Lessons from Implementing TB andHIV/AIDS Services through the

Private Health Sector in EthiopiaDr. Gilbert Kombe, Senior HIV/AIDS Technical Advisor

Abt Associates, Inc.

Discussion Outline

• Background

• Rationale for Engaging Private Sector

• How We Work- Partnership Model

• Results: Private Sector Contribution to Tuberculosis andHIV/AIDS Services

• Lessons Learned

• Parting Thoughts

Background

• Collaboration between the public and private healthsectors is nascent in Ethiopia.

• Private sector capacity is big

– 49 hospitals, 570 medium and higher clinics and1155 specialized clinics

• Private health sector is an integral part of expandingTB and HIV/AIDS coverage - MOH advocates forcollaboration

• Private providers feel that they have moral and socialresponsibility to deliver care

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Rationale for engaging the private sector in TB andHIV/AIDS services

• Private (commercial) sector is a major provider of health services in Ethiopia– Physician to population ratio is 1:38,000 - 25% of Ethiopia's 2,085

physicians work in the private sector –– 23% of specialists (Addis Ababa, Harar and Dire Dawa) work in the

private sector

• Private clinics are already contributing to prevention, diagnosis, and treatmentservices for other infectious diseases

– Client perceive and value the quality of services in private sector

• Public sector cannot meet the TB and HIV/AIDS needs alone (overstretched)

– TB is fourth leading cause of hospital admission• Prevalence per 100,000: 579• Annual incidence (all cases) per 100,000: 378 (WHO 2009)• Incident target for 2015: 156 per 100,000

– HIV/AIDS: Adult HIV 2.3% (2009) FHAPCO (PLWHA = 1,116,216)

• 290,000 PLWHA are in need of ART (FMOH, December 2008)

• 128,000 are receiving ART (FMOH, December 2008)4

What does the Private Sector Program-Ethiopia do?

• HIV counseling and testing– Mobile HCT implemented by four private service providers

through subcontracts since July 2007 in Addis Ababa, Amhara,SNNPR, Afar and Oromia regions

– Mobile HCT targets MARPS – mobile services have anadvantage to reaching these groups

– HCT at 157 private (commercial) clinics

• PPM-DOTS– 90 private clinics and 18 workplace clinics in Addis Ababa,

Amhara and Oromia regions

• Antiretroviral therapy– Initiating services at approximately 20 higher clinics in Addis

Ababa

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Using a partnership model to effectively engage theprivate health sector

PSP-Ethiopia• Facilitate process to engage private

clinics• Capacity building/training of private

providers• Subcontract mobile HCT services

and facilitate MoUs for PPM-DOTS,ART and static HCT services

Private Clinics• Adhere to national guidelines• Provide RHB-subsidized TB drugs for free to clients• Set fees for consultations and laboratory examinations• Report on program activities using MOH standard

registers and formats• Participate in meetings with the RHB and woreda

health offices• Actively participate in defaulter tracing.

Regional and Local Health Offices• Integrate the private clinics into their supply chains for TB drugs

and laboratory reagents• Provide supportive supervision and external quality assurance• Incorporate the private providers into regional review meetings• Collect and compile service statistics• Provide support with defaulter tracing for better TB outcomes

Federal Ministry of HealthProvides overall leadership and set clear direction for PPM-DOTS, ART and mobile HCT

Drive policy changes required that allow private sector providers to implement DOTS and ART

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Private sector approach: implementationprocess

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Service Delivery Supervision and Mentoring

Advocacy for PPM & referral

Service Promotion

Site Initiation

Capacity Building Link to Supply Chain

Site Preparation

Clinical and Systems Training

Memorandum of Understanding / Subcontracts

Foundation Identify Referral Network

Select Service Sites

Conduct Rapid Assessment

Build Consensus with all Partners

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BO2

Slide 7

BO2 The emphasis of this slide is the need to develop a new implementation process that takes into the consideration the added steps to bring anew player - the private sector - into the national program The way you described the steps was perfect and did in fact stress the newapproach. I have highlighted the special/added steps. You can remove if they are not correct or too much going on.Barbara O'Hanlon , 5/7/2009

Key aspects of partnership model success

• Ministry leadership with the national guidelines and regionaltargets for PPM-DOTS expansion enabled fast growth

• Careful site selection set the stage for program success

– Facilities need high volume to contribute to Region’s public health goals

– Sites willing to train multiple full-time GPs & nurses are ideal

– Physical infrastructure is important since sites generally can’t remodel

– Owner commitment is vital

• The Region enters an MOU with sites which establishes a clearresponsibilities

– The MOU establishes real commitment to the program by owners andthe RHB and its local health offices

– Enables Region and implementing partner to hold sites accountable

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Key aspects of the partnership model success cont

• Joint supportive supervision strengthens collaboration

• Regional lab EQC for sites are building confidence

• Advocacy workshops (2—3) strengthen the public-privatelinkage

• PPM sites integrated in Region’s routine TB programreview meetings

• Clinical seminars bring public and private providerstogether to discuss challenging TB clinical issues

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Results I. Increased access to mobile HCTservices through innovative private channels

