Sample characteristics
We enrolled and interviewed 153 participants across seven public and seven private PHC facilities – an average of 11 per study site. There was a shortfall of one participant at one study site. Table 1 shows the demographic, socio-economic and health related characteristics of our study sample. Two thirds (67%) of our study sample were female; the mean age was 40. The majority of our study population were economically active (63%), had no health insurance (91%) and earned up to $621 per month (68%). Almost two thirds (64%) reported having an educational level between Grade 8–12 (secondary/high school), 27% had completed their secondary/ high school education, while 3% had no formal education. The mean total household income reported was $453 per month with a mean household size of 4 people.
Table 1
Demographic, socio-economic and health related characteristics of respondents, N = 153
Characteristics
|
N (%)
|
Gender, n (%)
|
|
Male
|
51 (33)
|
Female
|
102 (67)
|
Age (mean, SE)
|
40 (1.05)
|
Relationship status, n (%)
|
|
Married
|
43 (28)
|
Unmarried
|
110 (72)
|
Education, n (%)
|
|
No Education
|
4 (3)
|
Some primary education (Grade (GR) R – GR 6)
|
15 (10)
|
Completed primary education (GR 7)
|
8 (5)
|
Some secondary education (GR 8-GR11)
|
56 (37)
|
Completed secondary education (Gr12/matric)
|
41 (27)
|
Certificate/diploma from college/technical college /university
|
23 (15)
|
Undergraduate from college/ technical college /university
|
6 (4)
|
Health insurance, n (%)
|
|
No
|
139 (91)
|
Yes
|
14 (9)
|
Monthly income, n (%)
|
|
≤ $69
|
18 (12)
|
$69.01 - $207
|
34 (22)
|
$207.01 - $414
|
36 (24)
|
$414.01 - $621
|
16 (10)
|
$621.01 - $828
|
4 (3)
|
$828.01 - $1379
|
4 (3)
|
$1379.01 - $1724
|
2 (2)
|
> $1724
|
1 (1)
|
Refused to specify/did not know
|
38 (25)
|
Mean household incomea (USD)
|
$453
|
Household size (Mean, SE)
|
4 (0.18)
|
Economically activeb, n (%)
|
|
No
|
57 (37)
|
Yes
|
96 (63)
|
Socio-economic status group, n (%)
|
|
1 – low SES
|
51 (33)
|
2 – medium SES
|
51 (33)
|
3 – high SES
|
51 (33)
|
Chronic disease (HIV, diabetes, hypertension), n (%)
|
|
No
|
65 (42)
|
Yes
|
88 (58)
|
a 65 participants were excluded from this calculation as they either reported a household income of 0, or refused to respond; standard error of the mean is not reported as this was a categorical variable. |
b A participant was classified as economically active if they reported working in either the formal sector, informal sector or being self-employed. |
When asked about the health sector where they usually accessed care, 73 (48%) indicated usually visiting a public health facility, 49 (32%) usually chose a private health facility and 31 (20%) frequently utilised a mix of both facility types (Table 2). Education, health insurance, monthly income and SES were significantly associated with usual PHC choice (p ≤ 0.05).
