Quality care for TB and HIV/AIDS in sub-Saharan Africa through franchised private providers

Building upon the existing health infrastructure in the private sector, health franchising is capable of diagnosing and treating Tuberculosis (TB) and Human Immuno-deficiency Virus (HIV)/ Acquired Immune Deficiency Syndrome (AIDS) on a large scale, is highly cost effective, reaches previously underserved populations, and is rapidly expandable.

The Problem

HIV infects 25 million people in sub-Saharan Africa and kills 2.3 million people each year. TB infects 2 million Africans and is the leading killer of people with AIDS. Effective treatments exist for both of these diseases. For TB and HIV/AIDS, drugs are becoming increasingly affordable. The primary constraint in attacking these illnesses in sub-Saharan Africa is an effective health care infrastructure. While WHO-supported national TB programs have been effective at implementing DOTS strategies in most sub-Saharan Africa countries, these programs are reaching less than 40% of the infected population. Delivery of ARV treatment exists only on a small scale.

Where the Poor Go for Health Care

For a large faction of African poor, the public health infrastructure is unavailable, difficult to access or severely understaffed by qualified providers. As a result, the lowest African income quintile receives over 60% of health care services directly from the private sector. For the poor, the choice associated with health care is often not a choice between private and public, but between private and no care at all.

From a public health perspective, working with the private sector is challenging because the providers are heterogeneous. Licensing, quality of care, reliability of drugs, regularity of access, completion of treatment regiments, pricing, follow up and diagnostics abilities vary widely across providers. These challenges are especially important for TB treatment and anti-retroviral therapy (ART) because of the need to follow well-defined guidelines and continuity of care to have an effect at individual and population level and to minimize the risks of drug resistance.

The Franchise Model

Health franchising addresses these challenges by providing reliable, affordable, quality care where people actually go for treatment. A health franchise brings existing private providers into an umbrella network thus reducing heterogeneity. A private clinic that becomes a franchisee agrees to purchase drugs and supplies from the franchise, adhere to quality and brand standards, submit to monitoring, and to fixed and posted prices. In exchange, the franchisee (the contracted provider) will receive reliable delivery of safe quality drugs, technical support, regular training and the association with a high-quality brand supported by a national advertising campaign.

A franchise’s strategic advantage lies in its ability to expand more quickly and cost effectively than public or Non-governmental organization (NGO) clinics. Because they work with pre-existing businesses, a franchise pays neither clinic-level salaries nor capital costs. Providers already exist, they work to serve their communities and to earn an income, and the goals of the franchise leverage these two characteristics - existing human resources in target communities and service-related incentives – in order to open many sites quickly with limited new resources.

A Solution: Healthspot Franchise International

The goal of the Healthspot Franchise International (Healthspot) is to utilize this same private provider network model to deliver quality TB and HIV/AIDS care, following international and national standards, in sub-Saharan Africa. An international NGO will plan and organize the phased deployment of national franchises. In the first phase, limited franchises will be established in Kenya and shortly thereafter to Tanzania and then Uganda. When the treatment protocols, distribution model, incentive structure and management systems are honed, Healthspot will be expanded within those countries and other countries in the region.

The international NGO will contract to, or establish, a national franchise organization (NFO) at the country level. The NFO will be responsible for recruiting franchisees, enforcing clinic standards, delivering training, purchasing and distributing drugs and products, collecting data and marketing.

The typical franchisee will be a mid-level provider such as a nurse or clinical officer with an existing private practice. This franchisee will be recruited by the NFO. Although the goal of Healthspot is to deliver quality care for TB and HIV-AIDS to the poor, most of the franchisee business will be general health services: family planning, fractures and headaches, and consultations and drug sales for malaria, diarrhea, pneumonia and other common illnesses – the normal activity of these providers, now accomplished with quality-controlled drugs and quality-supervised protocols. In addition, the franchisees will also treat TB and opportunistic infections resulting from HIV. It is this integration of traditional general practice and public health services, targeting TB and HIV-AIDS that makes the franchise system unique and cost effective.

ART will be added in coordination with guidelines of the National AIDS Committee (NAC), approximately 12 months after initiation of the franchise in a country.

Cost Structure and Treatment for TB

For TB, the clients will pay $0.50 for testing, and a National Tuberculosis Program (NTP)-certified laboratory will do testing off-site. Once testing positive, the client will receive the full course of treatment drugs for free. The client will be charged an affordable fee, US $4.00, for consultations provided by the franchisee. Payment in full will be upfront, and will cover all consultations throughout the course of care. The franchisee will dispense the medication over a 6 or 8-month period, notifying franchise outreach workers if the client fails to meet the treatment program. The franchisee will receive a $15 bonus once the treatment is successful completed, and the client will receive a completion bonus of $4.00 making the full treatment free for those who complete the course of care.

Cost Structure and Treatment for HIV and AIDS

HIV testing on-site, using rapid tests will begin as ART is rolled out through the franchise network. Irrespective of ARV availability and awareness of sero-status, patients with confirmed or suspected HIV will be given prophylaxis, counseling, and care for all outpatient services at affordable rates – priced to match the low-end of the for-profit market.

Initially, franchise-employed consultant-physicians will initiate ART, and local community organizations and NGOs to collaborate on treatment support and compliance. In a second phase, the franchisees themselves will initiate ART with supervision from consulting physicians. In all cases pricing will be affordable, with first line ART drugs free, and consultations set at approximately US $2.00 per month, and providers reimbursed for no-fee care provided to up to 10% of their ART clientele.

Local Governments

Healthspot is designed to make use of existing infrastructure and human resources in health services in sub-Saharan Africa that are normally beyond the control of national health services, but which nonetheless play an important role in providing care to the poor throughout the developing world. Healthspot will recruit from existing private providers only, will integrate their services into national public health programs through government run training, alignment with government clinical protocols, and ongoing and complete sharing of treatment and cure data with the appropriate government departments and national programs. Relevant government programs will be partners in providing oversight and regulation of private franchisees. In this way, the healthspot will formalize the status of private providers and integrate their services into the national public health structure.

Current Activites

Healthspot is developing a pilot initiative starting in collaboration with SHEF/CFW, the Kenyan TB and Leprosy Program, and the community NGO KICOSHEP to delivery TB care in Kibera slums near Nairobi. Provider selection and training will start in September and October 2004. Healthspot is working with USAID to prepare for an evaluation of lab capacity and needs in the targeted start-up areas of Kenya, including Nyanza Province, Kibera, and the Thika District of Central Province. Healthspot is also advanced in negotiations for German government support for start of franchise operations in a number of SADC region countries.

Startup Financial Needs

Healthspot is being developed with a five year ramp-up horizon, with a first phase planning for initiation in three countries staggered 6 months apart, with go/no-go decision points at 24 months based on planned evaluations. Year one costs are projected as $3M, which will cover development of training, guidelines, and M&E programs, and start up of national franchisers, and franchise networks in two countries. The funding needs for both phase one years total US $10 to $12 million, depending upon the pace of introducing ART at the end of year two.

Supporters

The Rockefeller Foundation and the StopTB department of the World Health Organization are supporting the Healthspot Franchise International conceptual development. For further information contact Dominic Montagu at dmontagu@healthspotfranchise.org or Gijs Elzinga at gelzinga@healthspotfranchise.org.

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