COVID-19: insights from contracting the private sector for critical care

The COVID-19 epidemic was expected to result in shortages of public-sector critical care beds. This prompted the Western Cape Department of Health to explore ways to address the shortfall, culminating in a service-level agreement with the private sector and national level development of a system of reimbursement for critical care. This chapter describes the experience of formulating the agreement and the insights gained. Since the shift of patients between the sectors did not materialise, the most important outcome was that the parties were able to conclude this agreement, and the engagement provided insights beyond the original problem. The process revealed a lack of national leadership and co-ordination capacity; high levels of fragmentation; different visions of what care should be provided; the complexity entailed in contracting; capacity constraints in both sectors; and data constraints to inform policy choices. The most prominent lesson was that a trusting relationship was essential to the success of this initiative, built on a vision and a value system that all parties could endorse. We recommend the establishment of national-level capacity for public−private engagement, reviewing the regulations constraining contracting, fast-tracking the national data management system, enhancing in-house administrative capacity to complement the use of intermediaries, conducting a critique of this engagement, and a cost assessment of the options for expanding critical care capacity. It is premature to make a judgement on the success of the agreement. However, it provided a real-time demonstration of the complexities and constraints for such engagement within the South African context and it showed how, with trust and commitment, we can develop solutions. We should build on this experience by addressing the constraints, so that progress is made towards the more integrated health system as envisaged by National Health Insurance and required for universal health coverage.