Table 2
Demographic, socio-economic and health related characteristics of the study population by usual PHC choice
Characteristic
|
PHC usually accessed (usual PHC)
|
p-valuea
|
|
Public sector [N = 73]
|
Private sector
[N = 49]
|
Mix of both sectors [N = 31]
|
|
|
N (%)
|
95% CI
|
N (%)
|
95% CI
|
N (%)
|
95% CI
|
|
Gender
|
|
|
|
0.11
|
Male
|
20 (27)
|
18–39
|
22 (45)
|
32–59
|
9 (29)
|
16–47
|
Female
|
53 (73)
|
61–82
|
27 (55)
|
41–68
|
22 (71)
|
53–84
|
Age (mean, SE)
|
39(1.6)
|
35–42
|
42 (2)
|
38–46
|
40 (1.8)
|
36–43
|
|
Relationship status
|
|
|
|
|
|
|
0.12
|
Married
|
15 (21)
|
13–31
|
16 (33)
|
21–47
|
12 (39)
|
23–57
|
Unmarried
|
58 (79)
|
69–87
|
33 (67)
|
53–79
|
19 (61)
|
43–77
|
Education
|
|
|
|
|
|
|
0.02
|
No Education
|
3 (4)
|
1–12
|
1 (2)
|
0.3–13
|
0 (0)
|
|
GR R – GR 6
|
7 (10)
|
5–19
|
4 (8)
|
3–20
|
4 (13)
|
5–30
|
GR 7
|
5 (7)
|
3–16
|
2 (4)
|
1–15
|
1 (3)
|
0.4–20
|
GR8-GR11
|
23 (32)
|
22–43
|
17 (35)
|
23–49
|
16 (52)
|
34–68
|
Gr12/matric
|
27 (37)
|
26–49
|
9 (18)
|
10–32
|
5 (16)
|
7–34
|
Certificate/diploma
|
8 (11)
|
6–21
|
10 (20)
|
11–34
|
5 (16)
|
7–34
|
Undergraduate
|
0 (0)
|
|
6 (12)
|
6–25
|
0 (0)
|
|
Health insurance
|
|
|
|
|
|
|
0.002
|
No
|
72 (99)
|
91–100
|
39 (80)
|
66–89
|
28 (90)
|
74–97
|
Yes
|
1 (1)
|
0.2-9
|
10 (20)
|
11–34
|
3 (10)
|
3–26
|
Monthly income b
|
|
|
|
|
|
|
0.02
|
≤$69
|
10 (14)
|
7–24
|
5 (10)
|
4–22
|
3 (10)
|
3–26
|
$69.01 - $207
|
18 (25)
|
16–36
|
12 (25)
|
14–38
|
4 (13)
|
5–30
|
$207.01 - $414
|
13 (18)
|
11–28
|
12 (25)
|
14–38
|
11 (36)
|
21–54
|
$414.01 - $621
|
7 (10)
|
5–19
|
2 (4)
|
1–15
|
7 (23)
|
11–41
|
$621.01 - $828
|
0 (0)
|
|
3 (6)
|
2–17
|
1 (3)
|
0.4–20
|
$828.01 - $1379
|
0 (0)
|
|
4 (8)
|
3–20
|
0 (0)
|
|
$1379.01 - $1724
|
0 (0)
|
|
1 (2)
|
0.3–13
|
1 (3)
|
0.4–20
|
> $1724
|
0 (0)
|
|
0 (0)
|
|
1 (3)
|
0.4–20
|
Not specified
|
25 (34)
|
24–46
|
10 (20)
|
11–34
|
3 (10)
|
3–26
|
Mean household incomec
|
$326
|
|
$570
|
|
$485
|
|
|
Household size (Mean, SE)
|
4 (0.29)
|
|
3 (0.28)
|
|
4 (0.38)
|
|
|
Economically actived
|
|
|
|
|
|
|
0.046
|
No
|
34(47)
|
35–58
|
12(24)
|
14–38
|
11(35)
|
21–54
|
Yes
|
39(53)
|
42–65
|
37(76)
|
62–86
|
20(65)
|
46–79
|
Socio-economic status group
|
|
|
|
|
|
|
0.02
|
1 – low SES
|
30(41)
|
30–53
|
13(27)
|
16–41
|
8(26)
|
13–44
|
2 – medium SES
|
28(38)
|
28–50
|
12(24)
|
14–38
|
11(35)
|
21–54
|
3 – high SES
|
15(21)
|
13–31
|
24(49)
|
35–63
|
12(39)
|
23–57
|
Chronic disease (HIV, diabetes, hypertension)
|
|
|
|
|
|
|
0.56
|
No
|
34(47)
|
35–58
|
20(41)
|
28–55
|
11(35)
|
21–54
|
Yes
|
39(53)
|
42–65
|
29(59)
|
45–72
|
20(65)
|
46–79
|
a p-value for a X2 test of association between the specified population characteristic and usual PHC choice |
b The chi squared test on the monthly income variable did not include the 38 participants who refused to provide an income |
c 65 participants were excluded from this calculation (40 from the public sector, 20 for the private sector and 5 from those accessing a facility mix) as they either reported a household income of 0, or refused to respond; standard error of the mean is not reported as this was a categorical variable |
d A participant was classified as economically active if they reported working in the formal/informal sector or being self-employed |
Healthcare seeking behaviour and utilisation
The majority of participants interviewed at both public and private facilities (84% and 82%, respectively) reported having accessed primary healthcare at that facility prior to enrolment. When asked to indicate the PHC clinic at which they usually access care, participants revealed a tendency to cycle between sectors. Those interviewed in the private sector were three times more likely to use a mix of facility types than participants interviewed in the public sector (30% versus 10% respectively, Fig. 1). When asked to indicate if they see themselves changing the facility where primary healthcare was usually accessed (i.e. public sector to private sector or vice-versa) one participant interviewed in the private sector, usually utilising a mix of facility types, indicated a willingness to switch citing affordability (‘It’s all affordability’) as a driver of this decision.
