The goal of USAIDs Private Health Sector Program (PHSP) is to enable the GOE and Regional Health Bureaus (RHBs) to partner with private health service providers to deliver affordable and quality public health services to increase access, affordability and quality of standard service packages for TB, Malaria, HIV/AIDS. The program will strengthen GOE oversight including licensing, accreditation, supervision; improve client education; and strengthen referral mechanisms between private and public health providers. Regions include: Tigray, Ahmara, Oromiya, SNNPR, Dire Dawa, Harari and Addis Ababa. The program will strengthen an enabling environment for public health services in the private sector through policy, advocacy and assistance to GOE and private sector representative bodies in reforming RHB licensing, regulation and supervision protocols; improving access to commercial financing; and private health insurance reforms. Implementation of PHSP anticipates discernable changes including increased access to public health service packages and scale-up of services in private health clinics and increased access and affordability to Ethiopians. Cost effectiveness, quality of health services and prevention interventions delivered at private health clinics will be improved. Sustainable mechanisms for QA/QI in private health clinics will be established and private educational institutions/GOE stewardship and quality of pre-service education in private nursing, laboratory and pharmaceutical programs will be strengthened. 4 vehicles are needed due to scale-up in Tigray and more sites in the other regions. A midterm evaluation is planned, with emphasis on the private sector. Pipeline budget reprograming action will be the source of funding for COP 2012.

PHSP will continue to improve the quality of the TB/HIV service delivery; this includes provision of technical support to 86 private clinics providing TB/HIV services in 4 administrative regions (Amhara, Oromia, SNNPR, and Tigray) and 2 cities (Addis Ababa, Dire Dawa). PHSP will also support TB/HIV services at for-profit and large and medium company clinics. In FY2012 the program will expand to additional 100 private clinics. PHSP will ensure TB service provision in private clinics comply with national standards by ensuring the use of national TB formats for patient registration and that TB drugs are provided for free in accordance with national policy. PHSP will coordinate with other partners through the national TB TWG and create linkages with community level activities for defaulter tracing. With high attrition among health personnel, the program will support quality training to ensure sustainability of high-quality services in the private clinics. PHSP will continue to support joint supportive supervision with RHBs and conduct external quality control activities for TB lab services to ensure high quality laboratory diagnosis at USG supported clinics. PHSP will also develop/disseminate IEC materials for USG supported clinics to improve quality of service. The project will use PDAs to facilitate faster and more efficient data transfer from supported sites to the PHSP head office. In FY2012 PHSP will establish innovative ways to strengthen referral networks and referral confirmation for clients of private facilities referred to public facilities including a tracking mechanism for TB defaulters. PHSP will collaborate with partners working at the community level to help establish a tracking mechanism for TB patients at private clinics. PHSP will provide technical support for the integration of HIV and TB services into workplace clinical settings and train drug vendors to improve TB referrals for people seeking consultation at pharmacies.

Anecdotal data suggest that 50% of HIV counseling and testing and 20% of TB diagnosis in Addis Ababa occurs in the private sector. Due to the variability of service quality and the limited capacity of the government to regulate the private sector, technical assistance to improve the quality of lab services is critical. In collaboration with EHNRI, PHSP will strengthen the capacity of selected private labs and develop a mechanism for branding lab services that meets standards set through a central accreditation system, improve the monitoring and quality control of private clinics through supportive supervision; and advance private-public partnerships through qualified referrals for selected services, training and shared manuals. PHSP will also collaborate with EHNRI/FMHACA to develop standard accreditation and supportive supervision tools and support regional level Quality Assurance (QA) and Quality Control (QC) mechanisms for USAID-supported clinics in collaboration with RHBs. PHSP will also work with EHNRI to create a more robust role for private enterprises in such areas as EQC, local production of reagents, surveillance studies and equipment maintenance. In collaboration with EHNRI, PHSP will train lab staff on lab diagnosis of HIV,TB, Malaria ,STIs and OIs using a centrally developed training manual, train on proper lab management including forecasting and budgeting; develop SOPs and provide related mentoring. PHSP will help USAID-supported clinics to establish a functional recording and reporting system in compliance with national requirements; implement appropriate quality control measures to ensure acceptable accuracy and precision in lab tests and create linkages with other lab services for efficient service continuity. To add value to USAID supported clinics delivering TB and HIV services, PHSP will provide minor materials such as infection prevention materials (masks, dust bins) and sputum collection caps. The program will also support minor renovation such as widening of windows to avoid overcrowding.

