1. Public-Private Partnership to Scale Up and Sustain TB and HIV Care in Ethiopia Tesfai Gabre-Kidan, MD Country Director, Private Health Sector Abt Associates Inc. Ethiopia

2. Presentation Private sector (PS) capacity that could rapidly scale up TB, HIV and other care stands idle In the long run PS will be easily sustainable Bias against the private health sector Actual numbers from Ethiopia – The WHO initiative – The guideline – The contribution Sharing a vision

3. 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, and Nutrition identified as urgent national health issues Human dev. Index 170 th /177 UNAIDS

4. TB numbers Prevalence=8 th in the world, 2 nd in Africa All cases =572, 359 Mortality =64 per 100,000 population Detection =50 % of all forms and 36% smear + PTB Treatment =84% success MDR on the rise with little or no access to Tx Yet, Ethiopia has made tremendous gains. It is one of the 4 SSA nations that has achieved significant progress towards meeting the 2015 MDGs Source: WHO, 2010

5. HIV numbers in Ethiopia HIV prevalence 2.4% Urban7.7% Rural0.9% Adult HIV Incidence 0.26% Urban 2.04% Rural0.2% HIV + Population 1,216,908 Urban: 760,475 Rural 456,432 New HIV Infections 137,494 Urban: 86,130 Rural: 51,364 AIDS Deaths 28,073 Urban 17,586 Rural 10,487

6. Facilities & Staff PublicPrivate Hospitals 10095 Health Centers 1365-- Clinics, including NGO --2853 General Practitioners 1008 728 Internists 7252 Pediatricians 4749 OB/GYN 8372 Nurses 12,1809820 Response capacity Public sector in Ethiopia lacks the capacity to meet the major public health care demands e.g. 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

7. The bias Why is the private health sector sidelined from providing key public health services? Perceptions: – It only serves the urban rich – Will abuse public resources – Morally wrong Unregulated, private health sector may do greater harm than good

8. Provider Utilization

9. Care Usage

10. PHSP In 2006 USAID funded a project to rollout TB care to the private sector WHO recommended, MOH initiated A milestone guideline on private health sector TB care was published in 2007 The project which started with 20 pilot sites has now expanded 265 sites The scope of the project has also expanded from TB/HCT to include integrated comprehensive HIV care, FP, STI and Malaria It has gained acceptance by the regions which now consider PHS as the third pillar in their health care delivery system

11. The Potential In Amhara, the second largest region with a population of 18 million, only 31 private for profit clinics accounted for 24% of the regional TB detection In AA, 11 start up PHS sites contributed 15.2% of the total AA city TB detection In a VCT campaign in 2009, the private sector contributed > 55% It has the flexibility to pilot new approaches, e.g. PMTCT And is small enough to to take reasonable risks

12. Facility Number of facilities Pre-ART Patients Patients enrolled in ART Percent total Enrollment rate (%) Public Hospitals 93479274124.3578.79 clinics2411569622855.3353.83 Total1504859.6 Private Hospitals 162013185516.4892.15 Clinics 37664333.8456.53 Total277982.3 ART Enrollment rate in Addis Ababa

13. Patient StatusPublic sector service (%)Private sector service (%) Started on ART46,460 (83.03)9,494 (16) Drop outs6,677 (14.3)1,652 (17.40) Lost to follow up847 (1.82)111 (1.16) Stopped medications271 (0.58)19 (0.20) Died3179 (6.84)287 (3.92) Positive pregnant2279420 Pregnant received ARV1766329 Neonate received ARV1051331 Negative exposed neonates66050 Positive exposed neonates74 (3.25%)6 (1.42%) ART & PMTCT quality of care indicators in Addis Ababa

14. Private Sector Lab QA Internal proficiency and external quality assessment (EQA) are better than that of the public, e.g. the discordance of sputum smear reading by the private sector dropped from 5.7% at baseline to 0.7% But very expensive dependent on importing panels We strongly propose that these be brought in under the oversight of the EHNRI

15. Sharing a vision Current Health care is: – Disease oriented – Episodic – Curative – Urban centered – Physician dependent model of care Transition to Wellness and Environmentally Oriented Primary Care – Comprehensive, not vertical or disease oriented – 3 dimensional Continuum, not episodic – Mindful to both quality and cost – Accountable to both patients and regulatory bodies - The new kid in the horizon is non-communicable diseases. - My recommendation is a strong NO to vertical approach