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Background: South Africa is severely affected by the AIDS pandemic and this has resulted in an already under-resourced public sector being
placed under further stress, while there remains a vibrant private sector. To address some of the resource and personnel shortages facing the
public sector in South Africa, partnerships between the public and private sectors are slowly being forged. However, little is known about the
willingness of private-sector doctors in the eThekwini Metropolitan (Metro) region of KwaZulu-Natal, South Africa to manage public-sector HIV and
AIDS patients. Objectives: To gauge the willingness of private-sector doctor to manage public-sector HIV and AIDS patients and to describe factors that
may influence their responses. Method: A descriptive cross-sectional study was undertaken among private-sector doctors, both general practitioners (GPs) and specialists,
working in the eThekwini Metro, using an anonymous, structured questionnaire to investigate their willingness to manage public-sector HIV and AIDS
patients and the factors associated with their responses. Chi-square and independent t-tests were used to evaluate associations. Odds ratios were
determined using a binary logistic regression model. A p value < 0.05 was considered statistically significant. Results: Most of the doctors were male GPs aged 30–50 years who had been in practice for more than 10 years. Of these, 133 (77.8%)
were willing to manage public-sector HIV and AIDS patients, with 105 (78.9%) reporting adequate knowledge, 99 (74.4%) adequate time, and 83 (62.4%)
adequate infrastructure. Of the 38 (22.2%) that were unwilling to manage these patients, more than 80% cited a lack of time, knowledge and
infrastructure to manage them. Another reason cited by five doctors (3.8%) who were unwilling, was the distance from public-sector facilities.
Of the 33 specialist doctors, 14 (42.4%) indicated that they would not be willing to manage public-sector HIV and AIDS patients, compared with
only 24 (17.4%) of the 138 GPs (p < 0.01). Conclusion: Many private-sector doctors are willing to manage public-sector HIV and AIDS patients in the eThekwini Metro, potentially
removing some of the current burden on the public health sector.
Health systems in developing countries are in crisis; the deficits include a lack of sufficient health professionals, inadequate finance and poor
quality of service, together with poor infrastructure, which includes a lack of reliable water, sanitation and electricity.1 Without
adequate infrastructure, doctors and nurses cannot provide quality care even when they are available. Underlying this is a serious shortage of
skilled, trained managers and the deficit is greatest in sub-Saharan Africa, where 17% of the total health workforce is employed as managers,
compared to 33% globally. Many countries are now engaging the private sector in partnerships with the public sector as a means of rebuilding
their infrastructure and improving access to services.1
To address some of the resource and personnel shortages facing the public health sector in South Africa, partnerships between the public and
private health sectors are slowly being forged. In May 2006, the Minister of Health launched the National Consultative Health Forum2 to
discuss key strategic health issues, including tuberculosis, HIV and AIDS, recruitment and retention of health professionals, and transformation of
the health sector.3 South Africa has an extensive antiretroviral treatment programme:371 731 patients were initiated on antiretroviral treatment in 2007, whilst approximately 76 217 (22%) received treatment funded
by medical schemes, private-sector and development partners for 2006, a number which increased to 28% in 2007.4 Governments and donors
are increasingly considering the private sector as a potential partner in addressing the growing demand for sustainable HIV and AIDS treatment.
Given the weaknesses and strengths of both sectors, a partnership between the public and private sectors has became a viable policy option since
neither the public nor the private sector alone can deliver competent, accessible and affordable health care.5 The AIDS pandemic has severely affected South Africa, with an estimated 5.7 million South Africans living with HIV and AIDS in 2007.6
HIV and AIDS thus constitutes the major part of the South African burden of disease.7 High levels of internalised stigma encourage
people to hide their condition8 and many HIV and AIDS patients prefer to consult a private-sector doctor in order to avoid the stigma.
9 However, little is known about willingness of private-sector doctors to manage public-sector HIV and AIDS patients. This study
investigated the issue in the eThekwini Metropolitan (Metro) area of KwaZulu-Natal (KZN) and described possible factors that could influence
doctors’ responses.
Study design, study area and sample population
This descriptive cross-sectional study of private general practitioners and specialists was undertaken in the eThekwini Metro of KZN.
