Table 6.

Characteristics of contracts by case

	Centralized-purchaser model	Decentralized-purchaser model	Contracted-purchaser model
Type of services	• Provide the full range of PHC services adhering to PHC guidelines and essential drugs list (EDL) at PHC facilities.
	• Clinical mentoring, training, support and capacity building of other health care workers at the PHC facility.
	• Provide oversight to PHC facility staff with regards to clinical governance and quality assurance.	• Provide oversight to PHC facility staff with regards to clinical governance.	• Quality assurance within PHC facilities through: performing clinical file audits, data reviews, monitoring supply chain management and equipment issues. • Participate in infection prevention and control activities in PHC facilities.
Contract formality	• Intent was to have a classical, complete and legally binding contract. • Monitoring performance and behaviours of GPs has been difficult and costly to enforce. • Centralised purchaser (NDOH) unable to monitor GPs directly. This monitoring function delegated to DHO. However, DHO feels unempowered to exercise this authority effectively due to nature of contractual relationship (DHO not direct purchaser).	• Contract is classical, complete and legally binding. • Some aspects lean towards relational type of contract (due to decision-maker preferences)	• Contract is the most classical, complete and legally binding of the three.
Contract duration	• Duration varies: 6 month, 1 and 2 year contracts; linked to funding availability which is received from NT on an annual basis. • Modified over time as the GPs were initially not willing to sign contracts of shorter duration.	• Annual. Aligned to an annual business plan, and is provided annually by the NDOH, which in turn is received from NT on an annual basis.	• Duration varies: one or two year contract, which is aligned to contracted purchaser’s contract with NDOH.
Provider selection	• Advertisements stipulating requirements placed.	• Advertisements stipulating requirements placed. • Intent was to have a competitive process.	• Advertisements stipulating requirements placed.
	• Not clear if all candidates appointed following interview process.	• Candidates appointed following interview process.
	• Possibly influenced by contextual factors and supply of doctors.
Specification of performance requirements and monitoring	• Performance requirements limited to delivery of services, timely submission of complete and quality timesheets and minimal or no incidents or default or breach of contract. • No specification of performance requirements relating to monitoring provision of clinical services, clinical governance or quality assurance.	• Performance requirements are specified in detail in the job description. • These cover four areas: (1) provision of clinical services, (2) clinical governance, (3) mentoring and support of other facility staff and (4) administrative tasks (completion of registers, timesheets and claims). • Specification of monitoring not clear. Performance monitoring done informally with exception of monitoring of administrative tasks.	• Performance requirements are specified in detail in the job description. • These cover five areas: (1) provision of clinical services, (2) staff and personal development, (3) facility quality improvement, (4) infection control and (5) finances (correct and timely timesheet and leave submissions). • Performance monitoring is done formally every six months. • GPs are required to maintain a detailed portfolio of evidence in support of their performance.
Provider payment mechanisms	• Completed monthly timesheets signed by GP, facility manager, GPCI district coordinator and district manager are required for payment to be effected monthly. • GPs are required to sign daily attendance registers at the facility, which is used to verify hours worked on the timesheet. • Payments were initially done through the NDOH finance department, and were later outsourced to an external Contracted Payroll Company. • Remuneration rate: R438 per hour (2016/17, exchange rate 1 USD = R14.7)	• GPs are placed on the district HR payroll and paid a fixed monthly amount. • Payments are executed by the district finance department. • The daily facility attendance register and completed monthly timesheets are signed by the GP, facility manager, sub-district manager, GPCI district coordinator and district manager used as verification mechanism. • If the GP does not work the required hours, the district manager has the authority to stop the monthly payments. • Remuneration rate based on years of experience. Between R180 and R312 per hour (2016/17).	• Completed monthly timesheets signed by GP, facility manager, district support partner and project manager required for payment to be effected monthly. • GPs are required to sign daily attendance registers at the facility, which is used to verify hours worked on the timesheet. • Payments are executed centrally by SP. • Remuneration rate: R500 per hour (2016/17).