Context

Tuberculosis (TB) and Human Immuno-deficiency Virus (HIV) /Acquired Immune Deficiency Syndrome (AIDS) are increasing throughout sub-Saharan Africa at alarming rates. World Health Organization (WHO) supported national TB programs have been effective at implementing Direct Observed Treatment Short Course (DOTS) strategies in most sub-Saharan Africa countries, but there are still an increasing number of active TB cases. For HIV/AIDS, which does not have an equivalent effective strategy, the situation is much worse. The planned widespread implementation of Anti Retroviral Therapy (ART) treatment will bring additional challenges as the limited human resources in African health systems struggle to address the needs of a large and needy new patient population.

Both TB and HIV/AIDS require effective close-to-client services in order to assure easy access to diagnosis (critical to passive detection) and continuity of treatment. At the same time, the risk of drug-resistance development brought on by poor treatment or non-compliance makes it imperative that an effective quality control system be in place for any diagnosis or treatment program. Public health planning needs also necessitate an effective integration of provider data with national Management Information Systems (MIS) data on both TB and HIV.

Evidence from sub-Saharan Africa has shown that at least half of the patients who ultimately receive treatment from national TB programs do so after receiving an initial 4 to 12 weeks of treatment from private providers subsequent to the onset of symptoms (Enwuru et al 2002, StopTB, Hanson unpublished). The 50+% of patients with active TB who are not treated by national TB programs receive care from private providers if they receive any care at all.

TB and HIV/AIDS in sub-Saharan Africa

Sub-Saharan Africa holds over 70% of all HIV/AIDS cases, and tuberculosis is at an all time high and rising (2). Life expectancy, low already, is falling in many countries. TB will not diminish as long as prevention and care of HIV/AIDS is restricted (3) - the two diseases are entwined in a deadly relationship.

TB is the cause of death for one out of every three people with AIDS worldwide. In sub-Saharan Africa, up to 70% of patients with sputum smear-positive pulmonary TB is HIV-positive. It is necessary to address TB and HIV in an integrated package, with coordinated opportunities for testing and treatment of both diseases, linked to support for therapy continuation and prophylaxis against opportunistic infections.

For both TB and HIV/AIDS the critical steps of testing, reporting, and assuring full compliance with treatment regimens requires; close-to-client’ services. In sub-Saharan Africa , existing health infrastructure is often not able to provide this, particularly for the populations most at risk.

The Commission on Macroeconomics and Health estimates that globally over 23% of the costs of scaling up TB treatments and 25% of the cost of scaling up ART will be attributed to infrastructure (Mills, Brugha et al. 2002). In sub-Saharan Africa, the investment needs attributed to infrastructure will be higher.

Health Seeking Behavior

Evidence from National Health Accounts research, economic studies of health seeking behavior, and analysis of Demographic and Health Surveys (DHS) data suggests that an increase in government services, when and if it comes, will not be sufficient to increase diagnosis and entry into treatment to the rates set by the Millennium Development Goals (Ngalande-Banda and Walt 1995; Rosen and Conly 1999; Leonard 2000) (1).

Analysis of DHS data from 22 countries in Africa found that for the poorest income quintiles, more than 60% of health care services were directly purchased from the private sector (Prata et al2004 draft.) and that for the poor the choice of service source is not between private and public providers, but between private and no care at all.

One of the conclusions of the DOTS Expansion Working Group of WHO's Stop TB Partnership is that it will be impossible to attain the Millennium Development Goals of detecting 70% of the estimated TB cases and curing 85% of the detected cases by 2005 without significant involvement by the private sector. Recent deliberations on the human resource needs to expand access to ART in conjunction with the 3x5 goals have also reached the conclusion that the private for-profit and non-profit sector must be integrated with delivery at multiple levels.

Private Providers

Private providers in all countries are heterogeneous, incorporating a wide range of formal and informal practitioners at every level of training.

For clients, the reasons to seek out private providers are many and varied, including:

However, as has been documented repeatedly in both developed and developing countries, the limited oversight, and financial incentives of private providers giving fee-for-service treatment often results in highly variable quality of care. The opportunities to intervene with private providers in order to improve quality, standardize prices, and empower clients have been studied both in theory and in practice. While various interventions have had measurable effect, none have provided sufficient assurances of quality that they have been adopted on a large scale.

Health Franchising

Health franchising is an application of commercial franchising systems to socially motivated health programs that incorporates all of the interventions that have been shown to have some effect individually (training, oversight, performance-based incentives, ongoing relationships with monitoring). Health franchising programs, also often called social franchising programs, have been used successfully for more than seven years for clinical family planning programs in Asia and Africa, and for essential drug provision and Voluntary Counseling and Treatment (VCT) programs in Africa. In India and Kenya, health franchise programs have been able to enroll private providers already operating at the panchayat or village level, providing close-to-client services on a scale that few public health programs in any part of the world can emulate. In the Philippines, health franchising of safe delivery services have proven popular among both providers and clients and profitable as well; USAID has recently underwritten the introduction of privately provided TB care in a quasi-franchise network. A Global Fund proposal for private TB franchising in Pakistan has been recommended for approval (mid 2004).

For health interventions, where control of quality and ease of access are critical, health franchising provides an opportunity to leverage existing private infrastructure with minimal supplemental investment. Control systems used in this delivery model necessitate charging user fees, and may limit access among the very poor. However, as noted above, we know from the World Bank that the very poor in Africa already pay user fees, for all services including TB and HIV/AIDS care with no assurances of quality, no linkages to government surveillance, and often no awareness of the alternative free services available from the government. User fees in a franchise, therefore, can be used as a point of leverage to improve the services and awareness of services for patients across all income levels as well as to control prices.

End notes:

(1) Throughout sub-Saharan Africa more than 1/2 of all people who reported receiving care of any kind for Acute Respiratory Infections during the past year were cared for in the private sector (DHS from 22 countries of Sub-Saharan Africa).

(2) Williams, B.G., Nunn, P. & Dye C. Weathering the storm. 2 nd Global TB/HIV Working Group Meeting Durban, South Africa, June 2002 (Publication in preparation)

(3) Curry, C.S.M., Williams, B.G. & Dye C. Prevention versus cure for the management of tuberculosis in countries with a high prevalence of Human Immunodeficiency Virus. (Publication in press) JAHA (2002). "A giant leap forward -"Development of Comprehensive Accreditation System for Healthcare Services in India"." Journal of the Academy of Hospital Administration14(2): 61.

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