Contracting of private medical practitioners in a National Health Insurance pilot district: what has been the effect on primary healthcare utilisation indicators?

Background: In 2012, the National Department of Health in South Africa started contracting of private medical practitioners (MPs) as part of the first phase of National Health Insurance (NHI) in 11 pilot districts to improve access to healthcare. Aim: The aim of this study was to describe the effect of contracting private MPs on the utilisation of primary healthcare (PHC) services in public healthcare facilities. Setting: A National Health Insurance pilot district compared to a non-pilot district. Methods: A quasi-experimental ecological study design was used to compare selected PHC utilisation indicators in the District Health Management Information System from June 2010 to May 2014 between a pilot and a non-pilot district. Both single and controlled interrupted time series analyses were used for comparing before and after implementation of the intervention. Findings: Single interrupted time series analysis showed an increase in adults remaining on anti-retroviral therapy, clients seen by a nurse practitioner and clients 5 years of age and older in both districts. However, controlled interrupted time series analysis found no difference in all parametres. Despite a decrease in total headcounts in both districts using single interrupted time series analysis, controlled interrupted time series analysis found no differences in all parameters before and after the intervention. Conclusions: The increase in utilisation of PHC services in the pilot district may not be attributable to the implementation of contracting private MPs, but likely the result of other healthcare reforms and transitions taking place in both districts around the same time

Predictors of time to sputum culture conversion in multi-drug-resistant tuberculosis and extensively drug-resistant tuberculosis in patients at Tshepong-Klerksdorp Hospital

Setting: Klerksdorp-Tshepong Hospital Complex MDR-TB Unit, North-West Province, South Africa.Background: To determine the time to sputum culture conversion (TTSCC) and factors predictive of TTSCC in patients with multi-drug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB) in the North-West Province.Methods: A retrospective cohort study, abstracting patient demographic and clinical data, laboratory results, dates of sputum testing and sputum culture conversion results, from medical records of 526 MDR-TB and 47 XDR-TB patients started on TB treatment between 01 January 2012 and 31 December 2014. Predictors of TTSCC were determined by Cox proportional hazards regression.Results: The median age was 38 years (interquartile range 31­47) with 64% being male. Overall, 79% (449) were Human Immunodeficiency Virus (HIV)-infected. The median TTSCC was 56.5 days and 162.5 days for MDR-TB and XDR-TB patients, respectively. In the multivariate analysis, age [hazard ratio (HR): 0.89, 95% confidence interval (CI): 0.96­0.99], being underweight (HR: 0.631.61, 95% CI: 0.451.03­0.882.51), Acid Fast Bacilli (AFB) positivity (HR: 0.72, 95% CI: 0.51­1.01) and having XDR-TB (HR: 0.36. 95% CI: 0.19­0.69) were predictive of longer TTSCC.Conclusion: Predictors of TTSC allow for MDR-TB- and XDR-TB-diagnosed patients to be identified early for effective management. Those with risk factors for delayed sputum culture conversion which are being underweight and having XDR-TB should be monitored carefully during treatment so that they can achieve sputum culture conversion early