The Health Franchise Initiative

May, 2004

Gijs Elzinga & Dominic Montagu

Gijs.elzinga@rivn dmontagu@berkeley.edu

2

Overview

• HFI introduction

• Selected Countries

• Operations of the Franchise

• Target Population

• Roll-out plans and cost

• Organization plan

• Timeline of activities

The Private Sector in HealthcarePrivate Expenditure on healthcare:

– Indonesia, 83% of all healthcare expenditure is private

– Kenya, 53%

– India, 70+%

Private Consultations:

– Vietnam, 60% of physician consultations in private sector

– Pakistan, 80%

Exclusively Private as % of all doctors:

– Nigeria, 78%– Malawi, 21%

# clinics in 5 years

National Population

Pop. Covered by Franchise

% of Pop HIV+

TB incidence

Kenya 525 31,293,000 10,500,000 8.0% 0.51%

Tanzania 600 35,965,000 12,000,000 4.2% 0.34%

Uganda 400 24,023,000 8,000,000 2.5% 0.32%

Nigeria 2000 116,929,000 40,000,000 3.0% 0.24%

Cameroon 250 15,203,000 5,000,000 6.1% 0.15%

Malawi 200 11,572,000 4,000,000 7.3% 0.43%

Zambia 200 10,649,000 4,000,000 11.3% 0.65%

Country Selection

4175 83,500,000

5

Operation 1: Overview

Franchisees:–Nurses and clinical officers–Urban slum, peri-urban, dense rural–Full time private practice

Services:–General practice–Essential drugs–TB diagnosis and treatment–HIV testing–HIV opportunistic infection treatment–ART

Operation 2:Drug Supply

• Quality generics for general meds• Global Drug Facility • ARV supplies uncertain

• Suppliers– MEDS– UNICEF – Crown Agents– International Dispensary Association (IDA)

Drug Supply Steps Product selection

Product registration

Forecasting

Funding

Acquisition

Shipment to country

Assembly in country

Storage

Security

In-country transportation

In-store managementFinal use by prescribers/patients

Key components Reliability

Flexibility

Scalability

Operation 3: Training

• Competency Based Training (CBT) • Certification • Collaboration

– DOTS

– ART management

– counseling

–Kenya and Tanzania:

Preparation• Needs Assessment

Training Modules1: Franchise management

2: Drug management

3: Financial management

4: Public Health

5: Clinical TB care

6: Clinical HIV/AIDS care

7 on ARV delivery

• NTLP• NAC• FHI Kenya• Moi University, Eldoret• Aga Khan Hospital

• Mildmay International• Kenya Assoc. of Professional Counselors• Network of Researchers in Eastern and Southern Africa

Operation 4: TBTable of Contents

of the technical policy document for TB:1. Introduction

1.1. Basic understanding of tuberculosis epidemiology

1.2. Tuberculosis and HIV

1.3. Basic understanding of pathology

1.4. The DOTS strategy for tuberculosis control

1.5. The National TB control program

2. Diagnosis of pulmonary tuberculosis in adults

2.1 Diagnostic approach

2.2. Clinical features

2.3. Sputum smear microscopy

2.4. Differential diagnosis of pulmonary TB

2.5. Chest X-rays in diagnosis

2.6. Culture and drug sensitivity testing

2.7. Biopsy

3. Diagnosis of pulmonary tuberculosis in children

4. Diagnosis of extra-pulmonary TB, adults & children

5. StandardizedTB case def. & treatment categories

5.1. Standardizedcase definitions

5.2. Category of patient for registration on diagnosis

5.3. Standardizedtreatment categories

6. Management of patients with tuberculosis

6.1. Anti-TB drugs

6.2. TB treatment regimens

6.2.1. New cases

6.2.2. Re-treatment cases

6.2.3. Children

6.2.4. Special situations: pregnancy, breast-feeding women, renal failure, liver disease

6.3. TB treatment for HIV infected persons

6.4. Monitoring of TB patients during treatment

6.5. Directly observed therapy (DOT)

6.6. Tracing of patients who interrupt treatment

7. Side effects of anti-TB drugs

7.1. Minor and major side-effects

7.2. Prevention of side effects

7.3. How to manage drug reactions and when to refer

8. TB/HIV co-infection and disease

8.1. HIV testing and counselling

8.2. Management of Opportunistic Infections

8.3. Cotrimoxazol preventive therapy (CPT)

8.4. Anti-retroviral therapy

8.5. Home based-care

9. Multi-Drug resistant tuberculosis

10. Communication & education of the patient & family

10.1. Confidentiality

11. When to refer a patient

12. Recording, reporting and notification

PTb testing $0.50

Active Tb treatment $4.00

Weekly drug re-supply free

Ancillary care/counseling free

Collection on-site by provider/ franchise staffTesting in DOTS-certified lab - 2 tests, then refer for x-ray

