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experience under the tap: value added and constraints of private public partnerships in Ghana experience under the tap: value added and constraints of private public partnerships in Ghana team members: richard n. amenyah 1 nii akwei addo 2 kwesi eghan 1 sally-ann ohene 2 henry nagai 1 stephen ayisi addo 2 bernard dornoo 2 enoch osafo 3 gilbert buckle 3 yussif ahmed rahman 1 nii boey ocansey 4 evelyn awittor 5 FHI 1 NACP 2 NCS 3 PEF 4 WB 5 THE WORLD BANK, WASHINGTON DC 30 TH NOVEMBER, 2006

HIV/AIDS in Ghana • The median HIV prevalence (ANC) – – – 1994 2. 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+ New AIDS HIV+ births No. in need of ART Number on ART: 269, 698 26, 167 4, 366 67, 000 6, 131 (Oct)

Counselling and Testing Sites Region Public Mission Private Total 174 33 Grand total 104 Counselling and Testing Sites Region Public Mission Private Total 174 33 Grand total 104 311 2004 2005 2006 Item M F Total Clients 7, 879 7, 611 15, 490 5613 11, 379 17, 009 12, 305 33, 665 45, 970 Confirmed Pos 1, 564 2, 562 4, 126 665 1, 176 1, 841 2, 251 4, 691 6, 942

ART sites • 2 teaching hospitals • 10 regional hospitals • 14 district level ART sites • 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 selffinancing facilities • Funding – – – Global Fund TAP/World Bank Df. ID Royal Netherlands Embassy GTZ Government of Ghana

HAART Summary all sites Adult & Pediatric Cumulative all sites Male Female Total Clinical HAART Summary all sites Adult & Pediatric Cumulative all sites Male Female Total Clinical care 5, 072 8, 182 13, 254 HAART 2, 380 3, 751 6, 131 OI 4, 986 8, 006 12, 992 16 36 52 (0. 8%) Loss to follow up 58 (0. 9%) Stopped HAART due to adverse events Treatment failure 21 21 42 (0. 7%) Death 88 104 192 (3%) # still alive and on therapy 5, 829 (95%)

HOW HAS THE PRIVATE SECTOR CONTRIBUTED? HOW HAS THE PRIVATE SECTOR CONTRIBUTED?

Treatment Acceleration Program (TAP) Public and Private Sector Partners • Public sector – NACP/MOH/GHS/HRU 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

FHI TAP SITES FHI TAP SITES

TAP activities in scaling up HIV care 1. FHI – – – 4 for-profit TAP activities in scaling up HIV care 1. 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 CD 4 linkage instituted between TAP sites and Public site Refurbishment 2. NCHS • 6 not-for profit sites operating since May 2006 • Training: 40 trained on ART, OI, VCT/PMTCT, LMIS, HMIS 3. PEF • • Work place programmes Championed the setting up of the Ghana Business Coalition Against HIV/AIDS in April 2006

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

General Client flow system Pharmacy Laboratory services Medical officer Receptionist Filing clerk/Records Nurses/counsellor Payment General Client flow system Pharmacy Laboratory services Medical officer Receptionist Filing clerk/Records Nurses/counsellor Payment Status • Out-of-Pocket • NHIS • Employer

TAP- mentoring in action • Monitoring and supervision: – FHI provides on-site skills enhancement TAP- mentoring in action • 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 (FHI) Service Statistics: Jan-October 2006 Indicator Expected Target Actual target achieved 675 1, TAP (FHI) Service Statistics: Jan-October 2006 Indicator Expected Target Actual target achieved 675 1, 380 675 308 # eligible for ART - 156 # receiving ART October 2006 OI prophylaxis 280 130 400 227 # counseled and tested (VCT/PMTCT) # enrolled into clinical care by October 2006 DEATHS 8

Site service statistics (ART) Site service statistics (ART)

TAP-The Private sector adopts National Guides • Technical Capacity – Accreditation of sites and 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

TAP-opens the door for the private sector! • Clinician, Odorna Clinic ‘TAP has brought TAP-opens the door for the private sector! • 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 “When Korle-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” Hope, confidence, convenience, shorter waiting times, more time with providers, stigma reduction etc

TAP-A true Public-Private Partnership in Action • Improved coordination and collaboration – Regular meetings 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 – CD 4 enumeration done • For profit sites sample are referred to a central public sector lab for enumeration • Not for profit sites do CD 4 remuneration on site – All TAP sites are linked to the National supply chain for HIV test Kits

TAP-A true Public-Private Partnership in Action • Improve financial management and contracting practices – 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

TAP- Constraints in the partnership • • • Even with the pro-poor approach of TAP- Constraints in the partnership • • • 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 2 • Public sector designed trained program are often TAP- Constraints in the partnership 2 • 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

Conclusion • FHI under TAP has engaged the private sector to demonstrate its complementary 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?