Background
Study setting
Analyzing a PPPH initiative through the health systems building blocks
Study objective and contributions
Methods
Sample size, sampling, and characteristics of participants
Key informant interviews
Type of Key Informant | Number of Interviews Conducted |
---|---|
MOH | 5 |
RHB | 6 |
PHFA | 6 |
PHSP staff | 6 |
PHFs | 18 |
Development Credit Authority (DCA) | 2 |
DCA beneficiaries | 3 |
Federal regulatory bodies | 4 |
Total KIIs | 50 |
Endline health facility assessment of PHSP-supported PHFs
Region | Number (percent) of health facilities |
---|---|
Addis Ababa | 21 (19.81) |
Afar | 5 (4.72) |
Amhara | 21 (19.81) |
Benishangul-Gumuz | 4 (3.77) |
Gambella | 4 (3.77) |
Oromia | 27 (25.47) |
Southern Nations, Nationalities and People Region | 13 (12.26) |
Tigray | 11 (1.38) |
Total | 106 (100.00) |
Technical Area | Number (percent) of health facilities |
---|---|
TB | 75 (70.75) |
Malaria | 50 (47.17) |
FP | 54 (50.94) |
MNCH | 36 (33.96) |
Data collection, management, and analysis
KIIs
HFA
Trustworthiness
Results
Leadership and governance
Development of policies to support PHFs in the overall health system
The public-private partnership is one of the pillars in [the] Health Sector Transformation Plan…to create an enabling environment for the private sector to invest in health. The private health sector is cross-sectoral and goes beyond the health sector; there is a PPP [public-private partnership] proclamation, policy and direction, and implementation guideline[s]...approved by the Ministry of Finance. These are ventures where the private and public sectors can mobilize their resources and invest for improving the health system.
Remaining gaps
The PPMs currently focused on free social franchising programs; there is a lack of understanding of the concept of other modalities of PPPH among the authorities…Although we have more than a decade of experience in PPPH, our experience is limited to free public health services.
Revisions to regulatory standards
The previous requirements recommended by the FMHACA [Food, Medicine and Health Care Administration and Control Authority] were very rigid and not suitable for the Ethiopian context (for example, minimum number of staff per service) and it didn’t have the incentives to encourage private facilities.
We conduct supervisions as per a standardized checklist. For example, we come across health facilities that don’t adhere to the TB infection prevention guidelines. [….] We give feedback and discuss with the owner if the standards are not met. Based on the supervision outcomes, there were facilities that might be disallowed to provide specific services. We try to strengthen these facilities.
Remaining gaps
It is easy to regulate the private health sector and take action against them for not following the standard, but when you come to the government facilities you can’t control them. Sometimes the authority doesn’t accept the issues with the public health centers, as it may lead to conflict, so the control is focused on the private sector.
Trust between public and private health sectors
Government used to consider the private sector as just organizations established only for profit, hence there was no interaction between those bodies. People come for our services and they make the decision for their own benefit. The negative view has been changing.
Remaining gaps
There is a low commitment of facility owners to keep providing the service since these services are not profitable. Both TB and malaria medications and laboratory services are free according to the country’s law. But sometimes, patients are asked to buy the medicine from outside. They [PHF] also charge high for laboratory services.
Access to essential medicines
Incorporation of PHFs in the government’s integrated pharmaceutical logistics system
We have seen some hope for malaria elimination which is our goal. The PPM guideline provides guidance and approval to the PHFs to give malaria treatment free of charge including free medication, allowing only payment for diagnosis.
We give health education which has increased people’s awareness and demand [for service]. Even with malaria being sporadic, the number of patients increased compared to before. People are aware that medication is free. […] Not only for malaria but also for HIV and TB, the medication supply has to be sustainable and continuous for quality service.
Remaining gaps
Products | Reported Stockouts in PHFs (Percent) |
---|---|
FP commodities (n = 54) | |
Oral contraceptive pills | 2% |
Injectables | 6% |
Implants | 7% |
IUCDs | 6% |
Condoms | 15% |
Malaria drugs (n = 50) | |
Artemisinin-based combination therapy | 44% |
Chloroquine | 34% |
Quinine | 54% |
Artesunate | 58% |
Primaquine | 50% |
TB drugs (n = 75) | |
Rifampin (R) + isoniazid (H) + pyrazinamide (Z) + ethambutol (E) | 11% |
We submit requests for medicine to government health facilities. A stronger connection with the government HF is needed so that we can get medicines when we request. There are times even when the drugs are available in their stocks at the [public] health facilities but we don’t get them on time.