Healthcare utilisation over 12 months was similar across sectors, with a weighted average number of annual visits of 6.25 for those usually accessing care in the public sector (N = 73), 5.83 for those usually accessing care in the private sector (N = 49), and 5.81 for those using a mix of facilities (N = 31). An analysis of the utilisation distribution did however reveal a difference across the “Usual PHC” options (Fig. 2). The data showed higher visit frequency (defined as consulting a healthcare provider six or more times a year for this analysis) amongst those usually accessing care in the public sector (58% in comparison to 45% amongst those usually choosing to visit the private sector). The majority (80%) of participants with a higher visit frequency in our study sample had been diagnosed with one or more of the chronic conditions of interest in this research (i.e. HIV, diabetes or hypertension). Lower visit frequency (defined as consulting a healthcare provider three or fewer times a year for this analysis) was more likely to be associated with usually accessing care in the private sector (38% in comparison to 29% in the public sector). These participants were also less likely to have been diagnosed with one or more of the chronic conditions of interest (38% reported being diagnosed with either HIV, diabetes, hypertension of a combination of these diseases).
Whilst we interviewed an equal number of patients currently accessing private and public facilities, the type of facility where patients were diagnosed and treated for HIV, TB, diabetes and hypertension differed across sector (Fig. 3).
Equal numbers were diagnosed and treated for hypertension across sectors (50% and 45%), whereas more patients are diagnosed (75%) and treated (75%) for diabetes in the public sector. Despite the greater expense and specialised care required for TB and HIV, a relatively high proportion of TB and HIV patients are treated in the private sector (75% and 42% respectively). More patients were diagnosed (71%) and treated (75%) for TB in the private sector, but this is probably driven by the low numbers (5/7 were diagnosed with TB in the private sector and 3/4 were treated for TB in the private sector) and the inclusion of a specialised TB clinic in the private sector sample.
Patients were asked to list the different healthcare services that they had accessed over the last 12 months and where they access them. They could choose more than one service, e.g. chronic services (related to diabetes, hypertension, HIV, TB, asthma, cancer etc.) and/or acute services (including minor ailments), and/or ‘other’ services including maternal and child health, sexual and reproductive health services, and support services (eye, oral, palliative etc.) (Table 3). An analysis of all services and facilities accessed by patients over the last 12 months revealed that acute services and chronic care services were the most commonly accessed services (46% and 43%). Public hospitals and private clinics were more likely to be accessed for acute services (64% and 57%), whilst public PHC clinics and private GPs were more likely to be accessed for chronic care services (44% and 52%). Our sample of patients only accessed private hospitals twice in the preceding 12 months: one for acute services and one for maternal and child health services. Public clinics provide the majority of maternal and child health care services (included in the ‘Other’ category).
