Expanding Affordable TB and HIV Care through the Private Sector in Ethiopia

1. Expanding Affordable TB and HIV Care through the Private Sector in Ethiopia Tesfai Gabre-Kidan, MD Chief of Party Private Health Sector Program Abt Associates, Ethiopia

2. Outline of Presentation • HIV care demand and the Ethiopian perspective • Why engage & support the private health sector (PHS) in Ethiopia? • How does the Private Health Sector Program engage/support the private health sector? • What are the challenges • What are the achievements • What are future plans for working with the PHS?

3. Ethiopian Context Ethiopia • Population of 80 million • Primarily rural - 83% • GDP per capita of US$190 • Significant challenges in meeting health care needs of the populace • THE as a percentage of GDP - 4.9%, The lowest in SSA • 1.0 physician per 37,209 people • 70% care is out of pocket • TB, HIV/AIDS, Malaria, MCH, FP and Nutrition identified as urgent national health issues UNAIDS

4. HIV Epidemic in Ethiopia Generalized epidemic primarily driven by heterosexual behaviors National adult prevalence rate is 2.1% Urban prevalence rate is 7.7%; rural rate is 0.9% Estimated 1.2 million people living with HIV in 2010

5. Response capacity • Public sector in Ethiopia lacks the capacity to meet the HIV care target • The PLH distribution based on CD4 count suggests that 47 – 63 % of the HIV population needs ART today • At the current capacity, it will take the Public Sector 13.2 to 16.6 years to enroll those in need • It will take public + private 4.2 to 5.2 years

6. Why Support/engage the PHS ? Tap Existing Capacity • Increase access to all aspects of HIV care • Scale up and accelerate testing and enrollment in ART and PMTCT • Decongest the overburdened sites: exceeding 5,000/physician • Improve referral and other systems Sustainability • Trend in shifting site of care: Public Private • Follow the trend & revisit health care delivery strategy Changes in Policy Environment • Given the magnitude of the national health urgency and crippling HR shortage, the entire national health workforce needs to be engaged in order to meet the demand in key public health and other services

7. How? PPM-DOTS HCT MHCT Public-Private-Mix-DOTs…PPM-DOTs • Perfect entry point: • Perceived as key public health service • Easily understood • Easily implementable • Illustrative of the need to engage PHS • WHO recommended • USAID funded • MOH initiated • PSP-E implemented • Built from ground up, took over a year • Adaption of a guideline that allowed the PHS to provide public health services: TB/HIV for the first time • Paved the way for the expansion of PHSP scope to include HCT, MHCT and ART.

8. Mobile CT Mobile CT USAID initiative to address at-risk populations MCT is outsourced to local private teams Carefully piloted in two regions that had the capacity to monitor the implementation closely Started in 2007 along truck routes By 2009, it had grown to 59 towns in 4 regions and 2 city administrations Staffed by a team of 5-6 nurse counselors, supported by one receptionist and a lab tech under a tent 2 teams per town who stay for 1- 3 weeks depending on population size and response

9. MHCT Sites

10. Private sector flexible to client preferences Taking services “off the beaten path” Coffee ceremony to educate and mobilize FSWs for mobile HCT 10 Innovative strategies - “moonlight” services to reach at-risk groups

11. Key achievements of the PHSP • Established and maintained partnership and program ownership • National, regional and local key stakeholders participation in the policy, planning, assessment, monitoring and evaluation • Built capacity of private sector providers and clinic owners • Clinical, managerial and financial trainings – 1779 since October 07 • Supervision, mentorship and EQC – 146 clinics • Pioneered the initiation of PPM/DOT at private clinics & workplaces • TB/HIV services initiated in 146 facilities • A total of 8631 TB patients treated since October 06 • A total of 176,978 clients were counseled and tested for HIV since October 06 • Provided MHCT to at-risk population • In 59 towns in four regions • A total of 121,397 clients were counseled and tested since July 2007 • MHCT has now integrated FP and STI to its activities • Created & Strengthened Systems : • IQC, EQC • Referral linkages • Integration of services

12. What are the challenges in engaging the PHS? • Policy: exclusion from service delivery, training. The private sector is excluded from donor funded activities • Perceptions: profit driven, care very little for poor people • Staff attrition rate: discontinuous implementation; very frequent training required to implement & sustain programs • Systems: HMIS; Referral linkages; Supply chain • Compensation: < $1 for counseling and testing…sustainable? • Practice setup: Inefficient and ineffective

13. Moving forward with PHS in Ethiopia DO MORE OF THE SAME! Public health services are now being successfully expanded into the private sector; building on the PPM-DOTS experience Quality of services in the private sector is high and above the nationally accepted benchmarks The successful implementation of the services has earned Abt Associates and the country program, PHSP, the confidence of the MOH and especially the Regional Health Bureaus As a result, Addis Ababa Health Bureau has extended an invitation to PHSP to help it pilot a community based PMTCT Regional labs are also considering PHSP to propose an internal and external quality control model for the private labs