum public sector rate much lower than
remuneration in private practice
 Appeal to the altruism of private GPs
 National campaign by Minister to mobilise GP support

4. Related Literature
 Strong evidence of pro-social behaviour from experimental
economics (Fehr & Schmidt, 1999)
 Public sector employees have stronger pro-social preferences
than private sector employees (Perry & Wise, 2010)
 Doctors expected to be motivated by patient benefit and
ethical practice rather than profit (Arrow, 1963; McGuire, 2000)
 Utility functions of doctors include benefit to patients (Ellis &
McGuire, 1986; Farley, 1986)
 Demonstrated heterogeneity in altruism of medical students
(Godager & Wiesen, 2013)
 More altruistic medical students choose to work in public
sector (Serra et al, 2010; Kolstad & Lindkvist, 2012)

5. Study Objectives
 Likely uptake of sessional contracts by private GPs
 Quantify relative importance of different contract
elements
 Contrast personal income and benefit to patients
 Using a stated preference discrete choice experiment
(DCE)

6. Methods
 DCE Design [Ngene]
 Generic design: 2 alternatives + opt-out
 8 attributes derived from preliminary research
 Incremental design strategy
 Orthogonal design  Priors from first 25 responses  Bayesian D-
Efficient design (Rose & Bliemer, 2009)
 DCE Analysis [Limdep/Nlogit]
 Multinomial logit (MNL)
 Heterogeneity of preferences
 MNL interactions with GP and practice characteristics
 Mixed (Random parameters) logit (MXL)
 Latent class logit (LCM)

7. DCE Design
ATTRIBUTE LEVELS
1. Distance to nearest
public sector doctor
 20km
 40km
2. Basic contract rate  R 265 per hour (11ZAR=1USD)
 R 350 per hour (33% increase)
 R 435 per hour (66% increase)
 R 520 per hour (100% increase)
3. Deprivation allowance  None
 An additional R 85 per hour (33% increase)
4. Performance bonus  None
 An additional R 85 per hour if meet specified quality targets for
consultation records, referrals & adherence to treatment
protocols
5. Travel reimbursement  R 100 per trip (35% increase)
 R 130 per trip (50% increase)
6. Free CPD points for
induction and training
 None
 15 points
7. Type and location  Fully-functional container clinic in an informal settlement
 Fixed clinic in the township
8. Distance from your  10km

8. DCE Choice Task
Which of these two contracts would you choose?
CONTRACT A CONTRACT B NEITHER
⃝ ⃝ ⃝

9. Respondents and Sampling
 National database of ~8000 active GPs
 Random sample of 493
 Email invitation
 15.1% response rate
 Online survey
 DCE + socio-demographic questionnaire

10. Respondents
Male 64.4%
Age 48.8 ± 10.4
Time working as private GP 18.5 ± 10.5 year
Charge per consultation for insured patients R 297.70 ± 49.78
Charge per consultation for cash patients R 254.71 ± 62.23
Estimated turnover per hour R 1119.95 ± 600.39
Have done sessional work in public sector 22.5%
Said were likely to do sessional work in public
clinic
50.0%

11. Coeff (SE)
Contract characteristics
Nearest public sector doctor 20km further away 0.000 (0.093)
Increase in basic contract rate of R85 per hour 0.569 (0.175) ***
R170 per hour 1.447 (0.174) ***
R255 per hour 2.013 (0.171) ***
Additional deprivation allowance of R85 per hour 0.571 (0.110) ***
Additional performance bonus of R85 per hour 0.486 (0.095) ***
Additional transport allowance of R100 per trip 0.580 (0.153) ***
R130 per trip 0.686 (0.171) ***
10 CPD points for induction and training 0.061 (0.089)
Fixed clinic 0.429 (0.096) ***
Facility 20km nearer to current practice 1.024 (0.156) ***
Opt-out constant 3.083 (0.237) ***
Pseudo R-squared 0.123
*** p<0.01, ** p<0.05, * p<0.10
MNL