Table 3
All healthcare services accessed over the last 12 months by sector and facility type
|
Service area
|
Service and facility classification
|
Chronic care
|
Acute care
|
Other
|
Total
|
N (%)
|
N (%)
|
N (%)
|
N (%)
|
Primary care services
|
Public clinic
|
41 (44)
|
34 (36)
|
19 (20)
|
94 (47)
|
Private clinic
|
20 (43)
|
27 (57)
|
0 (0)
|
47 (24)
|
GP
|
14 (52)
|
12 (44)
|
1 (4)
|
27 (14)
|
Secondary/tertiary services
|
Public hospital
|
10 (36)
|
18 (64)
|
0 (0)
|
28 (14)
|
Private hospital
|
0 (0)
|
1 (50)
|
1 (50)
|
2 (1)
|
|
|
85 (43)
|
92 (46)
|
21 (11)
|
198 (100)
|
Drivers of usual PHC facility choice
Answers to multiple response questions indicated that affordability (67%) and a convenient location (60%) were the main reasons for usually accessing care at a public health facility. Those participants who usually accessed care in the private sector specified convenience of location (71%) and quality of the care received (59%) as their main reasons behind facility choice. Finally, participants usually utilising a mix of facilities indicated similar key reasons for visiting each sector type, a convenient location (48%) and affordability (39%) were the main drivers of public sector access while quality of care (71%) and location convenience (42%) emerged as key drivers of private sector access for this segment of the study population. Refer to Table 4 for more detail.
Table 4
Reasons for usually using a public or private facility or mix of both (this was a multiple response question)
|
Reason for usually using public facilities
|
Reason for usually using private facilities
|
PHC usually accessed
(usual PHC)
|
Public Sector (N = 73)
|
Mix of both sectors
[N = 31]
|
Private Sector (N = 49)
|
Mix of both sectors
[N = 31]
|
|
N (%)
|
N (%)
|
N (%)
|
N (%)
|
It is affordable
|
49 (67)
|
12 (39)
|
10 (20)
|
0 (0)
|
I receive good quality of care
|
9 (12)
|
4 (13)
|
29 (59)
|
22 (71)
|
It is convenient for me to access
|
44 (60)
|
15 (48)
|
35 (71)
|
13 (42)
|
There are no private/public health care facilities close by
|
0 (0)
|
0 (0)
|
0 (0)
|
0 (0)
|
I have been before and they could help
|
3 (4)
|
4 (13)
|
2 (4)
|
3 (10)
|
The staff are friendly/helpful
|
5 (7)
|
2 (6)
|
7 (14)
|
5 (16)
|
It has the medicine I need
|
12 (16)
|
8 (26)
|
5 (10)
|
9 (29)
|
Other*
|
0 (0)
|
2 (6)
|
2 (4)
|
1 (3)
|
*Other reasons specified included “It’s the first time I come to this facility”, “Confidentiality is guaranteed, “Do not use public facilities” and “I had an acute condition”
|
Patient satisfaction
All repeat patients to the facility of interview were asked to describe their level of satisfaction with the care received at that clinic: 97% of private sector clients were either very satisfied or satisfied with the service they received as compared to 74% in the public sector. The public sector had a higher proportion of patients who were either dissatisfied or indifferent (neither satisfied/ dissatisfied). This was reflected in the open-ended comments patients were asked to provide on their experience of care: 73% of negative comments (i.e. slow or long waiting times, staff shortages, inadequate opening hours or cramped facilities etc.) were by patients who attended a public sector clinic, whilst 63% of positive comments on the experience of care (friendly and good staff etc.) were by patients attending a private sector clinic (Table 5).
Table 5
General comment on experience of care by sector
Experience of care
|
Public sector
|
Private sector
|
Total
|
N (%)
|
N (%)
|
N (%)
|
Negative
|
Slow/long waiting times
|
11 (85)
|
2 (15)
|
13 (100)
|
Hours/size*
|
3 (75)
|
1 (25)
|
4 (100)
|
Other
|
6 (55)
|
5 (46)
|
11 (100)
|
Staff shortage
|
4 (80)
|
1 (20)
|
5 (100)
|
Positive
|
Satisfied
|
10 (37)
|
17 (63)
|
27 (100)
|
Friendly/good staff
|
1 (17)
|
5 (83)
|
6 (100)
|
Other
|
3 (60)
|
2 (40)
|
5 (100)
|
Total
|
38 (54)
|
33 (47)
|
71 100)
|
*Includes comments referring to inconvenient opening hours or cramped facilities
|