This province has the largest provincial population in South Africa, with just over 10 million people (20.9% of the total population of
47.9 million),10 and is the province with the highest prevalence of HIV, as indicated by antenatal clinic attendees’ data
(39.1% in 2006, compared to the national figure of 29.1%).11 The eThekwini Metro has a population of 3 090 126, comprising 51.9%
(1 605 080) women and 48.1% (1 485 046) men.12 Most of the eThekwini Metro is urban (central) and suburban (south, north and west),
with a small rural constituency (inner west and further south).
Study sample
The sample population comprised all general practitioners (GPs) and specialists that work in the private health care sector of the eThekwini Metro
area. These doctors are remunerated either by patients paying cash or via a medical aid scheme. They are independent of any funding from the
government. A comprehensive list of 1 255 GPs and specialists practicing in the eThekwini Metro was obtained from the Medpages Directory, the
KwaZulu-Natal Managed Care Coalition (KZNMCC, a private doctor grouping), the private doctors’ guilds, the Lancet Clinic Courier database,
and the Southern African HIV Clinicians’ Society. This was done to ensure that all eThekwini medical practitioners in the private sector
were included. The study initially identified doctors that managed HIV and AIDS patients in the private sector, and/or their reasons for not doing
so, and their training needs (Phase 1).13 There were 235 doctors from the Phase 1 study who indicated that they managed HIV and AIDS
patients, only 190 of whom indicated their willingness to participate in Phase 2 of the study. The second phase was undertaken to determine
the doctors’ willingness to manage public-sector patients in the eThekwini Metro, as well as to investigate the motivations for their
choice. Trained field workers were allocated to the doctors who had indicated their willingness to participate in this study. The doctors were first
telephoned, to ensure their availability and to confirm their consent. Most of the questionnaires were hand delivered and later collected. A
few questionnaires were faxed to participants and a few were faxed back by the doctors. No records of the doctors’ name or contact details were kept. The data were captured and analysed using SPSS version 15. Factors
influencing doctors’ willingness to treat patients, such as time, knowledge and infrastructure, were ranked from 0 to 3. The chi-square
statistic was used for categorical data analysis and the independent samples t-test for continuous data. A binary logistical regression model,
with all four factors entered as independent variables, was applied using a backward stepwise fitting method.
A p value < 0.05 was considered statistically significant. Ethical approval for the study was obtained from the Ethics Committee of the Nelson R. Mandela School of Medicine, University of KwaZulu-Natal.
The results provided a demographic profile of the doctors (Table 1), their willingness to manage public-sector patients (Table 2), and their
reported resources of time, knowledge and infrastructure (Table 3). A response rate of 90% (n = 171) was obtained.
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Table 1: Knowledge about illegal abortion (n = 328)
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Table 2: Doctors’ willingness to manage public-sector HIV and AIDS patients
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Table 3: Association between doctors’ willingness to treat public-sector HIV and AIDS patients and the availability of resources (time, knowledge, infrastructure)
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Demographic profile of private-sector doctors
Over 80% of the respondents were men and the majority of the doctors were GPs between the ages of 30 and 50 years. Three-quarters of the doctors
had been in practice for more than 10 years and were based in the central and southern areas of the eThekwini Metro (Table 1). The number of
doctors that were willing to manage public-sector HIV-infected patients and reasons that influenced their decisions are depicted in Table 2. Of the 77.8% (n = 133) of doctors who were willing to manage public-sector HIV and AIDS patients, the majority indicated that they had adequate
time and knowledge, but fewer considered that they had adequate infrastructure. However, some doctors who were willing to manage these patients
still acknowledged that they did not have adequate time, knowledge or infrastructure. There were significant differences amongst the doctors
willing/unwilling to manage public-sector patients: lack of time, knowledge and infrastructure were reported by over 85% of the unwilling
doctors (p < 0.005). However, they comprised less than a quarter of the sample. Another reason cited by five doctors (3.8%) was the distance
from public-sector facilities. The demographic variables such as age, sex, number of years in practice and area of practice were not associated
with doctors’ willingness to manage public-sector HIV and AIDS patients. There were, however, significant differences between specialists and GPs in their willingness to manage public-sector patients. Of the 33
specialists that responded, 14 (42.4%) indicated that they would not be willing to manage public-sector patients, whilst only 24 (17.4%) of the
138 GPs indicated their unwillingness to manage (p < 0.01). The relationship between the availability of resources and the doctors’
willingness to manage public-sector HIV and AIDS patients is ranked and shown in Table 3. As can be seen in Table 3, 81.6% of the doctors who were not willing to manage such patients indicated that they did not have adequate time,
knowledge or infrastructure to be able to manage these patients. The significant association between the ranking of the three factors (time,
knowledge and infrastructure) suggests that the availability of resources influenced the doctors’ decision whether or not to manage
public-sector HIV and AIDS patients (p < 0.01). Table 4 presents a model of doctors willing to manage public-sector HIV and AIDS patients. A statistical model ranking all the factors showed
that time was the most important predictor, followed by knowledge. Distance from public-sector facilities was also significant but not as
important as the other two factors. Infrastructure became non-significant once the other factors were adjusted for. However, the confidence
intervals were very wide, suggesting that the model should be interpreted with caution. This may be due to the small size of the sample.