Under this award there will be targeted health system strengthening activities with the end goal of creating an enabling environment for the private health institutions. This project will also be linked and work with USAID/DCA mechanism to overcome the financial barriers for the expansion of private health facilities.The absence of a comprehensive accreditation manual for health facilities and a proactive monitoring tool to help facilities improve their services is a critical barrier to quality delivery of health services. The poor state of health education in the country and the lack of appropriate screening mechanisms to ensure that graduates have learned the essentials are major barriers that impact the quality of health services. An increase the number of graduating health professionals from private institutions to address the current shortage of manpower without a focus on the quality of training may result in substandard service delivery. The following targeted activities will be rolled-out to strengthen the private health sector system: 1) PHSP will support FMHACA to produce comprehensive licensing and accreditation manuals for different health care providers. PHSP will engage professional bodies to obtain their buy-in for the accreditation program; 2) PHSP will work with FMOH to establish a framework for the engagement of the private health sector in publicly funded health activities, including the provision ART and TB services, quality management and surveillance in the health sector; 3) PHSP will also work with private medical colleges to improve quality of health education and the creation of alternative financing for health education; 4) PHSP will also work with professional bodies and other relevant associations to consolidate private health sector representation and networking; 5) PHSP will work to strengthen the capacity of RHBS to support the private health sector through incentive-based monitoring, supportive supervision and proper documentation of private health sector achievements in 5 RHBs (AA, Oromia, SNNPR, Amhara and Tigray). This project will strengthen the overall health system and regulatory environment.

This is a continuing activity. PHSP will strengthen the HCT service delivery system by expanding access to and demand for HIV counseling and testing services. The type of activity for HCT services will be mainly client-initiated testing through mobile outreach using the national testing algorithm to address previous challenges with client uptake. The mobile HCT will target MARPS and vulnerable groups such as CSWs, daily laborers, truck drivers, university students and women. The geographic coverage of the mobile HCT activity will be on urban centers and small towns along the high-risk transportation corridors. This mechanism will subsume OSSA's mobile and community based testing activity from CDC per the realignment. The activity will expand mobile HCT services in parallel with expanding long-term, facility-based CT services in the workplace and for-profit private clinics. The program takes into consideration the challenges posed by the intermittent nature of mobile CT services, especially the linking and channeling of demand created by social mobilization for the mobile HCT towards facility-based CT services. Supervision of the mobile HCT activity will be done jointly with Regional HAPCO offices and PHSP mobile HCT field officers, using nationally approved supervision tools. In order to ensure quality of service, aside from field supervision, PHSP will ensure that HCT services are provided only by qualified health workers. After every round of services, selected test results will be sent to regional labs for quality control. The test results will be recorded using nationally approved HCT formats and forwarded to city health offices. PHSP will continue to strengthen referrals and linkages so that clients who receive HCT will be efficiently referred to treatment and care providing facilities.