If positive: printed material and counseling about available government services (if any)

If non-compliance household follow-up by franchise-employed nurse

Successful treatment$15 bonus to provider

$4 bonus to client

Operation 5: HIV OIs

• Continuing Education– Initiation

– 4 times / year

• HIV testing

• Prophylaxis– CPT

– IPT for established patients

• Referral to cooperating hospital and/or consulting physician

Table of Contents

of the technical policy document for HIV/AIDS:1. Background information

1.1. HIV and AIDS

1.2. HIV/AIDS epidemiology

1.3. HIV Transmission

1.4. Prevention of HIV transmission in health units

1.5. Immuno-pathogenesis of HIV infection

1.6. Natural history of HIV infection

1.7. AIDS

1.8. WHO case definitions for AIDS where HIV testing is not available

1.9. WHO staging system for persons who are HIV-seropositive

2. Diagnosis and management of Opportunistic Infections

3. Tuberculosis infection & disease in HIV+ individuals

3.1. Intensified case finding of tuberculosis disease

3.2. Isoniazid preventive therapy (IPT)

4. Antiretroviral therapy for treatment of HIV infection

4.1. Antiretroviral drugs

4.2. Principles of antiretroviral therapy

4.3. Initiation of antiretroviral therapy

4.4. Adults and adolescents with documented HIV infection

4.5. Infants and children

4.6. Doses of ARVs in adults and adolescents

4.7. Doses of ARVs in children

4.8. Choice of ARV treatment regimen

4.9. Adults

4.10. Children

4.11. Monitoring antiretroviral therapy

4.12. Side-effects

4.13. Interactions between ARV drugs and other drugs

4.14. Antiretroviral drugs and TB treatment

4.15. Drug interactions

4.16. Treating TB and HIV together

4.17. Immune reconstitution syndrome

4.18. Options for ARV treatment in TB patients

5. Prevention of Mother To Child transmission

6. HIV/AIDS care services

6.1. Home and community care

6.2. Primary care

6.3. Secondary care

6.4. Tertiary care

7. Communication and patient education

7.1. HIV testing and counselling

7.2. Confidentiality

7.3. Supporting the patient and his family

8. Recording, reporting, notification

Operation 6: ART

• Phase 1: Govt & Mission Hospital– HIV testing, CD4 tracking, initiation of ART

– Franchisees: ARV supply and treatment support

• Phase 2: NFO Consulting Physicians– CD4 tracking, initiation of ART

– Franchisees: HIV testing, ARV supply & treatment support

• Phase 3: CO & Nurse delivery of ART– Franchisees: HIV testing, initiation of ART, ARV supply & treatment support, patient ed. & adherence support

– consulting physician supervision

Consulting Physicians• Initiation of ART• patient record tracking• referrals

Collaboration with

local community-based

NGOs for:1: VCT

2: Patient education

3: Patient identification

4: Pre-ARV counseling

5: Adherence support

11

Operation 7: quality

• Inputs– Medicine, stockage, timing– Equipement– Facility

• Providers– Selection– Training at start-up– Continuing ed

• Processes– External testing– Multi-system monitoring (MIS, random checks, mystery

clients)– Patient follow-up– Regular support

• Control of assets

12

Clients

• Demographics– 3rd and 4th SES quintiles– Slums & dense rural areas (eg. Kibera or Nyanza)

• Price of services– General consultation $0.20-$0.50– TB testing $0.50– TB drugs free– TB consultation and care $4.00– Opportunistic Infections according to disease– HIV testing $0.50– AIDS-related tests free– ARV free– ART $0.40/ weekly visit ~ $20/yr

Special support -TB5% of all TB and clients can be treated free of care, with the franchise reimbursing the provider for fees equivalent to what would have been paid

Special support -ARTVouchers for free care will be available for up to 10% of ART clients. Vouchers given by initiating physician, and collected as payment by franchisees

13

Number of clinics

-

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

4,500

Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7

MalawiZambiaNigeriaCameroonUgandaTanzaniaKenya

PHASE 1 PHASE 2 Continuation

14$0

$2,000,000

$4,000,000

$6,000,000

$8,000,000

$10,000,000

$12,000,000

$14,000,000

$16,000,000

Year 1 Year 2 Year 3 Year 4 Year 5 year 6 year 7

Malawi

Zambia

Nigeria

Cameroon

Uganda

Tanzania

Kenya

HFI expense

SubsidyPHASE 1 PHASE 2 Continuation

HFI

Organizational and operational development

16

Four Steps

1. Secure funding start-upsNairobi meeting June/July

2. Temporary housingFollowing June/July meeting

3. Growing independentAfter implementation start-ups

4. Scale upBased on evaluation start-ups

PHASE 2

PHASE 1

17

Board of key stakeholders

Internationalfranchiser

MAC FAC

Nationalfranchiser

FFF FF

FF

FF

FF

Nationalfranchiser

Nationalfranchiser

Nationalfranchiser

NTPNAC

Nationalfranchiser

Oversight, quality, and reporting

Structure

18

Before 30-06-04

a. Organizational clarity: roles, rules and responsibilities.

b. Financial transparency: structure & legal and fiscal implications.

c. M&E: content and finances & timing with go/no-go’s.