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Table 4: Model of doctors willing to manage public-sector HIV and AIDS patients
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Counselling of HIV and AIDS patients
Of the 159 doctors who responded about counselling of HIV and AIDS patients, only 67 (42.1%) indicated that they had sufficient time to
counsel these patients.
Remuneration
When asked whether they were adequately remunerated by medical aid schemes, only 14 (20.9%) of the 67 doctors perceived that they were adequately
remunerated. Although 103 (77.4%) felt that they were inadequately remunerated by medical aids, they were nonetheless prepared to manage
public-sector HIV and AIDS patients.
The results suggest that many private-sector doctors who manage HIV and AIDS patients are also willing to manage public-sector HIV and AIDS
patients. It was noted in this study that the GPs were more willing than the specialists to manage public-sector patients. This could be because
there are fewer specialists, particularly in the field of HIV and AIDS in the eThekwini Metro; specialists do have GPs referring their HIV and
AIDS patients to them.13 Normally when patients are referred they are at a more advanced stage than patients seen by GPs. Specialists
may have encountered failure in the management of these patients, which may have resulted in a lack of confidence in their ability to manage
HIV-infected patients.13 In addition, specialists treat many other infectious diseases and may not regard themselves as HIV experts.
14 The factors that were associated with the willingness of doctors to manage public-sector HIV and AIDS patients, such as time, knowledge and
infrastructure, would need to be improved as they may have contributed to doctors’ unwillingness to manage these patients. Although the
majority of the respondents were willing to treat public-sector HIV and AIDS patients, only 46% were confident that they had all three of the
components, that is, adequate time, knowledge and infrastructure, to manage these patients. Several past studies that have examined the role
of doctors in the management of HIV and AIDS patients have shown that doctors lacked the necessary knowledge and competency required for the
management of AIDS.15 In the 1990s, many studies recognised that the lack of, or inadequate, medical/clinical knowledge to treat
HIV and AIDS was a barrier that resulted in doctors not wanting to manage these patients.16 The present study confirms these trends,
because lack of knowledge was associated with doctors not wanting to manage public-sector HIV and AIDS patients. Even though these doctors were
managing private-sector patients, they may require additional knowledge to manage an increased load of patients, as would be the case if they
were to manage both private- and public-sector HIV and AIDS patients. Other studies have found that doctors with lower levels of knowledge saw
fewer patients17 and that doctors who had high patient volumes tended to be better informed.14 Coupled to inadequate HIV training or knowledge was the time factor; as a result of a lack of training and experience in managing HIV and AIDS
patients, doctors may need to spend more time managing these patients. Such doctors could then manage fewer patients compared to the number that
could be managed by their more experienced colleagues, resulting in more time subsequently being spent on fewer patients.13 Lack of
time or a demand on the doctors’ time was a commonly cited reason for doctors not willing to manage HIV and AIDS patients in the developed
world.16 Our findings are consistent with other studies, where lack of infrastructure, or poor infrastructure, such as lack of support
staff, the structure of a general practice, lack of specialty backup support for patients who develop complications, or
lack of community social services or resources,16 have presented barriers to doctors willing to manage HIV and AIDS patients. Private-sector doctors are important in the delivery of health care. An recent Indian study found that although there was an abundance of HIV
testing in the private sector, it was accompanied by inappropriate practices and inadequate knowledge, reflecting deficiencies in the implementation
of policy guidelines.18 Despite this, the needs of private providers, who are a major source of health care in India, have to be
acknowledged and, with the use of supportive and regulatory mechanisms, this sector could be used effectively to provide better HIV testing
services.18 This sentiment is echoed by the CEO of the KZNMCC, who stated that private–public partnerships require constructive engagement between the two sectors, whereby the resources, expertise and personnel
within the private sector can be harnessed to create a solution that achieves the objective of health for all. Achieving this requires that
both sectors be regulated optimally and relevantly, and that this partnership is the solution to ensure that there is a sustainable health system