The HVOP program is linked to other component programs implemented by PHSP, including the mobile HCT services and facility-based STI, TB and HIV services at private clinics. PHSP will work to satisfy the demand created as a result of social mobilization for HIV testing activities. As part of the PEPFAR Ethiopia realignment process, mobile counseling and testing activities under the CDC partner OSSA will be subsumed by Abt starting first quarter of FY 2013. PHSP will promote the proper and consistent use of condoms among high-risk and vulnerable groups, such as commercial sex workers, daily laborers, truck drivers, university students, women and other vulnerable groups. Barriers to condom use and condom use knowledge, attitudes and practices in the context of HIV and family planning (FP) will be assessed through a meta-analysis of existing research. The health information education communication (IEC) system will be improved as IEC packages will be disseminated and medium-size companies and private health facilities along the high-risk corridor where the mobile HCT is provided. The geographic coverage of the program will be largely in the urban centers and towns along three high-risk corridors (Addis Metema; Addis- Djibouti; Addis-Moyale routes). The IEC package will include malaria, TB, FP, and diabetes which will maximize benefits from costs associated with developing and disseminating these materials. The packaging of HIV-related messages with other messages will have cost savings and increase listener attentiveness. The quality of the promotion activity will be monitored with field technical officers who will ensure that condoms are distributed to vulnerable groups and that high-risk individuals receive information on the benefits of correct and persistent condom use. In addition, performance-based contracts will be outsourced to local private institutions to promote early treatment seeking for STIs, create awareness of the link between STIs and HIV, and distribute STI drugs to private and company based clinics. This activity will also engage pharmacies and druggists to refer STI cases to facilities and will train and build the capacity of private company clinics for STI management and condom use.

USAID Private Health Sector Program (PHSP) will support expanded access to and demand for MNCH/PMTCT services in Ethiopia. This is a relatively new activity that started with reprogrammed funds from COP FY2010. Strengthening of the overall private health system and the creation of an enabling environment for the private health sector will be essential outputs of this agreement. The four major technical focus areas: I) Creation of an enabling environment, II) Building the technical capacity of private higher clinics, III) Promotion and demand creation for PMTCT services, and IV) Quality assurance and quality control activities. The lack of PMTCT services at higher clinics represents a considerable missed opportunity in preventing mother to child HIV transmission, as significant numbers of antenatal care and a considerable number of deliveries take place in private higher clinics. A recent joint rapid assessment of 20 higher clinics made by Addis Ababa Regional Health Bureau and PHSP (May 2010) showed that the number of mothers seeking antenatal care at private clinics is significant. It was also noted from the assessment that the number of labor and deliveries that take place in private higher clinics are high as well. Despite the high demand for services from these facilities, the facilities are not equipped to provide proper HIV screening and follow-up services. PMTCT services will be initiated at 12 private clinics in Addis Ababa in the first year, and will engage a total of 100 private clinics nationwide in the delivery of PMTCT service in five years time. PMTCT interventions at private higher clinics will focus more on the first three PMTCT components and link with community outreach services and public facilities, etc., for the fourth component. The project will use the national PMTCT guidelines and protocols to initiate PMTCT services in selected higher clinics with high prenatal client load. PHSP will create the necessary network and working relationships with the national PMTCT technical working group, the RHBs and community based organizations to create widely accepted PMTCT services in private higher clinics.

This is a continuing activity aimed at strengthening and expanding ART services at private clinics. The program will prioritize identification and enrollment of HIV positive pregnant women for ART in selected high-volume private clinics. The activity will ensure that private facilities which provide integrated TB and HIV services will have strong functional linkages between TB and HIV services. Despite a delay in the initiation of ART through private clinics, the PHSP during FY 2009 & FY 2010 worked to overcome many of the policy issues that were barriers for the expansion of ART services at private sector run clinics and will continue to work with the GoE legislative bodies. PHSP is now on track to expand to an initial 16 private clinics in Addis Ababa with the vision to expand to 60 private clinics in major urban centers during subsequent years. Better quality and confidentiality offered at private clinics will provide an option for ART clients who are economically better off who may opt to follow treatment at private clinics. PHSP will finalize minor policy issues related to the expansion of ART at private clinics, especially the provision of ART drug dispensing. It will also provide refresher and continued comprehensive clinical training for professionals at 50 private clinics and evaluate clinical outcomes, both for individuals and as a cohort, using CD4, weight and functional status as monitoring parameters. Adherence to treatment will be facilitated through counseling by ART nurses and linkages with CHWs supported by partner organizations. At initial stages, implementation will be aimed at 8 selected clinics after joint assessment and selection process with AA regional health bureau. PHSP will also work to improve the quality of laboratory services through supportive supervision, the use of QA and QC tools and strengthened capacity of RHBs and District and City health offices to supervise private sector providers.