Experience under the TAP: value added and constraints of Private Public Partnerships in Ghana

1. Experience under the TAP: value added and constraints of Private Public Partnerships in Ghana Team members: Richard N. Amenyah 1 Nii Akwei Addo2 Kwesi Eghan1 Sally-Ann Ohene2 Henry Nagai1 Stephen Ayisi Addo2 Bernard Dornoo2 Enoch Osafo3 Gilbert Buckle3 Yussif Ahmed Rahman1 Nii Boey Ocansey 4Evelyn Awittor5 FHI1NACP2 NCS3 PEF4 WB5 THE WORLD BANK, WASHINGTON DC 30TH NOVEMBER, 2006

2. 2.7% median HIV prevalence in 2005 HIV/AIDS in Ghana • The median HIV prevalence (ANC) • 1994 2.4% • 2003 3.6% • 2004 3.1% • 2005 2.7%. • Generalised epidemic • Current estimates – 2006 • HIV+ 269,698 • New AIDS 26,167 • HIV+ births 4,366 • No. in need of ART 67,000 • Number on ART: 6,131 (Oct)

3. Counselling and Testing Sites

4. 2 teaching hospitals 10 regional hospitals - 14 district level facilities 7 mission facilities 7 public facilities 6 private self financing facilities And Anglogold Ashanti 2 uniformed service facilities Start 1 Dec 2006 Cost of Treatment VCT: 5000 cedis ($.50) PMTCT: Free Clinical care + ART: 50,000 cedis ($5 / month) in public and Mission facilities and $30/mon in private self-financing facilities Funding Global Fund TAP/World Bank DfID Royal Netherlands Embassy GTZ Government of Ghana ART sites

5. HAART Summary all sitesAdult & Pediatric

6. HOW HAS THE PRIVATE SECTOR CONTRIBUTED?

7. Treatment Acceleration Program (TAP)Public and Private Sector Partners • Public sector • NACP/MOH/GHS/HRU • Mandate: HIV treatment, care and support • Research agenda on household surveys • Private sector • Family Health International (FHI) • Worldwide TA in HIV/AIDS Programming • Piloted the comprehensive START Program in Ghana – June 2003 • 4 for-profit TAP sites • National Catholic Health Service (NCHS) • Responsible for 25% health delivery in Ghana • Pioneer in home based care • 6 not for-profit TAP sites • Private Enterprises Foundation • Workplace HIV/AIDS programmes

8. FHI TAP SITES

9. FHI 4 for-profit sites operating since March 2006 Training: 38 clinical/counseling staff trained on ART, OI, VCT/PMTCT, LMIS, HMIS, and good laboratory practices ARV’s supply system established Centralized CD4 linkage instituted between TAP sites and Public site Refurbishment NCHS 6 not-for profit sites operating since May 2006 Training: 40 trained on ART, OI, VCT/PMTCT, LMIS, HMIS PEF Work place programmes Championed the setting up of the Ghana Business Coalition Against HIV/AIDS in April 2006 TAP activities in scaling up HIV care

10. TAP- HIV CARE AND TREATMENT Acceptance & Voluntary disclosure Counseling & Testing Lab & Clinical assessment & monitoring PATIENT Drug dispensing & Adherence counseling Prophylaxis & Treatment of Opportunistic Infections Antiretroviral Treatment counseling

11. General Client flow system • Payment Status • Out-of-Pocket • NHIS • Employer

12. Monitoring and supervision: FHI provides on-site skills enhancement through mentoring and technical assistance for maintenance to SOPs Participatory engagement for building systems for QA/QI TAP- mentoring in action

13. TAP (FHI) Service Statistics: Jan-October 2006

14. Site service statistics (ART)

15. TAP-The Private sector adopts National Guides • Technical Capacity • Accreditation of sites and providers • Training of staff • Standardization of HIV care and treatment according to National guidelines and protocols to assure quality of care • Good Lab Practice adopted to support HIV care • National HMIS and LMIS -paper and computer based systems implemented • National communication materials for client education available • Infrastructural capacity • Rehabilitation • Supply of laboratory equipments

16. Clinician, Odorna Clinic ‘TAP has brought hope and confidence to our patients ; it has also made it possible for our clinic to talk openly about HIV and even display a signage like you see in front of the hospital’ Counselor-Anglo-gold Hospital “Because of TAP, our HIV infected miners have access to ART and this has made it possible for some of them to go back to work’ Patient at Narh Bita Hospital “WhenKorle-Bu referred me to Narh-Bita I was initially worried and unsure about the type of service to expect. However, because the patients here are fewer, and doctors spend a lot of more time on me I have not regretted coming ……my company pays for my hospital bills” TAP-opens the door for the private sector! Hope, confidence, convenience, shorter waiting times, more time with providers, stigma reduction etc

17. TAP-A true Public-Private Partnership in Action • Improved coordination and collaboration • Regular meetings between the NACP and the Implementing Partners (IP) • Regular meetings between the IPs and the sites • Streamlining of HIV prevention, care and treatment reporting format for public and private • FHI/NCHS are intermediaries facilitating the coordination and collaboration of the private sector with public institutions • Improved integration of procurement and logistic systems • Public sector procures ARVs for TAP sites • CD4 enumeration done • For profit sites sample are referred to a central public sector lab for enumeration • Not for profit sites do CD4 remuneration on site • All TAP sites are linked to the National supply chain for HIV test Kits

18. TAP-A true Public-Private Partnership in Action • Improve financial management and contracting practices • Contracting mechanisms (sub-agreements) directs resources to sites with minimal bureaucracy whilst allowing IP oversight and local decision making and hence smooth running of HIV programmes under TAP • Independent accounts required of IPs and sites

19. Even with the pro-poor approach of TAP uptake of services in the private sector is low due to the absence of NHIS cover and this increasingly limits access An estimated 15% of patients at the for-profit sites are unable to pay for services as shown below The Component of the cost of services are consultations, OI/ARV treatment and Lab test TAP- Constraints in the partnership

20. TAP- Constraints in the partnership2 • Public sector designed trained program are often times not conducive for private for profit sector players • Modular training program? • Human resource limitation • Staff attrition • Inability to deliver a comprehensive HIV program model

21. Conclusion • FHI under TAP has engaged the private sector to demonstrate its complementary role to the public sector in ART roll out in Ghana • The pro-poor approach of TAP brings in an element of equity since it can target both the rich and the poor • TAP has demonstrated that quality standards of HIV care and treatment can be assured by the private sector through constant engagement Q: AFTER TAP WHAT NEXT?

22. THANK YOU