Private health facilities do not always place the request [for drugs] on time and sometimes ask for supplies at the very end […], we try to arrange from public facilities nearby so the service was not interrupted.
Health information systems
Inclusion of PHFs in the HMIS reporting system
Just like public facilities, proper trainings are provided to PHF representatives on how to use the HMIS system and proper reporting. We identify gaps during supportive supervisions and try to improve their reporting qualities.
Remaining gaps
Similar gaps are [found in] both private and governmental facilities; the HMIS reports are not submitted timely; they do the work and keep registers at the health facilities but do not take reporting seriously. However, this is more common in the PHFs—to submit poor quality data. Data quality gaps include not reporting timely. When you go to the zonal, woreda, and other lower levels, you might find other problems, but these are the problems at the regional level.
Reporting and recording formats are frequently being changed. Sometimes we will be given a single sheet of reporting paper and logbooks, and we were told to duplicate them. This is costing us additional money.
Regarding the data quality, a deep assessment is required to identify the underlying causes, such as workload, negligence, or lack of knowledge. If I take our facility as an example, the workload is the reason for low data quality not knowledge. It is good to have regular internal monitoring to improve data quality and add more trained staff.
Human resources
Training
Before the training on malaria [detection], we used to send patients with fevers for typhoid screening only, now patients are tested for malaria also as per the guideline.
There was a gap in up-to-date knowledge on maternal health services between government and private facility staff before we received training on BEmONC. Previously, when staffs from the public facilities talked in different professional meetings, we [private facilities staff] used to get confused as our education was limited from the university training. We now have same knowledge.
Remaining gaps
There are government facilities that get training, but private facilities haven’t been involved. Private facilities are providing similar services as the government facilities, yet we are not getting refresher training. A recent example is the family member index training for HIV/AIDS, where we were not invited and didn’t get the training. This is something that has to be corrected.
Service delivery
Incorporation of PHFs in the national laboratory quality assurance program
We have developed a guideline for sample referral linkages across regions and national laboratories among private and public laboratories.
Incorporation of PHFs in the laboratory transportation system and referral linkage
Remaining gaps
The postal service does not access all the PHFs. Sometimes the specimen transport from some health facilities was done with public transport. There is a shortage of specimen transportation material, triple packaging materials, etc. at the postal services as well.
Contributions from PHF to service delivery
Our community members when they are sick, they often go to the private health facilities. As they find PHFs as accessible and less time-consuming. By strengthening the private sectors, we are filling the gap in the public sectors, decreasing the load from public facilities, and supporting the health of the community.
TB service delivery
PHFs contribute about 15% of TB case detection in the National TB program, though only 700 (out of 10,000) PHFs are trained and engaged in TB program. Our lesson is to increase the enrolment of PHFs for TB case detection.
Service | Number (Percent) |
---|---|
Trained staff to provide TB treatment | 64 (85.3) |
Trained staff to conduct acid fast bacilli test | 66 (88.0) |
Conducts diagnosis | 75 (100.00) |
Provides treatment | 69 (92.0) |
Conducts referral | 74 (98.7) |
Follow-up of referred cases | 43 (57.0) |
Conducts HIV testing for TB cases | 71 (94.7) |
Gene Xpert test requested for all TB cases for drug susceptibility testing | 43 (57.3) |
Contact tracing (responded always or sometimes) | 69 (92.0) |
Malaria service delivery
Service |
Number (Percent)
|
---|---|
Trained staff to provide malaria treatment | 46 (92.0) |
Trained staff for malaria microscopy | 42 (84.0) |
Investigates patients with fever with blood film | 48 (96.0) |
Reports malaria cases weekly using public health emergency management | 44 (88.0) |
Conducts internal quality control | 48 (96.0) |
Regional lab conducts EQA | 43 (86.0) |
Keep slides for EQA | 47 (94.0) |
Experienced stockouts of at least one of the anti-malarial drugs in past six months | 39 (78.0) |
Remaining gaps
We have received training on malaria diagnostics. But, after the lab technician left, there is none […] it would have been better if more, at least two, lab technicians were trained.
Supervision previously helped us to get feedback and solution to our issues and helped improving services. Now, it has stopped and we don’t when we will get supportive supervision.
Finance
When support stopped, the quality of care is affected. We are providing services as per previous training, we are not getting the updated knowledge on HIV/AIDS treatment.