12. Facility
Fixed
Clinic
Fixed
Clinic
Fixed
Clinic
Container
Fixed
Clinic
Fixed
Clinic
Fixed
Clinic
Fixed
Clinic
Fixed
Clinic
Basic rate R265 R265 R265 R265 R265 R350 R265 R265 R265
Distance 30km 30km 30km 30km 10km 30km 30km 30km 30km
Transport
allowance
0 0 0 0 0 0 0 0 R100
Deprivation
allowance
0 0 0 0 0 0 R85 0 0
Performance –
related bonus
0 0 0 0 0 0 0 R85 0
Nearest doctor 20km 40km 20km 40km 20km 20km 20km 20km 20km
CPD points 0 0 10 0 0 0 0 0 0
Total/Hour R265 R265 R265 R265 R265 R350 R350 R350 R365
UPTAKE 7.5% 7.9% 8.0% 5.2% 16.9% 12.2% 13.3% 12.6% 12.9%
Model Simulations

13. Facility
Fixed
Clinic
Fixed
Clinic
Fixed
Clinic
Fixed
Clinic
Fixed
Clinic
Fixed
Clinic
Basic rate R350 R435 R520 R350 R520 R520
Distance 30km 30km 30km 30km 30km 30km
Transport
allowance
0 0 0 R100 R130 R130
Deprivation
allowance
0 0 0 R85 R85 R85
Performance –
related bonus
0 0 0 R85 R85 R85
Nearest doctor 20km 20km 20km 20km 40km 40km
CPD points 0 0 0 0 10 10
Total/Hour R350 R435 R520 R620 R820 R820
UPTAKE 12.2% 21.8% 34.6% 43.6% 77.2% 78.6%
Model Simulations

14. Coef (SE)
Contract characteristics
Nearest public sector doctor 20km further away -0.051 (0.109)
Increase in basic contract rate of R85 per hour 0.723 (0.213) ***
R170 per hour 1.721 (0.211) ***
R255 per hour 2.315 (0.210) ***
Additional deprivation allowance of R85 per hour 0.630 (0.131) ***
Additional performance bonus of R85 per hour 0.565 (0.113) ***
Additional transport allowance of R100 per trip 0.689 (0.181) ***
R130 per trip 0.870 (0.204) ***
10 CPD points for induction and training 0.017 (0.105)
Fixed clinic 0.333 (0.114) ***
Facility 20km nearer to current practice 1.128 (0.190) ***
Opt-out constant 3.784 (0.315) ***
Demographic characteristics Interaction with opt-out
Under 50 years old -0.252 (0.162)
Upper tertile of turnover per hour 0.980 (0.181) ***
Currently doing sessional work -0.584 (0.196) ***
Likely to accept sessional work in public clinic -1.089 (0.156) ***
Pseudo R-squared 0.212
*** p<0.01, ** p<0.05, * p<0.10
MNL Interactions

15. Mixed Logit
Mean (se) SD (se)
Contract characteristics
Nearest public sector doctor 20km further away 0.028 (0.180) 0.241 (0.255)
Increase in basic contract rate of R85 per hour 1.955 (0.436) *** 1.496 (0.444) ***
R170 per hour 4.579 (0.496) *** 0.772 (0.297) ***
R255 per hour 5.869 (0.543) *** 1.933 (0.302) ***
Additional deprivation allowance of R85 per hour 1.446 (0.247) *** 0.930 (0.188) ***
Additional performance bonus of R85 per hour 1.014 (0.241) *** 1.441 (0.272) ***
Additional transport allowance of R100 per trip 1.267 (0.318) *** 0.793 (0.371) **
R130 per trip 1.964 (0.349) *** 0.465 (0.416)
10 CPD points for induction and training 0.412 (0.184) ** 0.340 (0.242)
Fixed clinic 1.794 (0.435) *** 2.986 (0.416) ***
Facility 20km nearer to current practice 2.399 (0.680) *** 4.333 (0.520) ***
Opt-out constant 7.626 (0.771) *** 6.630 (0.708) ***
Pseudo R-squared 0.504
*** p<0.01, ** p<0.05, * p<0.10