five years hence.19 Public–private partnerships (PPP) can take various forms, depending on whether the private sector is involved in financing and/or providing
health care. Two of the many categories could be, (1) where the public sector pays the private sector for the caring of public-sector patients,
for example HIV and AIDS patients can be diverted from hospitals to accredited private health care providers and paid for per capita and (2)
where the private-sector doctor works for a specified number of hours in a public-sector facility.20 However, there are many challenges that face PPP, including the pervasive mistrust between the sectors, which need to be overcome. There
should also be strong governmental leadership and political will to form this partnership, with all partners being well-informed about the
business plan as well as about one other. There should be coordination between the Ministries of Health and Finance, the latter ultimately
approving the partnership agreement, with the Ministry of Health benefiting from the additional health infrastructure and charged with managing
the private partner. There should also be support from the communities, because civil society has a significant role to play in health care
delivery in sub-Saharan Africa.1 National Health Insurance, which insures the national population for the costs of health care, has been advocated as part of a programme of
health care reform. It may be administered by the public sector, the private sector, or a combination of both sectors. Funding mechanisms vary
with the particular programme and the country. The CEO of KZNMCC has suggested that
with the proposed national health insurance in Government, there is a great need for both sectors to work together. Private practitioners and
private health care generally are resource-rich and can help ensure the seamless implementation of a NHI programme.19
Firstly, this study considered the basic requirements of GPs and specialists, namely time, knowledge, infrastructure and distance from
public-sector facilities, in determining their willingness to manage public-sector HIV and AIDS patients, but there may be additional factors
that influence their decisions. Secondly, the results of this study may not be applicable to all private-sector doctors in South Africa,
because the sample size was relatively small and confined to the eThekwini Metro. Thirdly, this was a self-reported study; the reliability of
self-reporting is difficult to substantiate because information was collected and analysed based on what the doctors reported. Finally, as a
cross-sectional study, the direction of the association may not be causal.
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Conclusion and recommendations
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There is a clear willingness in the private sector to help government manage the HIV-infected population in South Africa. It now depends on the
government to explore this possibility further and establish a well-regulated partnership with the private sector to share resources in the
management of HIV and AIDS patients and to provide a framework of incentives, both financial and non-financial. Various models could be examined
in order to ensure an effective partnership and service delivery. Urgent educational interventions should be sought in order to improve the
knowledge base of private-sector doctors to HIV and AIDS management. Structured continuing medical education programmes and workshops should
be conducted in order to facilitate the broadening of HIV and AIDS management amongst private-sector doctors.
The authors would like to thank the NRF for funding this project and Tonya Esterhuisen, the statistician from the UKZN College of Health
Sciences, for her assistance.
1. Wilton Park, in cooperation with The Global Health Group at the University of California, San Francisco, Global Health Sciences and The
Healthcare Redesign Group. Public–private investment partnerships in health systems strengthening. Proceedings of the 909th Wilton Park
Conference; 2008 April 9–11, Wilton Park, UK [document on the Internet]. 2008 [cited 2009 April 17]. Available from:
http://www.wiltonpark.org.uk/documents/conferences/WP909/pdfs/
WP909.pdf 2. Department of Health. National consultative health forum. Proceedings of the National Consultative Health Forum; 2006 May 18–19; Sandton,
South Africa [homepage on the Internet]. Available from: http://www.doh.gov.za/docs/misc/nhcf.html 3. MediaClubSouthAfrica.com. Health care in South Africa [homepage on the Internet]. No date [cited 2009 April 9]. Available from:
http://www.mediaclubsouthafrica.com/ index.php?option=com_content&view=article&id=102%3Ahealthcare&catid=34%3Adeve
lopment_bg&Itemid=52 4. Progress report on declaration of commitment on HIV and AIDS, Republic of South Africa. Reporting period: January 2006–December 2007.