As of March 2009:

• A total of 84,141 clients receivedmobile HCT services in 59 townsalong major transport corridors

• 36.7% of clients were females

• HIV prevalence among clients:5.1% (3.4% among males and8.0% among females)

• 58.4% of HIV+ accepted referral toART services

• 11% of HIV-positive clients thatrefused referral to ART acceptedreferral to further counseling

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Coffee ceremony to educate andmobilize FSWs for mobile HCT

Private sector flexible and responsive to clientneeds and preferences

Innovative strategies - “moonlight”services to reach at-risk groups

Taking services “off the beaten path”

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Results II: Private sector is now a significantcontributor to national PPM-DOTS & HCT goals

Between October 2006 and March2009:

• 5,874 TB patients enrolled in PPM-TB sites

• Over the first 12-month period, 11new PPM-DOTS sites contributed15.2% of Addis Ababa’s annual casedetection

• 61% of all cases detected werepulmonary

• 37% pulmonary positive cases –lower than the 47% rate reported byWHO in 2009

• High rate of extra-pulmonary TB isconsistent with national rate of 36%

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Results III: HCT in private clinics

• 144,197 total clients receivedHCT in private sites (PPM-DOTS plus CT-only sites)

• PSP-E first to implement a newregister for tracking linkage ofTB clients to HCT

• 1,412 TB clients accepted HCTin the quarter they were enrolledsince October 2008 (33.4%were HIV-positive)

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Results IV: Building private sector capacity tohelp address public sector goals

6

19

30

49

143

211

252

439

3

98

95

17

71

113

49

157

0 100 200 300 400 500 600 700

Pharmacy Technicians

Basic ART & M&E

Basic VCT for Counselors

Supportive Suppervision on TB/HIV

Financial Management & Bookkeeping

New HIV Testing Algorithm (FingerPrick)

Rapid HIV, AFB & QA for Lab Techs

Basic TB/HIV,TB-DOTS & PIHCT

Number of Health Providers Trained by Topic in Private and Work Place Facilities(October 2006 - March 2009)

MaleFemale

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Results V: Private sector services compare favorablywith public sector: treatment outcomes

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0 10 2 0 30 4 0 50 6 0 70 8 0

Fa ilur e

De fau lt

T xC om ple te

D ea th

Tra nsfe r

Cur e

0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0%

Failure

Default

Tx Complete

Death

Transfer

Cure

2.0%

5.2%

5.4%

5.8%

11.6%

71.8%

Treatment Outcomes for 17 pilot PPM-DOTS sitesOctober 2007to March 2009

Results VI: Quality of services is high in private facilities

PSP-E: PPM DOTS EQC Results Summary by Region (Oct - Dec 2008)

101

77 70

108

28

66

279

123

6449

7792

76

141

4 2 0 4 5 2 24 0 0 316

2 30

50

100

150

200

250

300

East Amhara West Amhara Addis Ababa West Oromia East Oromia 1 East Oromia 2 East Oromia 3

Smear Negative Smear Positive Discordant Negative Discordant Positive

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Results VII: Quality of mobile HCT services is high

Region # of samplescollected for EQA

HIV Test Blind Re-checkingEQA Results

Concordant Discordant

Amhara East 1,443 1,443 0

Amhara West 1,006 1,000 6

OromiyaSouth

677 677 0

Total 3,126 3,120 6

Percentage 99.8% 0.2%

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Opportunities created by public-private mix

• Private sector values the “accreditation” from the publicsector for provision of TB and other services

• Assures private sector is trained and using current clinicalguidelines – creates greater standardization

• Sectors can learn from each other and engage in healthycomparisons (e.g. private sector EQC results for AFB)

• Private sector has more physicians and specialists thanpublic – greater patient access to these professionals

• PPP has strengthened supportive systems e.g. supportivesupervision, EQC, reporting, and supply chainmanagement

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Implementation challenges

• Policy framework needs to be clarified for other services

• National supply chain management system for TB weak

• Private facilities often have weak communication channels(internal and external) to note and solve system problems

• Referral, transfer, and TB/HIV collaboration challenging

• Private sector clinics are isolated and autonomous -makes organizing training, meetings, events challenging

• The private sector desires short, intensive capacitybuilding that minimizes time away from the clinic

• Private sector lacks systems for routine data collectionand reporting, as well as drug management

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Lessons learned in working with the privatesector

• Working with the private sector produces results and complimentspublic sector

• Building strong partnerships from the outset essential for success– Coordination and clearly defined roles & responsibilities for the public

and private sector in a partnership produces results

– Need for an honest broker to establish partnership

• Both public and private sectors need technical support inworking together and how to integrate private sector into day-to-day operations

• Advocacy workshops strengthen public-private referral linkages especially ondefaulter tracing

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Parting thoughts on going forward with theprivate sector in Ethiopia

• There is an opportunity to expand provision of publichealth services into the private sector building on thePPM-DOTS and HIV/AIDS experience

• Quality of services in the private sector is high andcontinues to improve

• Staff attrition is also an issue in the private sector andneeds to be addressed

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