16. Latent Class Analysis
Class 1 Class 2 Class 3
Mean (se) Mean (se) Mean (se)
Contract characteristics
Nearest public sector doctor 20km further away -1.372 (0.895) -0.022 (0.134) -0.038 (0.156)
Increase in basic contract rate per R85 / hour 2.648 (0.959) *** 1.172 (0.094) *** 0.876 (0.134) ***
Additional deprivation allowance of R85 / hour 2.829 (1.174) ** 0.888 (0.148) *** 0.846 (0.175) ***
Additional Performance bonus of R85 / hour 1.847 (0.963) * 0.823 (0.148) *** 0.719 (0.180) ***
Additional transport allowance of R100 / trip 3.238 (1.423) ** 1.149 (0.239) *** 0.943 (0.293) ***
R130 / trip 3.323 (1.441) ** 1.521 (0.253) *** 1.015 (0.331) ***
10 CPD points for induction and training 1.117 (0.798) 0.054 (0.129) 0.080 (0.150)
Fixed clinic 0.348 (0.642) 0.883 (0.148) *** 0.251 (0.173)
Facility 20km nearer to current practice 4.514 (1.471) *** 1.784 (0.254) *** 1.586 (0.342) ***
Opt-out constant 15.639 (4.315) *** 4.841 (0.431) *** -0.644 (0.631)
Class probabilities 0.296 0.462 0.242
Pseudo R-squared 0.394
*** p<0.01, ** p<0.05, * p<0.10

17. 7.5%
7.9%
8.0%
11.2%
12.6%
12.9%
13.3%
16.9%
21.8%
34.6%
0.0% 25.0% 50.0% 75.0% 100.0%
Baseline rate
↑ patient benefit
CPD points
25% ↑ P4P
25% ↑ deprivation
allowance
25% ↑ basic rate
25% ↑ transport allowance
Closer to own practice
50% ↑ basic rate
75% ↑ basic rate
Uptake of Sessional ContractGroup Average
(MNL)

18. 0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0%
0.0% 25.0% 50.0% 75.0% 100.0%
Baseline rate
↑ patient benefit
CPD points
25% ↑ P4P
25% ↑ deprivation
allowance
25% ↑ basic rate
25% ↑ transport allowance
Closer to own practice
50% ↑ basic rate
75% ↑ basic rate
Uptake of Sessional ContractLatent Class 1
(29.6%)

19. 4.8%
4.9%
5.1%
10.4%
11.0%
14.1%
13.8%
23.2%
34.6%
63.1%
0.0% 25.0% 50.0% 75.0% 100.0%
Baseline rate
↑ patient benefit
CPD points
25% ↑ P4P
25% ↑ deprivation
allowance
25% ↑ basic rate
25% ↑ transport allowance
Closer to own practice
50% ↑ basic rate
75% ↑ basic rate
Uptake of Sessional ContractLatent Class 2
(46.2%)

20. 44.3%
45.3%
46.3%
62.1%
65.0%
65.7%
67.2%
79.6%
82.1%
91.7%
0.0% 25.0% 50.0% 75.0% 100.0%
Baseline rate
↑ patient benefit
CPD points
25% ↑ P4P
25% ↑ deprivation
allowance
25% ↑ basic rate
25% ↑ transport allowance
Closer to own practice
50% ↑ basic rate
75% ↑ basic rate
Uptake of Sessional ContractLatent Class 3
(24.2%)

21. GP Concerns
 Sessional rates not market-related
 Security risks
 Likelihood and timeliness of payment by the
Department of Health
 Availability of medicines and equipment
 Lack of consultation in the formulation and design of
the policy initiative

22. Limitations
 Sampling bias
 Non-response bias
 Hypothetical bias
 Specification of patient benefit
 Decisions influenced by considerations outside of
contract design

23. Main Findings
 Low uptake of proposed public sector contracts by
private GPs
 Private GPs more motivated by own financial welfare
than potential benefit to public sector patients
 But significant heterogeneity in the pro-social
preferences of private GPs
 Some GPs completely opposed to public sector work
 Largest proportion mainly motivated by payment rates
 Small group with more pro-social orientation

24. Policy Implications
 Inform improvements in contract design
 Would require significant financial resources to
increase contract uptake
 Framing of financial incentives makes little difference
 No significant opposition to performance monitoring
 Target policy initiative to more pro-social GPs

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@RESYSTresearch
RESYST is funded by UK aid from the
UK Department for International
Development (DFID). However, the
views expressed do not necessarily
reflect the Department’s official
policies.
http://resyst.lshtm.ac.uk
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