Prepared for: United Nations General Assembly special session on HIV and AIDS [document on the Internet]. c2008 [cited 2009 June 1]. Available from:
http://data.unaids.org/pub/Report/2008/south_africa_2008_country_progress_report_en.pdf 5. Bjorkman JW. Public private partnerships in health care services of less developed countries. Paper presented at: IPSA Conference, Concordia
University, Montreal, Canada; 2008 April 30–May 2. [document on the Internet]. c2008 [cited 2009 May 14]. Available from: http:// www.montreal2008.info/site/images/PAPERS/section3/RC%2025%20-%20Bjorkman%20-%203.4.pdf 6. HIV and AIDS in South Africa [homepage on the Internet]. No date [cited 2009 May 20]. Available from: http://www.avert.org/aidssouthafrica.htm 7. Bradshaw D, Groenewald P, Laubscher R, et al. Initial burden of disease estimates for South Africa, 2000 [document on the Internet]. 2003
[cited 2009 May 29]. Available from: http://www.mrc.ac.za/bod/initialbodestimates.pdf 8. UNAIDS, HIV/AIDS and STI. National strategic plan 2007–2011: Report on the global AIDS epidemic. Geneva: UNAIDS; 2008. 9. Israel E. Fostering public–private partnership in HIV prevention, care and treatment in Vietnam. Paper presented at: 33rd Annual
Conference on Global Health; 2006 May 30–June 2; Washington DC, USA [document on the Internet] 2006 [cited 2009 April 9]. Available from:
http:// www.psp-one.com/files/3073_file_B3_Isreal.pdf 10. SouthAfrica.info. Gateway to the nation [homepage on the Internet]. No date [updated 2007 Sep; cited 2008 Dec 23]. Available from:
http://www.southafrica.info/about/people/popprov.htm 11. South Africa HIV and AIDS stats [homepage on the Internet]. No date [cited 2009 January 8]. Available from:
http://www.avert.org/safricastats.htm 12. eThekwini–Ulwazi-our shared knowledge [homepage on the Internet]. No date [cited 2009 January 8]. Available from:
http://wiki.ulwazi.org/index.php5?title=EThekwini 13. Naidoo P, Jinabhai CC, Taylor M. Role and contribution of private health care sector doctors in the management of HIV-infected patients in
the eThekwini Metropolitan area of KwaZulu-Natal. South Afr J Epidemiol Infect. 2007;22(1):13–17. 14. Quach L, Meyer K, McGarvey ST, Lurie MN, Phuong DO. Knowledge, attitudes and practices among physicians on HIV/AIDS in Quang Ninh, Vietnam.
AIDS Patient Care STDs. 2005;19(5):335–346. 15. Fournier PO, Baldor RA., Warfield ME, Frazier B. Patients with HIV/AIDS: Physicians’ knowledge, attitudes and referral practices.
J Fam Pract. 1997;44(1):85–89. 16. Naidoo P. Barriers to HIV care and treatment by doctors: A review of the literature. S Afr Fam Pract J. 2006;48(2):55. 17. Massiah E, Roach TC, Jacobs C, et al. Stigma, discrimination and HIV/AIDS knowledge among physicians in Barbados. Rev Panam Salud Publica.
2004;16(6):395–401. 18. Sheikh K, Rangan S, Kielmann K, Deshpande S, Datye V, Porter J. Private providers and HIV testing in Pune, India: Challenges and opportunities.
AIDS Care. 2005;17(6):757–766. 19. Chetty M. How sustainable is South African private health care? [homepage on the Internet] 2009 [cited 2009 April 17]. Available from:
http://medical.bizcommunity.com/ Article/196/148/34815.html
20. Goudge J. The public–private mix. [document on the Internet]. Centre for Health Policy. No date [cited 2009
April 17]. Available from: http://www.healthlink.org.za/uploads/files/chapter6_99.pdf
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