Selection of

these elements

is following the

advice of the

Price Waterhouse

Coopers Global

Risk Management

Group in The Netherlands.

19

Organizational clarity

done/in process• overall structure• overall functions• brand development• selection of host• full support Kenya &

Tanzania• high potentials interest

to do• tasks & responsibilities• national franchiser

capabilities• code of conduct• host arrangement

(MoU)• dispute & termination

clauses

For the execution of phase I and 2, that is the period before the real franchise is established, the development of a temporary Dutch foundation is recommended.

20

done/in process• financial incentive

structure of service provision

• cost estimates, cost-efficiencies

• funding required

to do• overall financial

structure and flows• fiscal/legal challenges

and solutions• responsibilities and

liabilities

Financial transparency

The final home country of the international component of the franchise depends on a number of considerations. One thereof are the legal and financial consequences of the preferred country.

21

M&E

For a well focused and close to real time M&E process, a tailor made management and information system (MIS) is essential.

done/in process• Identification and

specification of M&E components

• Go/no-go decision points and the timing thereof

to do• Organizational and

operational M&E components

• Reporting scheme of financial & operational variables for funding agencies

• MIS prior to operation (phase 2), • Qualitative evaluation at 12 months• Impact Evaluation - clients• Operations evaluation - organization• Impact evaluation - population

preparation 0 12 24 36 48 60

MIS

Process Evaluation

Qualitative evaluation

ImpactEvaluation: clients

Impact Evaluation on client health outcomes

Impact Evaluation: population

Impact Evaluation on community health outcomes

MIS data on providers and clients begins to be collected, ongoing, monthly

Community-level survey on access to

healthcare using DHS

instruments

Timeline: months

OperationsEvaluation onorganization

M&E

OperationsEvaluation

23

Timeline & go/no-go’s

• $8 M funding secured• formal countrysupport

• Start Start-ups• Activate MoUwith host

Go/no go conditions

Activities

• qualitative evaluation positive

• $ 100 M funding secured• impact & operational evaluation positive

• Establish independent organization

• Scale up to 7 countries

12 months 24 months

PHASE 1 PHASE 2

24

Before 30-06-04

• “done/in process” items completed by HFI team, GAG , and MAG

• “to do list” items executed by consultancy firm

- - -

• Price Waterhouse Coopers proposal:116 k euro (ex VAT)

• funding of this essential to avoid “Catch 22”

end

Additions to the ‘to do before 30-04’ list welcome !!

Acute respiratory infection and

treatment <5, 10 countries

0%

10%

20%

30%

40%

50%

60%

70%

poorest 2nd Q mid 4th Q richest0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Treated in the Private Sector

Treated in the Public Sector

Illness during previous 2 weeks (right hand axis)

Cameroon

Ethiopia

Malawi

Mozambique

Nigeria

Rwanda

Tanzania

Uganda

Burkina Faso NA

NA

NA

Country Existence of private

providers1

Geographic Dispersion

Legal status of private providers

Private providers legally prescribe

Government attitude on TB & ART franchising

SUMMARY OF IHSD COUNTRY REPORT

Country Selection

Kenya

Zambia

Footnote: 1. Private providers includes private sector doctors, nurses, clinical officers, lab technicians and pharmacists

Country Selection

Scale Existence of private providers

Geographic Dispersion

Legal status of private providers

Private providers legally prescribe

Government attitude on TB & ART franchising

KEY TO IHSD COUNTRY RANKINGS

0-10 providers per million

10-30 providers per million

30-60 providers per million

100-250 providers per million

60-100 providers per million

95% - 100% Urban

90% - 94% Urban

81% - 89% Urban

69% - 74% Urban

75% - 80% Urban

Franchise could function only with doctor oversight

Some restrictions on nurses but could operate franchise

No restrictions on nurses

NA

NA

Doctors, but not nurses, can prescribe

Nurses ability to prescribe limited

No restriction on nurses

NA

NANot interested in

franchising TB or ART

NA

Interested in franchising ART

but not TB

Interested in franchising ART and possibly TB

Interested in franchising ART

and TB